GGC Medicines


Adult Therapeutics Handbook

COVID-19 (Coronavirus) Infection

Management of COVID-19 (Coronavirus) Infection

Introduction

COVID-19 (coronavirus) is the illness caused by a new strain of coronavirus (SARS-CoV-2) first identified in Wuhan city, China. It can cause a cough and/or a fever/high temperature and serious complications in some patients.

Information in this guideline has either been directly endorsed by NHSGGC or originates from a reputable source, such as NHS Inform. It is intended to be updated as and when guidance changes.

Assessment / monitoring

The main clinical features of COVID-19 are well documented:

  • Fever and/or high temperature (defined as ≥37.8°C)
  • Continuous cough, which is defined as:
    • a new cough that has lasted more than 1 hour
    • where a patient has had 3 or more coughing episodes in 24 hours
    • where a patient may be coughing more than usual.
  • Loss of, or change in sense of smell (anosmia) or taste.

In addition to these, patients who are presenting to hospital with COVID, or who have been diagnosed with COVID during admission, may also be showing the following clinical features:

  • Dyspnoea
  • Fatigue/myalgia
  • Confusion
  • Viral illness with possible pneumonitis
  • Patients also may present at the immunological clinical stage, where most patients recover, but where there can be Acute Respiratory Distress Syndrome (ARDS) and/or cardiovascular collapse

Testing

The Coronavirus Information Hub on NHSGGC StaffNet has detailed advice about how to collect a sample and arrange suitable transportation to labs.

Investigations

  • CRP: may be raised or normal and does not reflect presence of bacterial co-infection.
  • Lymphopenia is common.
  • Transaminitis may occur.
  • NT-Pro BNP, Troponin and D-dimer may be elevated and need to be interpreted with caution.

Imaging

  • CXR - typical initial presentation is bilateral peripheral ground glass opacities.
  • Chest CT - only if it will change management.

Differential Diagnosis

Patients are likely to have co-morbidities. Always consider other diagnoses or dual pathology, including bacterial infection / sepsis. 

Management / treatment options

A Treatment Escalation Plan (TEP) is required for all suspected COVID-19 patients.

Oxygen

  • Suspected COVID pneumonia: target SpO2 90-94%.
  • If chronic obstructive pulmonary disease (COPD) or risk of hypercapnia: target  SpO2 88-92%.
  • Consider proning for ward patients with an oxygen requirement

Seek consultant review and treatment escalation plan if SpO2 is below the target levels stated above.

  • Do not use high-flow nasal oxygen or non-invasive ventilation (NIV) outwith designated locations and without respiratory consultant review or critical care recommendation.

Drug Treatment

Antibiotics:

  • Most patients do not require antibiotics. If they do, see table 1 below.

Table 1: Infection management

Presentation Choice of antibiotic:
Infective exacerbation of COPD with purulent sputum

Doxycycline oral 200mg as a one-off dose followed by 100mg daily

or

Amoxicillin oral 500mg 8 hourly 

Total course duration: 5 days.

Suspected bacterial pneumonia

Follow community acquired pneumonia guidelines available within the Lower Respiratory Tract Infections guidelines however, do not add clarithromycin unless on the advice of microbiology, Infectious Diseases team or respiratory specialist.

Doxycycline oral 200mg as a one-off dose followed by 100mg daily (5 days) may be used for atypical cover if required.

Suspected hospital acquired pneumonia - Non-severe

Doxycycline oral 100mg 12 hourly 

or 

Co-trimoxazole oral 960mg 12 hourly

Total course duration: 5 days.

Suspected hospital acquired pneumonia - Severe

Co-amoxiclav IV 1.2g 8 hourly +/- gentamicin IV (dosing info here, gentamicin max 3-4 days) 

or if penicillin allergy: 

Levofloxacin (monotherapy) oral 500mg 12 hourly (use the same dose IV if oral route compromised)

Total course duration: Review (usually 5 days).

  • Remember QTc prolongation with macrolides (such as clarithromycin) or levofloxacin, and drug interactions (doxycycline, macrolides, levofloxacin). See BNF for details of drug interactions.
  • If IV antibiotics are used, consider IVOST when patient is improving.

Steroids:

  • If the patient also has an infective exacerbation of COPD (IECOPD), give prednisolone oral 25mg daily for 5 days and also refer to the Acute Exacerbation of COPD guideline for further information. N.B. Prednisolone dose advised in COVID-19 for IECOPD is lower than the usual dose.
  • Do not stop steroids in patients who are receiving them long-term and increase as required if necessary. For general advice on the long-term use of corticosteroids in an acute situation see the Adrenal Insufficiency guideline.

IV Fluids

  • Assess fluid status (intake, CXR, renal function, blood pressure).
  • Febrile patients have high insensible losses.
  • Replacement fluids, with or without maintenance IV fluids, if inadequate oral intake.
  • Avoid fluid boluses as this may exacerbate ARDS.
  • Aim for euvolaemia (not over / under-filled).

Thromboprophylaxis

  • Patients with COVID-19 are at high-risk of venous thromboembolism (VTE) and thromboprophylaxis should be prescribed in all patients admitted to hospital with suspected or confirmed COVID-19 infection unless contraindicated.
  • See the thromboprophylaxis in COVID-19 patients guideline for further information.

Patients receiving systemic anti-cancer treatment (SACT)

Some cancer patients including, but not limited to, those receiving SACT are at very high risk of severe illness from COVID-19 and may be on the national shielding list. It is important to withhold all oral anti-cancer medicines, including chemotherapy and biological modifiers, in hospitalised patients and notify the on-call haemato-oncology or oncology team. There are particular risks associated with the use of Granulocyte Colony Stimulating Factor (GCSF) e.g. filgrastim / pegfilgrastim in patients with COVID-19. GCSF must be withheld in patients with suspected COVID-19 and discussed with the on-call haemato-oncology or oncology team. For more information see the West of Scotland Cancer Network guideline on the WoSCAN intranet site (NHS network access required).

Other considerations

  • ACE-Inhibitors (ACEI) and Angiotensin II receptor Blockers (ARB) 
    • There is no current evidence that taking these drugs, or stopping them, alters COVID-19 outcomes. 
    • Do not stop these drugs unless:
      • Haemodynamic upset (e.g. if SBP reduced by more than 20mmHg than usual measurement).
      • Acute Kidney Injury (serum creatinine >30% higher than 'baseline').
  • Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
    • Review the indication for use.
    • There is currently insufficient evidence of a link between the use of NSAIDs and clinical outcomes of COVID-19.
    • For the symptomatic relief of COVID-19, it is advised to use the lowest effective dose for the shortest duration. 
    • Patients currently on NSAIDs for clear medical reasons (e.g. arthritis) should not stop them.

Useful Links 

 

Content updated 29th May 2020.