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.
In older adults, COVID-19 can have an atypical presentation. Brief guidance has been provided below, but further information is available on NHSGGC StaffNet / Clinical Info / COVID-19 Clinical Guideline Page (link available if accessing via a NHS computer).
The main clinical features of COVID-19 are well documented:
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:
This patient group is more likely to have an atypical presentation of COVID-19 and are less likely to present with cough, dyspnoea or raised temperature. Atypical presentation may include:
Symptoms may be unreliable so consider early testing and if index of suspicion is high then repeat swabs.
The Coronavirus Information Hub on NHSGGC StaffNet has detailed advice about how to collect a sample and arrange suitable transportation to labs.
Patients are likely to have co-morbidities. Always consider other diagnoses or dual pathology, including bacterial infection / sepsis.
A Treatment Escalation Plan (TEP) is required for all suspected COVID-19 patients. If appropriate involve the palliative care team early and individualise the care.
Seek consultant review and treatment escalation plan if SpO2 is below the target levels stated above.
|Presentation||Choice of antibiotic:|
|Infective exacerbation of COPD with purulent sputum||
Doxycycline oral 200mg as a one-off dose followed by 100mg daily
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
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).
Dexamethasone has been shown to have benefit in some patients with severe COVID-19 as per the RECOVERY trial. Criteria for using dexamethasone includes: COVID-19 (suspected or confirmed) in patients requiring oxygen therapy as per targets, non-invasive ventilation or invasive ventilation, or extracorporeal membrane oxygenation (ECMO).
Dose of dexamethasone is oral /IV 6mg once daily for 10 days (stop prior to hospital discharge if within 10 days). Use tablets (or oral solution), unless swallow is an issue or there are significant concerns with regards to enteral absorption.
N.B. If dexamethasone 3.3mg/ml IV 1ml ampoule is used, then dosage required is 1.8ml (5.94mg) once daily for 10 days.
In pregnant or breastfeeding women, prednisolone oral 40mg daily (or hydrocortisone IV 80mg twice daily) for 10 days should be used, instead of dexamethasone. Use tablets (or oral dispersible tablets), unless swallow is an issue or there are significant concerns with regards to enteral absorption, in which case use IV hydrocortisone. Stop treatment if discharged from hospital within 10 days.
A proton pump inhibitor should be considered in patients on dexamethasone who are at high risk of gastrointestinal bleeding or dyspepsia:
Dexamethasone and COVID-19 can independently cause severe insulin resistance and impaired glucose metabolism. Combined, there is therefore a risk to people with and without known diabetes of significant hyperglycaemia and possible Hyperosmolar Hyperglycaemic State (HHS) or Diabetic Ketoacidosis (DKA). Therefore all patients with COVID-19 on dexamethasone (or alternative high dose steroid as above) will require capillary blood glucose (CBG) checks four times a day upon commencement.
Note that insulin, rather than the commencement or titration of sulphonylureas and other non-insulin hypoglycaemics, is recommended for the management of hyperglycaemia and glycaemic emergencies with COVID-19 infection and the use of high dose steroids. This is because COVID-19 may be cause pancreatic beta-cell dysfunction.
For further detailed guidance see the ABCD COVID: Diabetes document on dexamethasone therapy on http://abcd.care/coronavirus.
Co-administration of dexamethasone with remdesivir has not been studied, but based on metabolism, clearance and course duration, a clinically significant interaction is unlikely as:
This antiviral agent was previously available under the Early Access to Medicines Scheme (EAMS) for suspected or proven COVID-19 and is now a licensed product. It should be considered for use in severe cases only and must fulfil a series of criteria, which include:
At the time of decision to treat with remdesivir, the patient should not be receiving ongoing mechanical ventilation or ECMO. Patients who present with an initial rapid deterioration can, however, be considered for treatment with remdesivir, but multidisciplinary team assessment should determine if patients not suitable for escalation would benefit from initiation of treatment with remdesivir. If patients on remdesivir require escalation, continuation of the drug should be considered by multidisciplinary team assessment.
Dose of remdesivir IV is 200mg on day 1, followed by 100mg daily for 4 days (can be extended for a further 5 days after multidisciplinary assessment). For information on remdesivir, including monitoring, side effects, cautions and contraindications, see the the manufacturer's summary of product characteristics via www.medicines.org.uk. To obtain supply, or for further information, contact pharmacy (see Appendix 6 for contact details).
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).
Content updated 10th August 2020