COVID-19 Management
For patients suspected of having COVID-19, immediately perform RT-PCR testing as the diagnostic gold standard, isolate the patient with full infection control precautions until results are available, and if RT-PCR is unavailable or delayed, use chest imaging (chest X-ray or lung ultrasound) to guide clinical decisions while treating the patient as COVID-19 positive. 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 suspected infection 1
Symptomatic patients are defined as having at least one common COVID-19 symptom: fever, cough, shortness of breath, or acute respiratory illness 1
RT-PCR has 97% sensitivity and 100% specificity in symptomatic patients, resulting in 1-15 false negatives per 1000 patients tested (depending on prevalence) but essentially no false positives 1
Specimen Collection Sites
Collect specimens from nasopharyngeal (NP), anterior nasal (AN), oropharyngeal (OP), mid-turbinate (MT) swabs, saliva, or mouth gargle - all are acceptable alternatives to NP swabs 1
NP swabs remain the reference standard, but AN swabs and saliva show 81-92% sensitivity compared to NP, making them reasonable alternatives when NP collection is not feasible 1
Role of Chest Imaging
Do NOT use chest imaging as a first-line diagnostic test when RT-PCR is available with timely results 1
Use chest imaging (chest X-ray, lung ultrasound, or CT) when: 1
- RT-PCR is unavailable
- RT-PCR results are delayed beyond clinical decision-making timeframes
- Initial RT-PCR is negative but clinical suspicion remains high
- Patient requires hospitalization and you need to assess disease severity
- Patient has complications like pneumonia or pulmonary embolism
Chest X-ray lacks sensitivity for early COVID-19 and cannot detect subtle ground-glass opacities, making it inadequate for screening asymptomatic contacts 1
Negative chest CT does NOT exclude COVID-19, especially in early infection stages 1
Isolation and Infection Control
Immediate Actions for Suspected Cases
Treat all suspected COVID-19 patients as positive until proven otherwise - implement full infection control precautions immediately, do not wait for test results 1
Place patients in single-occupancy, well-ventilated rooms with restricted activity; if unavailable, maintain at least 1.1 meters (3.5 feet) distance between beds 2
Patients must wear medical masks (N95 preferred) when in the presence of others, including household members 2
Healthcare Worker Protection
All healthcare workers require trained use of adequate PPE: N95 masks, goggles, double gloves, face shields, and protective gowns when caring for suspected or confirmed COVID-19 patients 2
Avoid aerosol-generating procedures when possible; if necessary, perform with extreme caution and enhanced PPE 1
Isolation Duration for Confirmed Cases
Minimum 5-day isolation from symptom onset or positive test, but isolation can only end when ALL of the following are met: 2
- Fever-free for at least 24 hours without antipyretic medications
- Symptoms are resolving or absent
- Ideally, a negative rapid antigen test is obtained
Extend isolation to 10 days if symptoms persist, fever continues, or antigen testing remains positive 2
Do NOT 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
Special Populations
Immunocompromised patients require individualized assessment - do not apply standard 5-10 day criteria; they need longer isolation and potentially test-based strategies 2
After hospital discharge, confirmed cases should remain isolated for at least 2 weeks from the first positive test and until a negative RT-PCR is obtained 2
Risk Stratification and Cohorting
When Isolation Capacity Is Limited
Prioritize single-room isolation for high-risk patients (elderly, immunocompromised, those with diabetes, hypertension, heart disease, obesity, or chronic diseases) who are suspected but not confirmed COVID-19 positive 1, 3
Cohort low-risk suspected COVID-19 patients together when single rooms are unavailable, but never cohort high-risk uninfected patients with suspected cases 3
Transfer hemodynamically stable suspected patients to designated COVID-19 hub hospitals if your facility lacks dedicated pathways for COVID-19 management 1
Treatment Considerations
Antiviral Therapy (Remdesivir)
Remdesivir (VEKLURY) is FDA-approved for hospitalized COVID-19 patients and non-hospitalized patients with mild-to-moderate disease at high risk for progression 4
Dosing for adults and pediatric patients ≥40 kg: 200 mg IV loading dose on Day 1, then 100 mg IV daily 4
Treatment duration: 4
- Hospitalized patients on mechanical ventilation/ECMO: 10 days
- Hospitalized patients not on mechanical ventilation: 5 days (extend to 10 days if no clinical improvement)
- Non-hospitalized high-risk patients: 3 days (must start within 7 days of symptom onset)
Perform hepatic laboratory testing before starting and during treatment; discontinue if ALT >10× upper limit of normal or if elevation is accompanied by signs of liver inflammation 4
Critical Pitfalls to Avoid
Never end isolation before day 5 regardless of symptom resolution 2
Never rely solely on chest imaging to diagnose COVID-19 when RT-PCR is available 1
Never use repeat PCR testing routinely to clear isolation - this wastes resources and inappropriately prolongs isolation 2
Never manage suspected COVID-19 patients without full PPE until diagnosis is definitively ruled out 2
Never cohort high-risk uninfected patients with suspected COVID-19 cases - this dramatically increases their risk of severe disease and death 3
Never delay urgent or emergent surgery (TACS class 1 or 2) waiting for COVID-19 test results - proceed with full infection control precautions 1