What are the treatment guidelines for hospitalized Covid-19 patients?

COVID-19 Treatment Guidelines for Hospitalized Patients

Corticosteroid Therapy

All hospitalized COVID-19 patients requiring supplemental oxygen, noninvasive ventilation, or mechanical ventilation should receive dexamethasone 6 mg daily for up to 10 days. 1, 2, 3

• This represents the single most important mortality-reducing intervention in hospitalized COVID-19 patients requiring oxygen support 1
• Do NOT administer corticosteroids to hospitalized patients who do not require supplemental oxygen, as there is no mortality benefit and potential for harm 2, 3
• The standard regimen is dexamethasone 6 mg daily (oral or IV) for 10 days or until hospital discharge, whichever comes first 1, 2

Anticoagulation

All hospitalized COVID-19 patients should receive prophylactic-dose anticoagulation unless contraindicated. 2, 3

• Low molecular weight heparin (LMWH) is preferred over unfractionated heparin in the inpatient setting due to lack of routine monitoring requirements and decreased healthcare worker exposure 1
• For patients already on oral anticoagulation for atrial fibrillation, consider switching to therapeutic-dose LMWH or unfractionated heparin if oral anticoagulation needs to be discontinued during hospitalization 2
• Extended post-discharge thromboprophylaxis (14-30 days) should be considered for high VTE risk patients 1
• Intensified prophylaxis may be indicated in patients with obesity, known thrombophilia, intensive care treatment, or elevated D-dimers 4

IL-6 Receptor Antagonists

Consider IL-6 receptor antagonists (tocilizumab or sarilumab) for patients with increasing oxygen requirements AND evidence of systemic inflammation (e.g., CRP ≥75 mg/L). 1, 2

• This therapy is most beneficial when added to corticosteroids in patients within 24 hours of requiring noninvasive or invasive ventilatory support 1
• Do NOT use IL-6 receptor antagonists in patients not requiring supplemental oxygen 2
• Treatment reduces the combined endpoint of mechanical ventilation or death (OR 0.74,95% CI 0.72-0.88) 1

Respiratory Support

For hypoxemic respiratory failure without immediate indication for intubation, use high-flow nasal cannula (HFNC) or noninvasive CPAP. 2, 3

• Patients with severe hypoxemia (SpO2 <90% despite oxygen), dyspnea, or high respiratory rate should be admitted to intensive care 4
• Intubate promptly if noninvasive respiratory support fails; do not delay intubation 3
• Invasive mechanical ventilation with repeated prone positioning are key elements for severely hypoxemic patients 5, 4

Antiviral Therapy (Remdesivir)

Remdesivir may be considered for hospitalized patients NOT requiring invasive mechanical ventilation, with treatment initiated within 7 days of symptom onset. 6

• The recommended dosage is 200 mg IV loading dose on Day 1, followed by 100 mg IV daily maintenance doses 6
• Treatment duration: 5 days for patients not requiring mechanical ventilation/ECMO (may extend to 10 days if no clinical improvement); 10 days for patients requiring mechanical ventilation/ECMO 6
• The European Respiratory Society recommends AGAINST remdesivir for patients requiring invasive mechanical ventilation 2
• No dosage adjustment needed for any degree of renal impairment, including dialysis 6

Treatments NOT Recommended

Do NOT use the following therapies as they lack efficacy and may cause harm: 1, 2, 3

• Hydroxychloroquine (pooled mortality estimate 1.08,95% CI 0.97-1.19, effectively excluding benefit) 1
• Lopinavir-ritonavir 2, 3
• Azithromycin (unless bacterial co-infection is suspected) 2, 3
• Colchicine 3
• Interferon-β 3

Antibiotic Therapy

Only administer antibiotics when there is clinical evidence of bacterial co-infection. 2, 3

• Routine empiric antibiotics are not recommended 2, 3
• Bacterial co-infection is uncommon in COVID-19 at presentation 1

Monitoring Requirements

Before starting and during treatment, monitor: 6

• Hepatic laboratory tests (transaminases, bilirubin) 6
• Prothrombin time 6
• Renal function and platelet counts (for anticoagulation decisions) 1

Treatment Algorithm by Severity

Hospitalized, Not Requiring Oxygen

• No corticosteroids 2, 3
• Prophylactic-dose anticoagulation 2, 3
• No IL-6 antagonists 2

Hospitalized, Requiring Supplemental Oxygen

• Dexamethasone 6 mg daily 1, 2, 3
• Prophylactic-dose anticoagulation 2, 3
• Consider remdesivir if within 7 days of symptom onset 6

Hospitalized, Increasing Oxygen Requirements with Systemic Inflammation

• Dexamethasone 6 mg daily 1, 2, 3
• Add IL-6 receptor antagonist (if CRP ≥75 mg/L or other markers of inflammation) 1, 2
• Prophylactic-dose anticoagulation 2, 3
• HFNC or noninvasive CPAP 2, 3

Hospitalized, Requiring Mechanical Ventilation/ECMO

• Dexamethasone 6 mg daily for 10 days 1, 2, 3
• IL-6 receptor antagonist (if within 24 hours of ventilatory support initiation) 1
• Prophylactic-dose anticoagulation 2, 3
• Repeated prone positioning 5, 4
• Do NOT use remdesivir 2

Critical Pitfalls to Avoid

• Never delay corticosteroids in patients requiring oxygen 3
• Never give corticosteroids to patients not requiring oxygen 2, 3
• Never delay intubation when noninvasive support is failing 3
• Never use routine antibiotics without evidence of bacterial infection 2, 3
• Never overlook anticoagulation in any hospitalized patient 2, 3
• Never change anticoagulant regimen based solely on D-dimer levels 1

Infection Control

Strict adherence to infection control measures is essential: 5

• Hand hygiene and correct use of personal protective equipment (PPE) 5, 4
• Aerosol-generating procedures (intubation, bronchoscopy) require utmost precaution and preparation 5