• Infectious disease caused by SARS-CoV2 virus 
  • can be complicated by severe respiratory impairment but can involve almost any body system
• Follow appropriate infection prevention measures in patients with confirmed or suspected COVID-19 infection
• Guidance, treatment and infection prevention strategies are regularly updated and affected by prevalence of COVID-19 and region - the latest local policies must be consulted

Symptoms and signs

• No single symptom/sign is diagnostic for COVID-19, and neither does the absence of any features rule out disease
• Contact with probable/confirmed case - although this may not be apparent
• Fever
• Flu like symptoms
  
  • myalgia and arthralgia
  • headache
  • sore throat
  • fatigue, malaise and anorexia
  • sneezing and nasal congestion
• Cough
  
  • dry/productive/haemoptysis
• Breathlessness
• Altered sense of smell/taste
• Chest pain and tightness
• Confusion and delirium
• Rash
  
  • chilblains, urticaria

High risk characteristics

• Older age - aged ≥65 yr
• Male sex
• Ethnicity
• Obesity
• Unvaccinated
• Other comorbidities e.g.:
  
  • Cancer
  • cardiovascular disease
  • chronic diseases of kidney, liver and lungs
  • diabetes
• Immunosuppression
• Solid organ transplant
• Disability
• Frailty
• Pregnancy

Investigations

• FBC, U&E, LFT, CRP, blood glucose
  
  • lymphopenia, leukocytosis, and thrombocytopenia may be present
  • high neutrophil-to-lymphocyte ratio
• Real-time-reverse transcriptase polymerase chain reaction (RT-PCR)
  
  • positive RT-PCR confirms COVID-19
  • if COVID-19 still clinically suspected, repeat 24-48 hr later
• Procalcitonin
  
  • biomarker specific for bacterial infection that can support suspicion of secondary infection
• Extended spectrum respiratory atypical pneumonia swab
• Blood and sputum cultures
• PA chest X-ray
  
  • ground-glass opacification; consolidation

• Community-acquired pneumonia
• Other viral infections
  
  • Influenza
  • RSV
  • common cold
  • MERS
  • avian flu
• Pneumocystis jirovecii pneumonia
  
  • especially in presence of immunosuppression or HIV
  • send sputum culture
• Febrile neutropenia

• Manage patient at home unless:
  
  • oxygen is required to maintain target saturations SpO₂ ≥92%, ≥93% if pregnant unless risk of type 2 (hypercapnic)
  • respiratory failure then target SpO₂ 88-92% 
  • respiratory rate (RR) ≥30 breaths/min (bpm) and using accessory muscles
  • another medical condition or care issue necessitates admission
  • high risk of deterioration and observation required - consider Virtual Oximetry@Home service

Infection prevention

• Provide isolation advice at home or healthcare institution on discharge

Management of breathlessness

• If severe shortness of breathlessness occurs implement escalation plan - see below
• Change body position
• Lying prone

Management of fever

• Paracetamol 1 g oral 6-hrly
• Ibuprofen 200-400 mg oral 8 hrly - only to be used at lowest effective dose for shortest period to control symptoms
• Encourage adequate fluid intake
• Only commence antibiotics if additional bacterial infection suspected

Management of cough

• Avoid lying on back
  
  • less effective cough

Observe for signs of deterioration

• Advise patient and carers to observe for signs of deterioration that necessitate implementing escalation plan
  severe shortness of breath 
  
  • coughing blood
  • blue lips or face
  • feeling cold and clammy
  • pale and mottled skin
  • collapse or faint and difficult to rouse
  • new confusion
  • reduced urine output

Virtual Oximetry@Home Service

Refer patients with confirmed COVID-19 infection who can be managed in the community with high risk characteristics and at risk of deterioration, but do not currently require oxygen, to the Virtual Oximetry@Home Service for monitoring of oxygen saturation 

• Inclusion criteria 
  
  • confirmed COVID-19 infection
  • patient registered with GP in Stoke-on-Trent or Staffordshire area
  • aged ≥65 yr OR aged <65 yr and felt to be clinically vulnerable to COVID-19
  • patient maintaining saturations on air of ≥95% on discharge
• Exclusion criteria
  
  • service is for monitoring oxygen sats only, and not equipped to look after other active medical problems
• To refer to Virtual Oximetry@Home Service call Community Rapid Intervention Service (CRIS) on-call 0300 1230983, or send a referral email with patient details to [email protected]

COVID-19 treatments to prevent severe disease

Initiated as soon as possible after SARS-CoV-2 positive result and within 5 days of symptom onset. Indicated if:

• Patient does not need oxygen
• Increased risk for progression to severe COVID-19, see section 5 of NICE’s technology appraisal - guidance on nirmatrelvir
• Diabetes
• Heart failure

Nirmatrelvir and ritonavir (Paxlovid™)

• Firstline
• If confirmed/suspected co-infection with HIV 1, discuss with microbiology and infectious disease consultant
• For patients either of:
  
