What are the guidelines for Covid-19 isolation and treatment?

COVID-19 Isolation Guidelines

Core Isolation Duration

Individuals with COVID-19 should isolate for at least 5 days from symptom onset or positive test, and may end isolation when fever has been absent for at least 24 hours without fever-reducing medications, symptoms are resolving or absent, and ideally after a negative rapid antigen test. 1

• The minimum isolation period is 5 days from symptom onset, with the option to end isolation if specific clinical criteria are met 1
• Extended isolation up to 10 days is recommended if symptoms persist, fever continues, or antigen testing remains positive 1
• For hospitalized patients requiring invasive mechanical ventilation and/or ECMO, the recommended total treatment duration is 10 days 2
• For hospitalized patients not requiring invasive mechanical ventilation and/or ECMO, the recommended treatment duration is 5 days, with possible extension up to 5 additional days (total 10 days) if clinical improvement is not demonstrated 2

Isolation Setting Requirements

Patients should be placed in well-ventilated single rooms with restricted activity to minimize contact with others. 1

• If single rooms are unavailable, maintain at least 1.1 meters (approximately 3.5 feet) bed distance from others 1
• Ensure adequate ventilation by opening windows when possible 1
• Patients should wear a medical mask (N95 preferred) when in the presence of others, including household members 1

Testing to Guide Isolation Decisions

A negative rapid antigen test is a reliable indicator that an individual is no longer producing infectious virus and may end isolation. 3

• Rapid antigen testing is recommended for symptomatic individuals within 5 days of symptom onset for optimal performance 1
• A positive antigen test has high specificity and can guide isolation decisions without confirmation 1
• Research shows that viral clearance is first determined by infectious virus assay, followed by rapid antigen test negativity, then PCR negativity—supporting the use of antigen tests to determine when isolation can end 3
• After 5-9 days of isolation, approximately 54% of individuals still test positive on antigen tests, with declining positivity over time 4
• Repeat PCR testing is NOT recommended to guide discontinuation of isolation in most circumstances, as PCR can remain positive long after infectious virus is cleared 1, 5

Special Populations Requiring Extended Isolation

Immunocompromised patients with COVID-19 should undergo extended isolation of at least 20 or more days following symptom onset, as prolonged viral shedding occurs in this population. 6

• For severely ill patients or those on immunosuppressive medications, a case-by-case approach to isolation duration is recommended, potentially extending beyond 10 days 1, 7
• Surgical COVID-19 patients should remain isolated for at least 2 weeks from first positive test until negative RT-PCR is obtained 7
• Healthcare workers and those in high-risk settings may require negative testing before return to work 7

Patient Monitoring During Isolation

Patients should monitor body temperature and symptoms daily, and seek immediate medical attention if temperature exceeds 38°C (100.4°F) persistently, breathing worsens, or signs of pneumonia appear. 1

• Patients should clean hands immediately after coughing, sneezing, or touching potentially contaminated surfaces 1
• Patients should avoid sharing personal items such as toothbrushes, towels, tableware, and bed linens 1

Caregiver Precautions

Caregivers must wear N95 masks (preferred) or surgical masks (alternative) when in the same room as the patient. 1

• Caregivers should be healthy individuals without underlying diseases when possible 1
• Caregivers should monitor their own body temperature and symptoms closely 1
• Caregivers should avoid direct contact with patient's secretions, especially respiratory discharges 1
• Caregivers should clean and disinfect frequently touched surfaces using 500 mg/L chlorine-containing disinfectant daily 1

Discharge and Re-isolation Criteria

For complete hospital discharge, patients require normal temperature for more than 3 days without fever-reducing medications, significantly improved respiratory symptoms, substantially improved acute lesions on chest CT, and two consecutive negative RT-PCR tests with at least 1-day interval. 6, 7

• If RT-PCR reverts from negative to positive after discharge, patients should be isolated again and may be re-hospitalized based on clinical characteristics 6
• For retested positive patients after discharge, if lung imaging shows no progressive change compared to first discharge and patients have three negative RT-PCR tests from sputum and fecal specimens (each ≥24 hours apart, with at least one from fecal test), patients can be managed with home isolation and follow-up 6
• The median duration from hospital discharge to positive retest is approximately 14-15 days 6

Treatment Considerations

For non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression, treatment with remdesivir (VEKLURY) should be initiated as soon as possible after diagnosis and within 7 days of symptom onset, with a recommended total treatment duration of 3 days. 2

• The recommended dosage for adults and pediatric patients weighing at least 40 kg is a single loading dose of 200 mg on Day 1 followed by once-daily maintenance doses of 100 mg from Day 2 2
• Treatment should be initiated as soon as possible after diagnosis, as delayed initiation (up to 5 days after symptom onset) may reduce treatment effectiveness 3

Common Pitfalls to Avoid

• Do not rely on PCR testing to determine end of isolation—PCR can remain positive for weeks after infectious virus is cleared, leading to unnecessarily prolonged isolation 5, 8
• Do not use a one-size-fits-all 10-day isolation for all patients—this results in 4.8-8.3 days of unnecessary isolation for many patients who are no longer infectious 8
• Do not discharge immunocompromised patients after standard 5-10 day isolation—these patients require extended isolation of at least 20 days due to prolonged viral shedding 6
• Do not assume symptom resolution equals loss of infectiousness—symptom resolution lags behind viral clearance by several days 3