Treatment of Coronavirus Disease 2019 (COVID-19)
For hospitalized COVID-19 patients requiring oxygen or ventilatory support, corticosteroids (dexamethasone 6 mg daily or methylprednisolone 40-80 mg daily) are strongly recommended, while patients not requiring supplemental oxygen should NOT receive corticosteroids. 1, 2
Risk Stratification and Monitoring
All hospitalized patients require continuous monitoring of:
- Vital signs (heart rate, oxygen saturation, respiratory rate, blood pressure) 2, 3
- Laboratory parameters: blood counts, CRP, procalcitonin, organ function tests, coagulation studies, arterial blood gases 2, 3
- Serial chest imaging to assess disease progression 2
Patients at highest risk for severe disease include elderly individuals and those with chronic comorbidities 1, 4
Oxygen Therapy and Respiratory Support (Escalating Algorithm)
The approach should be escalated based on oxygen requirements:
Standard oxygen therapy (nasal cannula or face mask) for SpO2 <90% or PaO2 <60 mmHg 1, 2
High-flow nasal cannula (HFNC) or noninvasive CPAP (via helmet or facemask) when standard oxygen fails or respiratory rate >30/min despite conventional oxygen 1, 2
Invasive mechanical ventilation for refractory hypoxemia 2, 3
ECMO for refractory hypoxemia unresponsive to protective lung ventilation strategies 1, 2, 3
Pharmacologic Treatment
Corticosteroids (STRONG RECOMMENDATION)
The European Respiratory Society strongly recommends corticosteroids for patients requiring oxygen or ventilatory support 1:
- Dexamethasone 6 mg daily is the evidence-based regimen from the RECOVERY trial, showing mortality reduction in mechanically ventilated patients (41.4% vs 29.3%) and those on supplemental oxygen (26.2% vs 23.3%) 1
- Alternative: Methylprednisolone 40-80 mg daily (not exceeding 2 mg/kg/day) 2, 3
- Duration: Typically 3-5 days based on clinical response 2, 3
- Do NOT use in patients not requiring supplemental oxygen (no mortality benefit demonstrated) 1
IL-6 Receptor Antagonists (CONDITIONAL RECOMMENDATION)
Consider IL-6 receptor antagonist monoclonal antibodies for hospitalized patients requiring oxygen or ventilatory support 1
- Do NOT offer to patients not requiring supplemental oxygen 1
Remdesivir (NO RECOMMENDATION FOR MOST PATIENTS)
No recommendation is made for remdesivir in hospitalized patients not requiring invasive mechanical ventilation 1, 5
- Suggest NOT offering remdesivir to patients on invasive mechanical ventilation 1
- If used, dosing: 200 mg loading dose on Day 1, then 100 mg daily maintenance (adults ≥40 kg) 5
Anticoagulation (STRONG RECOMMENDATION)
All hospitalized COVID-19 patients should receive prophylactic anticoagulation 1:
- Evaluate venous thromboembolism risk 2, 3
- Use low-molecular-weight heparin or unfractionated heparin in high-risk patients without contraindications 2, 3
Treatments NOT Recommended
The following should NOT be offered based on strong or conditional recommendations:
- Hydroxychloroquine (strong recommendation against) 1
- Azithromycin (unless bacterial co-infection documented) 1
- Hydroxychloroquine + azithromycin combination 1
- Lopinavir-ritonavir (strong recommendation against) 1
- Interferon-β 1
- Colchicine 1
Management of Bacterial Co-Infection
Avoid blind or inappropriate antibiotic use 2, 3:
- For mild cases with suspected bacterial infection: amoxicillin, azithromycin, or fluoroquinolones targeting community-acquired pneumonia 2, 3
- For severe cases: empirical broad-spectrum coverage with de-escalation once pathogen identified 3
- Perform bacteriological surveillance before initiating antibiotics 3
Nutritional Support
Protein-rich nutrition is essential for all hospitalized patients 2, 3:
- Nutrition risk score <3 points: 25-30 kcal/(kg·d) energy and 1.5 g/(kg·d) protein 2, 3
- Nutrition risk score ≥3 points: Add oral supplements 2-3 times daily (≥18g protein/time) 2, 3
- Consider enteral nutrition tube if oral intake insufficient 3
Symptomatic Management
- Fever >38.5°C: Ibuprofen 200 mg orally every 4-6 hours (maximum 4 times/24 hours) 2, 3
- Increased respiratory secretions: Selective M1/M3 receptor anticholinergic drugs to reduce secretions and improve ventilation 2, 3
- GI bleeding risk: H2 receptor antagonists or proton pump inhibitors 2, 3
Infection Control Precautions
Healthcare workers must implement strict standard precautions 1:
- Personal protective equipment (gloves, masks, goggles) 1
- Hand hygiene with soap or 2-3% hydrogen peroxide 1
- Environmental disinfection: 2-3% hydrogen peroxide spray, 2-5 g/L chlorine disinfectant, or 75% alcohol for surfaces 1
- Note: Chlorhexidine is ineffective against SARS-CoV-2 1
Discharge Criteria
Patients may be discharged when ALL of the following are met 2: