What is the appropriate management for a patient suspected of having COVID-19, considering various symptom severities and patient demographics?

COVID-19 Management

For patients suspected of having COVID-19, immediately perform RT-PCR testing (nasopharyngeal swab) as the diagnostic gold standard, implement isolation precautions until results are available, and treat all suspected cases as COVID-19 positive with full PPE protocols until definitively ruled out. 1

Diagnostic Approach

Testing Strategy

• RT-PCR nasopharyngeal swab remains the reference standard for definitive COVID-19 diagnosis and should be performed on all symptomatic patients with at least one respiratory symptom (fever, cough, shortness of breath) 1

• Sensitivity of RT-PCR is 97% (95% CI, 93-99%) with 100% specificity when using nasopharyngeal swabs, making false positives essentially non-existent 1

• Alternative specimen collection sites can be used when nasopharyngeal swabs are unavailable: anterior nasal (81% sensitivity), mid-turbinate (92% sensitivity), saliva (92% sensitivity), or oropharyngeal swabs (78% sensitivity) 1

• Chest imaging (X-ray, CT, or lung ultrasound) should NOT be used as first-line diagnostic tool when RT-PCR is available with timely results 1

• Use chest imaging for diagnosis only when: RT-PCR is unavailable, results are delayed, or initial RT-PCR is negative but clinical suspicion remains high 1

Critical Diagnostic Pitfalls

• A negative chest CT does not exclude COVID-19, especially in early infection stages 1

• Chest X-ray lacks sensitivity for early COVID-19 and should not be used for screening asymptomatic contacts 1

• If RT-PCR results are unavailable and surgery or urgent intervention is needed, treat the patient as COVID-19 positive with all mandatory infection control precautions 1

Isolation and Infection Control

Immediate Actions for Suspected Cases

• Isolate all suspected COVID-19 patients immediately in single-occupancy, well-ventilated rooms with restricted activity until RT-PCR results confirm or exclude diagnosis 2

• If single rooms unavailable, maintain minimum 1.1 meters (3.5 feet) distance between patients and cohort suspected cases separately from confirmed negatives 2

• All healthcare workers must use full PPE: N95 masks, goggles, double gloves, face shields, and protective gowns when caring for suspected or confirmed cases 2

Isolation Duration for Confirmed Cases

For immunocompetent patients, isolation ends after day 5 ONLY when ALL three criteria are met: 2

• Fever-free for at least 24 hours without antipyretic medications
• Symptoms are resolving or absent
• Ideally, negative rapid antigen test obtained

Extend isolation to 10 days if: 2

• Symptoms persist beyond day 5
• Fever continues
• Antigen testing remains positive

For immunocompromised patients, use individualized test-based strategies with longer isolation periods—do not apply standard 5-day criteria 2

Critical Isolation Pitfalls

• Never end isolation before day 5 regardless of symptom resolution 2

• Never use repeat RT-PCR testing to determine when to end isolation—patients can remain PCR-positive for weeks (even beyond 14 days) without being contagious 2

• Never apply standard isolation criteria to immunocompromised patients without case-by-case assessment 2

Risk Stratification and Triage

High-Risk Populations Requiring Priority Protection

Patients at highest risk for severe disease and death include: 3

• Age ≥65 years (especially ≥80 years with incidence of 902 per 100,000)
• Cardiovascular disease (present in 32% of hospitalized cases)
• Diabetes (30% of hospitalized cases)
• Chronic lung disease (18% of hospitalized cases)

Hospitalization rates are 6 times higher and death rates are 12 times higher in patients with underlying conditions compared to those without 3

Triage for Imaging and Hospital Admission

Use chest imaging to guide admission decisions for: 1

• Patients with high risk of disease progression (comorbidities, age >60)
• Those not responding to oxygen supplementation
• Patients with acute clinical deterioration
• Those living in overcrowded settings where isolation is difficult
• Patients living with high-risk individuals (elderly, immunocompromised)

Treatment Considerations

Antiviral Therapy

For hospitalized patients, administer remdesivir (VEKLURY): 4

• Loading dose: 200 mg IV on Day 1
• Maintenance: 100 mg IV daily from Day 2
• Duration for mechanical ventilation/ECMO: 10 days total
• Duration without mechanical ventilation: 5 days (extend to 10 days if no clinical improvement)

For non-hospitalized high-risk patients with mild-to-moderate disease: 4

• Initiate remdesivir within 7 days of symptom onset
• Total treatment duration: 3 days
• Must be at high risk for progression to severe disease

Before starting remdesivir, perform hepatic laboratory testing and assess prothrombin time; monitor during treatment 4

Treatment Contraindications

Do NOT coadminister remdesivir with chloroquine or hydroxychloroquine—antagonistic effect demonstrated in cell culture studies 4

Return to Normal Activities

Patients can return to work/school after meeting 10-day criterion plus symptom improvement and 24-hour fever resolution without antipyretics 2

After hospital discharge, confirmed cases should remain isolated for at least 2 weeks from first positive test and until negative RT-PCR obtained 2

Special Surgical Considerations

For emergency surgery in suspected COVID-19 patients: 1

• Complete COVID-19 screening (RT-PCR + chest imaging) before admission to operating room when possible
• Surgery cannot be postponed for immediate (Class 1) or urgent (Class 2, within 1 hour) cases even without RT-PCR confirmation
• Use dedicated COVID-19 operating room pathway with full PPE protocols
• Consider transfer to COVID-19 hub hospital if dedicated pathway unavailable and patient hemodynamically stable

Surgical indications are not different in COVID-19 positive patients, but morbidity and mortality rates are significantly higher compared to negative patients 1