What are the guidelines for inpatient management of COVID-19?

Inpatient Management of COVID-19

Core Treatment Algorithm by Oxygen Requirement

All hospitalized COVID-19 patients should receive anticoagulation, and those requiring supplemental oxygen or ventilatory support should receive corticosteroids—these are the only interventions with strong evidence for mortality reduction. 1, 2

Patients NOT Requiring Supplemental Oxygen

• Supportive care only 1
• Do NOT use corticosteroids in this population—no mortality benefit and potential harm 1, 3
• Anticoagulation (prophylactic-dose) is strongly recommended 2

Patients Requiring Supplemental Oxygen (Non-Invasive Support)

• Dexamethasone 6 mg daily for 10 days (strong recommendation—reduces mortality by 3%) 1, 2, 3
• Prophylactic-dose anticoagulation (LMWH preferred over unfractionated heparin due to less monitoring and reduced healthcare worker exposure) 2
• High-flow nasal cannula (HFNC) or CPAP for hypoxemic acute respiratory failure without immediate need for intubation 1, 2
• Monitor closely for clinical deterioration requiring intubation within 1-2 hours 1

Patients with Increasing Oxygen Requirements AND Systemic Inflammation

• Add IL-6 receptor antagonist (tocilizumab or sarilumab) if CRP ≥75 mg/L or other markers of inflammation present 2, 3
• Must be initiated within 24 hours of requiring noninvasive or invasive ventilatory support 2
• Reduces combined endpoint of mechanical ventilation or death (OR 0.74,95% CI 0.72-0.88) 2

Patients Requiring Invasive Mechanical Ventilation and/or ECMO

• Dexamethasone 6 mg daily (continue for up to 10 days total treatment duration) 1, 4
• Therapeutic anticoagulation (consider switching from prophylactic dose) 2
• Low tidal volume ventilation (lung-protective strategy) with prone positioning 1
• IL-6 receptor antagonist if COVID-19-related inflammation present 3
• Do NOT use remdesivir in this population (conditional recommendation against) 1, 3
• ECMO for refractory hypoxemia: PaO2/FiO2 <100 mmHg despite optimized PEEP, neuromuscular blockade, and prone positioning 1

Remdesivir Considerations

Remdesivir has limited and controversial evidence in hospitalized patients. 1

• No recommendation for patients requiring supplemental oxygen only 1
• Suggest against use in patients requiring invasive mechanical ventilation 1, 3
• FDA-approved dosing if used: 200 mg loading dose Day 1, then 100 mg daily (5 days for non-ventilated, up to 10 days for ventilated patients) 4
• The European Respiratory Society does not recommend routine remdesivir use, contrasting with earlier American Thoracic Society recommendations 1

Treatments with Strong Recommendations AGAINST Use

These therapies should NOT be used—they provide no benefit and may cause harm:

• Hydroxychloroquine (strong recommendation against) 1, 2
• Lopinavir-ritonavir (strong recommendation against) 1, 2
• Azithromycin without bacterial coinfection (conditional recommendation against) 1, 3
• Hydroxychloroquine combined with azithromycin (conditional recommendation against) 1
• Colchicine (conditional recommendation against) 1

Critical Monitoring Parameters

• Hepatic function tests before starting and during treatment (especially with remdesivir) 4
• Prothrombin time before starting and during treatment 4
• Renal function and platelet counts for anticoagulation decisions 2
• Do NOT change anticoagulation based solely on D-dimer levels 2
• Oxygen saturation target: maintain SpO2 no higher than 96% in acute hypoxemic respiratory failure 1

Special Population: Immunocompromised/Hematologic Malignancies

For patients with hematological malignancies or transplant recipients, additional considerations include:

• Anti-SARS-CoV-2 monoclonal antibodies for seronegative patients with moderate-to-severe disease 1, 3
• Casirivimab/imdevimab may be considered in seronegative patients on non-invasive ventilation (no data for invasive ventilation) 1
• High-titer convalescent plasma within 72 hours of symptom onset if monoclonal antibodies unavailable 1
• Prolonged viral replication is more common in this population 1

Common Pitfalls to Avoid

• Do not delay intubation if patients fail to respond to HFNC or CPAP within 1-2 hours 1
• Do not use corticosteroids in patients not requiring oxygen—this causes harm without benefit 1, 3
• HFNC and CPAP are aerosol-generating procedures—require full PPE for healthcare workers 1
• Do not use remdesivir in mechanically ventilated patients—no survival benefit demonstrated 1
• Ensure adequate oxygenation but avoid excessive oxygen—target SpO2 ≤96% 1

Adjunctive Supportive Measures

• Prone positioning for patients receiving invasive ventilation (reduces mortality) 1
• Early mobilization once oxygenation and hemodynamics stable 5
• Psychological support for patients and families experiencing anxiety, fear, or depression 3
• Rehabilitation care as soon as clinically appropriate 3