  • aged ≥70 yr or
  • BMI ≥35 kg/m²
• Nirmatrelvir 300 mg (two pink tablets) and ritonavir 100 mg (one white tablet) twice daily for 5 days, to be taken together
  
  • reduce dose to 150 mg nirmatrelvir (one pink tablet) and 100 mg ritonavir (one white tablet) twice daily in moderate renal impairment (eGFR 30-60 mL/min)
• Avoid:
  
  • if severe renal impairment (eGFR <30 mL/min)
  • if severe hepatic failure
  • in pregnancy
  • if solid organ transplant patient - discuss with appropriate transplant centre
• Do not breastfeed during treatment and until 7 days after last dose

Remdesivir

• Second line, if Paxlovid™ unsuitable
• Must be given  within 7 days of onset of symptoms
• Loading dose 200 mg for 1 dose, then maintenance 100 mg once daily IV infusion, for 3 days in total
• Contraindicated:
  
  • if eGFR <30 or ALT >5x upper limit of normal​
  • in pregnant patients

Sotrovimab

• Third line and only use if nirmatrelvir plus ritonavir (Paxlovid™) and remdesivir contraindicated or unsuitable
• For patients weighing ≥40 kg
• 500 mg for 1 dose diluted in 50 mL or 100 mL glucose 5% or sodium chloride 0.9% and administered over 30 min through an in-line 0.2 micron filter

Molnupiravir

• Fourth line 
• Only for use in the community if alternatives are not suitable

Antimicrobials

• Antibiotics not indicated unless secondary bacterial infection suspected - see appropriate guideline

Care planning

• Complete care plan for deterioration in consultation with patient and carers to collaboratively establish appropriate escalation plan and how to access:
  
  • a move to secondary care
  • other community-based support (virtual ward, hospital-at-home or palliative care)

Infection prevention

• Admit patient to suitably isolated bed

Care plan

• Complete COVID-19 care plan in addition to admission care plans
  
  • latest version of care plan is available on Trust intranet site at A-Z > COVID-19 (Coronavirus) > COVID-19 Care plan and ward round guidance

Respect documentation

• Complete respect form to document escalation of treatment decisions
  
  • document stability of underlying health conditions
  • assess frailty using Clinical Frailty Score (CFS) available online 
    
    • do not use in younger people, those with long-term disability, learning disability or autism, who require individualised assessment
  • discuss treatment goals with patient (if possible) and relatives
  • include decisions about CPR, CPAP, non-invasive ventilation and intubation and critical care management

COVID-19 treatments to prevent severe disease

To be initiated as soon as possible after SARS-CoV-2 positive result and within 5 days of symptom onset. Indicated if:

• Patient does not need oxygen
• Increased risk for progression to severe COVID-19, see section 5 of NICE's technology appraisal - guidance on nirmatrelvir
• Diabetes
• Heart failure
• See section above in Treatment of non-hospitalised patient>COVID 19 treatments to prevent severe disease

Awake prone positioning

• Indications
• SpO₂ <94% and RR >22 bpm
  
  • patients on oxygen supplementation, NIV, and CPAP 
  • patient must be alert and able to safely self-prone
• Technique
  
  • Proning leaflet is available online
• Contraindications
  
  • need for immediate intubation
  • respiratory exhaustion
  • reduced consciousness
  • haemodynamic instability
  • trauma and recent surgery causing discomfort or musculoskeletal instability
  • pregnancy: second and third trimester

Oxygen

• See Hypoxaemia guideline
  
  • SpO₂ 88-92% for non-critical patients at risk of type 2 (hypercapnic) respiratory failure
  • SpO₂ 92-96% for all other patients with COVID-19 

Critical care referral

• If it has been agreed that escalation to critical care would be appropriate, refer to critical care on call if patient:
  
  • requires ≥40% oxygen to maintain SpO₂ ≥90%
  • is in respiratory distress with respiratory rate (RR) ≥30 bpm, using accessory muscles or is exhausted
  • rapid increase in oxygen requirement or decline in NEWS score

Enhanced respiratory support on respiratory ward

• Patients to be offered high flow nasal oxygen (HFNO) or CPAP if normocapnic or NIV if hypercapnic if:
  
  • not suitable for or do not wish to escalate to critical care or
  • are appropriate for enhanced support but not intubation or
  • are likely to respond to enhanced respiratory support and are not likely to need intubation
• Call respiratory HDU (ward 222) and respiratory support unit (ward 128) to discuss administration of HFNO, CPAP and NIV and discuss with consultant on call for NIV and CPAP

Corticosteroids

• If patient requires oxygen or ventilatory support and is not pregnant administer dexamethasone 6 mg daily or if unable to take medication orally, dexamethasone 1.8 mL (5.94 mg) of 3.3 mg/mL injection IV once daily for 10 days or until discharge if sooner
  
  • if pregnant give prednisolone 40 mg once daily, or if unable to take medication orally hydrocortisone 80 mg IV twice daily for 10 days or until discharge if sooner

