What is the recommended evaluation and management for an adult with suspected or confirmed COVID‑19, including polymerase chain reaction (PCR) or rapid antigen testing, isolation, vaccination, supportive care, antiviral therapy for high‑risk patients, and treatment of moderate to severe disease?

COVID-19: Evaluation and Management in Adults

Diagnostic Testing

For symptomatic adults with suspected COVID-19, perform RT-PCR testing on nasopharyngeal or naso-oropharyngeal swabs as the primary diagnostic method, with rapid antigen testing reserved for point-of-care situations requiring immediate results. 1

Testing Strategy by Clinical Context

• Symptomatic patients: RT-PCR remains the gold standard with highest sensitivity and specificity 1

  • Nasopharyngeal or naso-oropharyngeal swabs are the preferred sample sites 1
  • Molecular assays should target at least two distinct viral gene sequences 1

• Rapid antigen testing can be used when:

  • RT-PCR is unavailable or results are delayed 1
  • Immediate clinical decisions are required 1
  • Initial RT-PCR is negative but clinical suspicion remains high 1
  • Important caveat: Positive rapid antigen tests in low-prevalence settings require molecular confirmation due to high false-positive rates 2, 3

• Sensitivity considerations:

  • Antigen tests show 73.0% sensitivity in symptomatic patients (highest at 80.9% in first week of symptoms) versus 54.7% in asymptomatic individuals 2
  • Sensitivity declines significantly after the first week of symptoms (53.8%) as viral loads decrease 2
  • WHO minimum standards require 80% sensitivity and 97% specificity 3

Isolation Guidance

Isolate infected patients for at least 5 days, with isolation ending only if symptoms are resolving, fever has been absent for ≥24 hours without medications, and ideally a rapid antigen test is negative. 4, 5

• After 5-9 days of isolation, 54.3% of persons still test positive on antigen testing, with declining positivity over time 4

• Factors associated with prolonged antigen positivity include:

  • Earlier testing (day 5 versus day 9) 4
  • Symptomatic infection 4
  • Lack of prior vaccination or previous infection 4

• Patients should wear well-fitting masks when around others for 10 days after infection, even if isolation ends after 5 days 4, 5

Vaccination

All adults should receive a complete COVID-19 vaccination series with the most immediately available locally approved vaccine, as vaccination substantially reduces risk for severe illness, hospitalization, and death. 1, 5

• Vaccination reduces the risk of medically significant COVID-19 illness and is a cornerstone of prevention strategy 5
• For immunocompromised patients (including those with hematological malignancies), full vaccination programs are recommended despite potentially lower response rates 1
• Follow CDC or local health authority guidelines for vaccination schedules 1

Risk Stratification for Severe Disease

Identify high-risk patients requiring closer monitoring and early therapeutic intervention based on age >60 years, comorbidities (diabetes, hypertension, heart disease, obesity, chronic lung disease), immunocompromised status, and elevated inflammatory markers. 1, 5

• The ISARIC risk prediction tool incorporates: increased age, male sex, number of comorbidities, increased respiratory rate, low oxygen saturations, Glasgow coma scale, elevated urea and C-reactive protein 1
• Risk for medically significant illness increases with age, disability status, and underlying medical conditions 5

Chest Imaging

Do not routinely use chest imaging for diagnosis when RT-PCR is available with timely results; reserve imaging for patients requiring hospitalization decisions, those with suspected complications, or when RT-PCR is unavailable or delayed. 1

Specific Indications for Chest Imaging:

• For diagnostic workup when:

  • RT-PCR unavailable or results delayed 1
  • Initial RT-PCR negative but high clinical suspicion persists 1
  • Presentations suggest complications (pneumonia, pulmonary thromboembolism) 1

• For hospitalization decisions:

  • Patients with mild symptoms at high risk of progression (comorbidities, age >60, immunocompromised) 1
  • Deciding between regular ward versus ICU admission 1
  • Patients not responding to oxygen supplementation 1

• Chest radiography versus CT: Radiography has lower sensitivity but higher specificity than CT, is less resource-intensive, and is preferred in most settings 1

Treatment Considerations

Supportive Care

Provide supplemental oxygen to maintain SpO2 ≥95%, with escalation to noninvasive or invasive ventilation as clinically indicated. 1

• Monitor oxygen saturation continuously in hospitalized patients 1
• Consider noninvasive ventilation methods before intubation when appropriate 1

Antiviral and Immunomodulatory Therapy

For high-risk patients with COVID-19, initiate available antiviral therapies early in the disease course (first week of symptoms when viral loads are highest), considering concurrent medications and drug-drug interactions. 1

• Treatment decisions should account for:
  • Timing of illness (antivirals most effective early; immunomodulators may benefit later inflammatory phase) 1
  • Individual patient risk factors 5
  • Available therapeutic options in your setting 1

Special Populations

For immunocompromised patients (including those with hematological malignancies or on immunosuppressive therapy), temporarily discontinue immunosuppressive treatments during active COVID-19 until clinical resolution with RT-PCR clearance. 1

• Consider preexposure prophylaxis with monoclonal antibodies for immunocompromised patients when available 5
• Defer cellular therapies (HSCT, CAR-T) in patients with active COVID-19 or persistent viral shedding 1
• Continue JAK2-inhibitors and TKI/BTKi during infection 1

Thromboprophylaxis

Administer thromboprophylaxis with appropriate heparin dosing to all hospitalized COVID-19 patients, considering both COVID-19-associated hypercoagulability and underlying disease risks. 1

• COVID-19 is associated with increased thromboembolic complications 1
• Dosing should follow current recommendations accounting for both COVID-19 and patient-specific risk factors 1

Monitoring During Hospitalization

• Daily assessment of temperature and COVID-19-associated symptoms 1
• Regular monitoring of oxygen saturation 1
• Laboratory monitoring including complete blood count, coagulation studies, and inflammatory markers as clinically indicated 1
• Repeat SARS-CoV-2 testing for decisions regarding discontinuation of isolation precautions 1
  • Ct-values >30 associated with low/absent transmission risk (with adequate sampling quality) 1

Infection Control

Isolate COVID-19 positive patients in single rooms with appropriate personal protective equipment for healthcare workers; negative pressure rooms are preferred but positive pressure rooms should be avoided. 1

• Healthcare personnel require appropriate PPE when caring for SARS-CoV-2 positive patients 1
• Hand hygiene, face masks, distancing, and room ventilation are essential 1

Discharge Planning

Do not routinely use chest imaging to inform discharge decisions for hospitalized patients whose symptoms have resolved; base discharge on clinical and laboratory assessment. 1

• Exception: Consider imaging for patients who had severe COVID-19 or pre-existing chronic lung disease 1