How should I manage a confirmed adult with mild COVID-19 presenting with low-grade fever, cough, sore throat, mild fatigue, normal oxygen saturation (≥94% on room air) and no pneumonia, including supportive care and antiviral therapy for high-risk comorbidities?

Management of Mild COVID-19 in Adults

For adults with confirmed mild COVID-19 (normal oxygen saturation ≥94%, no pneumonia), management centers on symptomatic care at home with close monitoring, while antiviral therapy with nirmatrelvir/ritonavir should be initiated immediately for high-risk patients within 5 days of symptom onset. 1, 2, 3

Risk Stratification and Treatment Decision

• High-risk patients require antiviral therapy even with mild symptoms, defined as those with comorbidities (diabetes, cardiovascular disease, chronic lung disease, immunosuppression) or age ≥60 years 2
• Nirmatrelvir/ritonavir (Paxlovid) is the superior antiviral choice for non-hospitalized high-risk patients, demonstrating 87% reduction in hospitalization or death 2
• Treatment must begin within 5 days of symptom onset to achieve therapeutic benefit, even if baseline symptoms remain mild 3
• The standard dose is 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) taken together orally twice daily for 5 days 3

Critical Drug Interaction Warning

• Before prescribing nirmatrelvir/ritonavir, review ALL patient medications for potential interactions with strong CYP3A inhibitors, as ritonavir can cause severe, life-threatening drug interactions 3
• Certain medications require dose adjustment, temporary discontinuation, or additional monitoring during the 5-day treatment course 3

Symptomatic Management

Fever Control

• Paracetamol (acetaminophen) is preferred over NSAIDs for fever and symptom relief 1, 2
• Advise patients to take paracetamol only while fever and symptoms are present, not routinely to reduce temperature 1
• Fever typically peaks around day 5 after exposure, requiring close monitoring during this critical period 1

Cough Management

• Honey is recommended as first-line treatment for cough in adults 1
• Patients should avoid lying flat on their back, as this makes coughing ineffective 1
• If cough becomes distressing despite simple measures, consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1

Breathlessness Management

• Teach controlled breathing techniques, including pursed-lip breathing 1, 2
• Positioning is crucial: sitting upright increases peak ventilation, and leaning forward with arms bracing improves ventilatory capacity 1, 2
• Relaxing and dropping shoulders reduces anxiety-related hunched posture that worsens breathlessness 1

Hydration and Nutrition

• Ensure adequate hydration with regular fluid intake, limited to no more than 2 liters per day 1, 2
• Adequate nutritional support with protein-rich foods is important, with ideal energy intake of 25-30 kcal/(kg·day) and protein intake of 1.5 g/(kg·day) 1
• Bed rest is recommended during the acute phase 1

Monitoring and Red Flags

• Establish a treatment escalation plan immediately, as COVID-19 patients can deteriorate rapidly and require urgent hospital admission 1
• Monitor vital signs including heart rate, pulse oximetry, respiratory rate, and blood pressure 1
• Instruct patients to seek immediate medical attention if they develop:
  • Worsening breathlessness 1
  • Persistent chest pain 1
  • Confusion or inability to stay awake 1
  • Oxygen saturation <94% on room air 1

Antibiotic Use

• Avoid blind antibiotic use unless there is clear evidence of secondary bacterial infection 4, 1
• Routine antibiotics are NOT recommended for COVID-19 patients without clinical justification such as elevated white blood cell count, elevated C-reactive protein, or procalcitonin >0.5 ng/mL 4
• If antibiotics are considered necessary, perform comprehensive microbiologic workup before administration to facilitate adjustment or discontinuation 4

Isolation and Infection Control

• Complete the full 5-day treatment course (if on antivirals) and continue isolation in accordance with public health recommendations to maximize viral clearance and minimize SARS-CoV-2 transmission 3
• Hand hygiene is fundamental to prevent contamination and transmission 5

Treatments to Avoid

• Do NOT use hydroxychloroquine, as it may increase risk of death and invasive mechanical ventilation without improving outcomes 2
• Do NOT combine three or more antiviral drugs simultaneously due to increased risk of adverse effects 2
• Avoid azithromycin with hydroxychloroquine due to additive QT prolongation risk 2
• Do NOT routinely administer corticosteroids in mild COVID-19, as their use in viral pneumonia has been found to exacerbate infection and increase mortality rates 4

Special Considerations for Renal Impairment

• No dose adjustment needed for mild renal impairment (eGFR ≥60 to <90 mL/min) 3
• For moderate renal impairment (eGFR ≥30 to <60 mL/min): reduce to 150 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days 3
• For severe renal impairment (eGFR <30 mL/min): 300 mg nirmatrelvir with 100 mg ritonavir once on day 1, then 150 mg nirmatrelvir with 100 mg ritonavir once daily on days 2-5 3