What is the current protocol for managing a patient who tests positive for COVID-19 (Coronavirus Disease 2019)?

COVID-19 Positive Patient Management Protocol

For COVID-19 positive patients, implement immediate isolation for a minimum of 5 days from symptom onset or positive test, ending only when fever-free for 24 hours without antipyretics, symptoms are resolving, and ideally after a negative rapid antigen test, with extended isolation up to 10 days if symptoms persist or testing remains positive. 1

Isolation Duration and Criteria

Standard Isolation Protocol

• Minimum 5-day isolation period from symptom onset or positive test date 1, 2
• Isolation can end after day 5 only when ALL of the following criteria are met:
  • Fever-free for at least 24 hours without antipyretic medications 1
  • Symptoms are resolving or absent 1
  • Ideally, a negative rapid antigen test is obtained 1
• Extend isolation to 10 days if symptoms persist, fever continues, or antigen testing remains positive 1

Testing Strategy for Ending Isolation

• Do not use repeat PCR testing to guide discontinuation of isolation in most circumstances 1
• Rapid antigen testing is preferred for symptomatic individuals within 5 days of symptom onset 1
• A positive antigen test has high specificity and can guide isolation decisions without confirmation 1
• A negative antigen test in high clinical suspicion cases should be confirmed by NAAT 1

Critical Pitfall: Patients can show positive RT-PCR tests after 14 days despite no longer being contagious—do not use this to extend isolation unnecessarily 1, 3

Isolation Setting Requirements

Environmental Controls

• Place patients in well-ventilated single rooms with restricted activity 1
• If single rooms unavailable, maintain at least 1.1 meters (3.5 feet) bed distance from others 1
• Patients must wear medical masks (N95 preferred) when in the presence of others, including household members 1
• Patients should clean hands immediately after coughing, sneezing, or touching potentially contaminated surfaces 1

Healthcare Setting Precautions

• Isolate confirmed COVID-19 patients from negative patients to decrease in-hospital transmission 3
• Healthcare workers require trained use of adequate PPE (N95 masks, goggles, double gloves, face mask, protective gowns) 3
• Suspected/uncertain patients should be isolated and managed as COVID-19 positive until diagnosis is confirmed 3

Special Population Modifications

Immunocompromised and Severe Disease

• Case-by-case approach rather than standard criteria for patients with severe COVID-19 or those on immunosuppressive medications 1
• Do not apply the same criteria to immunocompromised patients as immunocompetent individuals—they require longer isolation and potentially test-based strategies 1

Surgical/Hospitalized Patients

• After hospital discharge, confirmed cases should be kept in isolation for at least 2 weeks from the first positive test and until negative RT-PCR test is obtained 1, 3
• Re-admit to COVID-ICU patients with severe pneumonia after emergency surgical procedures 3
• For stable asymptomatic or mild symptomatic COVID-19 patients, create a surgical dedicated ward to avoid contamination 3

Household Contacts

• Household contacts should quarantine for 14 days after last known contact with the index patient 4
• Shortened quarantine options: day 10 without test, or day 7 with negative test result 2, 4
• Among household contacts who test negative and remain asymptomatic through day 7, there is an 81% chance of remaining negative through day 14; this increases to 93% if asymptomatic with negative test through day 10 4

Complete Clearance Criteria (Stricter Standard for Healthcare/Congregate Settings)

When complete viral clearance documentation is required:

• Body temperature normal for more than 3 days without fever-reducing medications 1, 3
• Respiratory symptoms significantly improved 1, 3
• Two consecutive negative RT-PCR tests with at least one-day sampling interval 1, 3

Treatment Considerations

Antiviral Therapy

• Remdesivir (VEKLURY) is FDA-approved for hospitalized patients and non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression 5
• For hospitalized patients requiring invasive mechanical ventilation/ECMO: 10-day treatment course 5
• For hospitalized patients not requiring invasive mechanical ventilation/ECMO: 5-day course, extendable to 10 days if no clinical improvement 5
• For non-hospitalized high-risk patients: 3-day treatment course, initiated within 7 days of symptom onset 5
• Perform hepatic laboratory testing before starting and during treatment 5

Supportive Care

• Early empirical antibiotic treatment should be targeted to culture results, with de-escalation as soon as possible 3
• Anticoagulative measures should be implemented 6
• Dexamethasone, remdesivir, and tocilizumab appear most promising for therapy 6

Return to Normal Activities

• Most patients can return to work after meeting the 10-day criterion plus symptom improvement and 24-hour fever resolution 1
• Patients meeting these criteria are unlikely to be infectious 1
• Do not end isolation based solely on symptom resolution without meeting the minimum 5-day criterion 1

Key Clinical Pitfalls to Avoid

• Never use repeat PCR testing routinely to determine when to end isolation—patients can remain PCR-positive for weeks without being contagious 1, 3
• Never end isolation before day 5 regardless of symptom resolution 1
• Never apply standard criteria to immunocompromised patients without individualized assessment 1
• Never manage suspected COVID-19 patients without full PPE precautions until diagnosis is definitively ruled out 3