Tocilizumab

• Recombinant humanised monoclonal antibody that binds to interleukin-6 receptors thereby blocking the activity of pro-inflammatory cytokines
• In patient with confirmed active COVID-19 infection and all of:
  
  • patient already taking dexamethasone or steroids contraindicated
  • patient on oxygen and CRP ≥75 or within first 48 hr of starting invasive ventilation, NIV or CPAP
  • medical consultant must support prescription
• Prescribe and dispense using brand name, 8 mg/kg (max. per dose 800 mg) for 1 dose diluted in 100 mL of normal saline and given as IV infusion over 1 hr
  
  • IL-6 inhibitors must be prescribed on a separate prescription form/checklist which can be found via: Intranet > A-Z > COVID-19 (Coronavirus) > COVID-19 Care plan > Request Forms
• IL-6 inhibitors are contraindicated if ANY of the following; 
  
  • ALT or AST >5x upper limit of normal
  • neutropenia (<2.0)
  • thrombocytopenia (cut-off platelets <50 for tocilizumab)
• Use caution in patients who may be otherwise immunosuppressed or if clear evidence of a bacterial, fungal, viral or other infection besides COVID-19, including active tuberculosis, HIV or viral hepatitis. If serious infection occurs, interrupt treatment 
• Women of child-bearing age should take contraception for 3 months post-dose
• Hypersensitivity/allergic reactions are possible, report any adverse events to the MHRA by the dedicated COVID-19 Yellow Card Reporting Site

Remdesivir

• Must be given ​within 10 days of onset of symptoms
• Patient requiring supplemental oxygen
• Loading dose 200 mg for 1 dose, then maintenance 100 mg once daily by IV infusion for 5 days in total
  
  • if immunocompromised and slow to improve, can be extended to 10 days 
• Stop early if supplementary oxygen no longer required
• Contraindicated:
  
  • if eGFR <30 or ALT is >5x upper limit of normal​
  • in pregnant patients

Bariticinib

• For patients requiring supplemental oxygen and tocilizumab not suitable and no evidence of other infection that may deteriorate with JAK-inhibition (only one of tocilizumab or baricitinib can be given)
• Use must be confirmed by medical consultant
• 4 mg once daily orally
  
  • if aged ≥65 yr – reduced dose of 2 mg once daily
• Active, chronic, or recurrent infection (interrupt treatment if no response to standard therapy)
• History of atherosclerotic cardiovascular disease or other cardiovascular risk factors
• Risk factors for:
  
  • DVT/pulmonary embolism
  • malignancy
• Risk of: 
  
  • diverticulitis
  • viral reactivation
• Consult product literature
• If no response after 8 weeks, after discussion with medical consultant – discontinue treatment 
• Contraindications:
  
  • absolute lymphocyte count <0.5 x 10⁹ cells/L
  • absolute neutrophil count <1 x 10⁹ cells/L
  • haemoglobin <8 g/dL
  • tuberculosis (active)
  • eGFR <15 or on dialysis​

Antimicrobials

• Antibiotics not indicated for COVID-19 pneumonitis unless secondary bacterial infection suspected
  
  • purulent sputum
  • raised procalcitonin
  • deterioration after biomarker and clinical improvement
  • CXR changes suggest pneumonic consolidation
• See Community acquired pneumonia and Hospital acquired pneumonia guidelines

Prophylactic and therapeutic anticoagulation for venous thromboembolic disease

Prophylactic treatment

• For non-hypoxic patients, patients with an increased bleeding risk or those requiring advanced oxygen support (e.g. high-flow, CPAP/NIV or IMV)
• Omit if platelets <30, otherwise administer according to table below:

Table 1: Enoxaparin dose

• Stop prophylactic LMWH once patient is discharged unless significantly high risk of thrombosis (see below) and prolonged VTE prophylaxis for a total of 7 days - refer to district nurses:
  • past history of VTE
  • significant immobility
  • significant obesity
  • other comorbid conditions increasing VTE risk

Therapeutic anticoagulation

• Commence all hypoxic patients on low-flow oxygen (i.e. nasal cannula or venturi masks) who do not have an increased bleeding risk (HASBLED score >3 due to irreversible factors - see Atrial fibrillation guideline) on therapeutic enoxaparin - see Enoxaparin for VTE guideline
• Continue for maximum of 14 days and stop on discharge
• If platelets <100 or patient is pregnant, discuss with haematology before prescribing 
• If care escalated to CPAP, NIV, HFNO or invasive mechanical ventilation convert back to prophylactic dose
• Check platelets, eGFR and liver function and review patient risk daily

• People are usually infectious for 10 days after developing symptoms
• Provide infection control advice
• Before patient discharged, request CXR for 6-8 weeks 
• Arrange follow-up in outpatients to ensure continued recovery. If on review continued shortness of breath arrange:
  
  • lung function tests and refer to respiratory department
  • echocardiogram
  • if CXR not resolved, arrange CT chest