What is the recommended workup and treatment for an inpatient with suspected COVID-19 (Coronavirus Disease 2019)?

Inpatient COVID-19 Workup

For hospitalized patients with suspected COVID-19, obtain RT-PCR testing immediately, perform a thorough history focusing on fever, respiratory symptoms, and GI manifestations, conduct a detailed chest examination, obtain baseline liver function tests, initiate prophylactic anticoagulation, and obtain chest imaging to assess disease severity and guide disposition decisions. 1

Initial Diagnostic Workup

History and Physical Examination

• Obtain a comprehensive symptom history including fever, cough, shortness of breath, chills, muscle pain, headache, sore throat, new loss of taste or smell (anosmia has the highest positive likelihood ratio at 7.58 for COVID-19 diagnosis) 2, 3
• Document gastrointestinal symptoms thoroughly including nausea, vomiting, abdominal pain, and diarrhea, noting onset, characteristics, duration, and severity, as GI symptoms may precede respiratory symptoms by several days 2
• Perform a careful chest examination with particular attention to respiratory findings 2
• Measure oxygen saturation and respiratory rate to classify disease severity 1

Laboratory Testing

• Obtain RT-PCR testing for SARS-CoV-2 as the primary diagnostic modality 2
• Obtain baseline liver function tests (LFTs) at admission and monitor throughout hospitalization, particularly if drug treatment for COVID-19 is initiated 2
• Evaluate for alternative etiologies if LFTs are elevated 2
• Determine prothrombin time before starting remdesivir and monitor as clinically appropriate 4
• Stool testing is NOT recommended for routine diagnosis or monitoring of COVID-19 2

Imaging Studies

• Obtain chest imaging (CT or chest x-ray) when RT-PCR is unavailable, results are delayed, or initial RT-PCR is negative with high clinical suspicion 2
• Use chest imaging to guide hospital admission decisions for patients with mild symptoms, particularly those at high risk of disease progression or who represent increased dissemination risk 2
• Bilateral B lines on lung ultrasonography have a positive likelihood ratio of 7.09 for COVID-19 diagnosis 3

Disease Severity Classification

Classify patients into severity categories to guide treatment decisions: 1

• Moderate disease: SpO2 ≥94% on room air with evidence of lower respiratory disease
• Severe disease: SpO2 <94% on room air
• Critical disease: ICU admission criteria, mechanical ventilation requirement, ARDS, or septic shock

Treatment Initiation

Antiviral Therapy

• For moderate COVID-19, initiate remdesivir with a loading dose of 200 mg IV on Day 1, followed by 100 mg IV daily from Day 2 1, 4
• Treatment duration is 5 days for hospitalized patients not requiring invasive mechanical ventilation/ECMO, extendable to 10 days if no clinical improvement 4
• For patients requiring invasive mechanical ventilation/ECMO, use 10 days of remdesivir 4
• Monitor hepatic function during remdesivir therapy 1, 4

Corticosteroid Therapy

• Administer dexamethasone 6 mg daily for 10 days for patients requiring supplemental oxygen 1
• DO NOT use corticosteroids in patients not requiring oxygen, as this can be harmful 1

Anticoagulation

• Initiate prophylactic-dose LMWH for all hospitalized COVID-19 patients as soon as possible, with dosing adjusted for renal function, bleeding risk, and weight 1
• For patients on DAPT for recent ACS receiving prophylactic anticoagulation, continue DAPT 2
• For new-onset atrial fibrillation in hospitalized patients, start therapeutic-dose parenteral anticoagulation irrespective of CHA2DS2-VASc score 2

Antibiotic Stewardship

• Do NOT routinely prescribe antibiotics for COVID-19 1
• Reserve antibiotics only when clinically justified based on disease manifestations, severity, imaging findings suggesting bacterial superinfection, and laboratory data 1

Infection Control Measures

• Isolate confirmed COVID-19 patients from negative patients 1
• Healthcare workers must use complete PPE with proper training 1
• Report suspected cases immediately to the infection control officer 2
• Perform hand hygiene after each patient contact with 2-3% hydrogen peroxide solution or soap and water 2

Monitoring for Complications

Monitor for common complications including: 1

• ARDS
• Shock
• Myocardial dysfunction
• Acute kidney injury
• Arrhythmia
• Secondary bacterial/fungal infections

Critical Pitfalls to Avoid

• Never delay anticoagulation in hospitalized COVID-19 patients 1
• Never give corticosteroids to patients not requiring oxygen 1
• Never routinely prescribe antibiotics without clinical justification 1
• Never use biomarkers alone to decide antibiotic initiation 1
• Never forget hepatic monitoring with remdesivir therapy 1