What are the current recommendations for diagnosing, treating, and managing contacts of COVID-19 (Coronavirus Disease 2019) patients?

COVID-19: Current Recommendations for Diagnosis, Treatment, and Contact Management

Diagnosis

RT-PCR nasopharyngeal swab testing remains the gold standard for COVID-19 diagnosis, but a negative test does not rule out infection in patients with high clinical suspicion—repeat testing combined with chest imaging is essential in these cases. 1

Primary Diagnostic Approach

• Perform RT-PCR testing on nasopharyngeal specimens as the first-line diagnostic method, targeting at least two distinct viral gene sequences for optimal accuracy 1
• Nasopharyngeal samples are superior to oropharyngeal samples in early disease stages 1
• A positive RT-PCR from any anatomical source confirms SARS-CoV-2 infection, but false-negatives occur due to timing of sample collection, improper sampling technique, or missing the viral replication window 1, 2

When Initial Testing is Negative but Suspicion Remains High

• Repeat nasopharyngeal RT-PCR testing and add chest imaging (CT preferred, chest X-ray if CT unavailable) to confirm diagnosis and assess pneumonia severity 1
• Consider lower respiratory tract sampling (tracheal aspirate, bronchoalveolar lavage) in patients with negative upper respiratory specimens but signs of lower respiratory tract infection 1
• Chest CT scan is the most accurate radiological tool for uncertain cases 1
• Lung ultrasound can serve as a first-line screening tool when performed by skilled operators with limited CT access, helping discriminate low-risk from high-risk patients 1

Rapid Testing Alternatives

• Rapid antigen testing validated for circulating variants can be used for point-of-care diagnosis but must be confirmed by RT-PCR, particularly if negative in high-suspicion cases 1, 2
• Positive antigen tests have high specificity and can guide isolation decisions without confirmation 3

Testing to Avoid

• Do not use serological antibody assays for diagnosing acute COVID-19 infection—these are unreliable in the acute phase and should only be used for epidemiologic purposes or assessing prior exposure 1, 2, 4
• Do not test SARS-CoV-2 RNA in blood for initial diagnosis 1

Treatment

Antiviral Therapy: Remdesivir (VEKLURY)

Remdesivir is FDA-approved for hospitalized patients and high-risk non-hospitalized patients with mild-to-moderate COVID-19, with treatment initiated as soon as possible after diagnosis. 5

Dosing for Adults and Pediatric Patients ≥40 kg:

• Loading dose: 200 mg IV on Day 1
• Maintenance dose: 100 mg IV once daily from Day 2 5

Treatment Duration:

• Hospitalized patients on mechanical ventilation/ECMO: 10 days total 5
• Hospitalized patients NOT on mechanical ventilation/ECMO: 5 days (may extend up to 10 days if no clinical improvement) 5
• Non-hospitalized high-risk patients with mild-to-moderate disease: 3 days total, initiated within 7 days of symptom onset 5

Administration Requirements:

• Administer via IV infusion over 30-120 minutes 5
• Must be given in settings with immediate access to medications for treating anaphylaxis and ability to activate emergency medical services 5
• Perform hepatic laboratory testing and prothrombin time before starting and monitor during treatment 5

Key Safety Considerations:

• Discontinue if ALT elevation >10× upper limit of normal or if accompanied by signs of liver inflammation 5
• Monitor for hypersensitivity reactions during and for at least one hour after infusion 5
• Do not coadminister with chloroquine or hydroxychloroquine due to potential antagonistic effects 5

Antibiotic Stewardship

Routine antibiotics are NOT recommended for COVID-19 patients—prescribe only based on clinical justification such as disease severity, radiographic findings, and laboratory evidence of bacterial coinfection. 1

• Perform comprehensive microbiologic workup before starting empirical antibiotics to facilitate de-escalation 1
• Critically ill patients (ICU admission, mechanical ventilation) have higher risk of bacterial coinfection and may require antibiotics 1
• Higher WBC counts, elevated CRP, or procalcitonin >0.5 ng/mL suggest possible bacterial coinfection, but do not use biomarkers alone to initiate antibiotics in non-critically ill patients 1
• Do not routinely prescribe antibiotics for patients receiving immunomodulatory agents (corticosteroids, IL-6 inhibitors) given weak evidence of increased bacterial infection risk 1

Supportive Care Priorities

• Use H2 receptor antagonists or proton pump inhibitors in patients with gastrointestinal bleeding risk factors (mechanical ventilation ≥48 hours, coagulation dysfunction, renal replacement therapy) 1
• Assess venous thromboembolism risk and use low-molecular-weight heparin in high-risk patients without contraindications 1
• Provide nutritional support with protein-rich foods targeting 25-30 kcal/(kg·d) and 1.5 g/(kg·d) protein 1

Contact Management and Isolation

Isolation can end after at least 5 days from symptom onset when fever has been absent for 24 hours without antipyretics, symptoms are resolving, and ideally after a negative rapid antigen test. 3

Standard Isolation Criteria (Minimum Requirements):

• At least 5 days from symptom onset or positive test 3
• Fever-free for 24 hours without fever-reducing medications 3
• Symptoms resolving or absent 3
• Negative rapid antigen test (ideally) 3

Extended Isolation Indications:

• Extend isolation up to 10 days if symptoms persist, fever continues, or antigen testing remains positive 3

Isolation Environment Requirements:

• Place patients in well-ventilated single rooms with restricted activity 3
• If single rooms unavailable, maintain at least 1.1 meters (3.5 feet) distance from others 3
• Patients must wear medical masks (N95 preferred) when in presence of others 3
• Implement hand hygiene immediately after coughing, sneezing, or touching contaminated surfaces 1, 3

Special Populations:

• Immunocompromised patients and those with severe COVID-19 require case-by-case assessment rather than standard criteria 3
• Hospitalized/surgical patients after discharge: isolate for at least 2 weeks from first positive test and until negative RT-PCR obtained 3
• Some settings require two consecutive negative RT-PCR tests at least 1 day apart for complete clearance 3

Critical Pitfall to Avoid:

Do NOT use repeat PCR testing routinely to determine when to end isolation—patients can show positive RT-PCR tests after 14 days despite no longer being contagious 3

Healthcare Worker and Contact Precautions:

• Healthcare personnel caring for COVID-19 patients must use personal protective equipment and implement isolation in single rooms 1
• Do not place COVID-19 positive patients in positive pressure rooms 1