Symptoms are classically fever, cough and loss of taste or smell. Other symptoms include:
In elderly patients in particular:
SARS-CoV2 testing can be done via PCR, point of care and lateral flow devices. Also:
COVID pneumonitis is currently rare in vaccinated individuals. Always consider other diagnoses (with incidental COVID-19) or dual pathology, including bacterial infection / sepsis if the patient is unwell. Consider HIV testing / PCP pneumonia, particularly in patients with 'atypical pneumonia' who are COVID-19 negative.
The infographic summarises the management of adult patients admitted unwell with COVID-19. For further details of treatment management, see below.
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. As for all severe viral respiratory illness in pregnant women, delivery may be a "therapeutic option" and so regular discussion with the Obstetric and Neonatal Team is necessary.
Seek consultant review and treatment escalation plan if SpO2 is below the target levels stated above.
Non-invasive respiratory support (CPAP, nasal high flow therapy, non-invasive ventilation) is considered on a case-by-case basis for patients with COVID-19 severe respiratory failure. Respiratory support interventions are aerosol generating procedures so are only initiated in selected high dependency - hi-care areas. Please refer to site specific guidance on escalation thresholds and place of care for COVID-19 respiratory support.
Patients with COVID-19 are at high-risk of venous thromboembolism (VTE) and thromboprophylaxis should be prescribed in all in-patients with suspected or confirmed COVID-19 infection, unless contraindicated. See the thromboprophylaxis in COVID-19 patients guideline for further information.
Dexamethasone shows reduced mortality in patients with severe and critical 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). Patients with non-severe COVID-19 (i.e. not requiring oxygen to maintain target saturations) should not be given dexamethasone as there is no evidence that they derive benefit from it and may, instead, derive harm.
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. In pregnant or breastfeeding women alternative corticosteroids are recommended, see below for details.
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.
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 below) will require capillary blood glucose (CBG) checked once a day (at 4pm) upon commencement if not diabetic, and four times a day in those with diabetes.
For non-diabetic patients who have a CBG>12mmol/L, and for all those with diabetes, follow the guideline here for ongoing monitoring and management.
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:
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. Discuss all therapeutic options with the Obstetric Team as appropriate.
See the remdesivir flowchart (Group 1) for clinical indications in patients hospitalised due to symptomatic COVID-19 and brief dosing and monitoring information. For further information, see the manufacturer's Summary of Product Characteristics. The duration is 2-5 days and daily clinical response, U&Es and LFTs should be reviewed. Further detail is also provided in the GGC Remdesivir for patients COVID-19 guideline.
The decision to treat with remdesivir is not an emergency and should be made judiciously after assessment and in a timely manner during office hours. Do not call out the on-call pharmacist to obtain supply.
Tocilizumab and sarilumab are immune modulating drugs. The REMAP-CAP and RECOVERY trials have reported a survival benefit with the use of these agents in hospitalised COVID-19 patients meeting certain criteria. These benefits were additional to the benefits of systemic steroids, such as dexamethasone. Tocilizumab is now licensed for the treatment of COVID-19 and the use of sarilumab in COVID-19 is off-label. Tocilizumab is the treatment of choice, but sarilumab may be used if there are any restrictions in tocilizumab supplies. The decision to treat with either agent is not an emergency and should be made judiciously after assessment and in a timely manner during office hours. See the GGC IL-6 receptor antagonist for adult patients with COVID-19 pneumonia guideline for details of: the different clinical indications for using either agent, exclusion criteria, process for obtaining supply, dosing and administration information and monitoring details. There is additional guidance for preparation and administration of sarilumab - see worksheet. Please note that it should be administered via a 0.2-micron inline filter, which should be available in the ward areas that keep stock of sarilumab.
Both tocilizumab and sarilumab are potent immunosuppressant drugs. Patients are at risk of opportunistic infection following administration. Both drugs will suppress C-reactive protein for several weeks and this should therefore not be relied upon as an indicator of infection / inflammation.
Ensure patients receive the GGC tocilizumab and sarilumab patient information leaflet. It contains important information, including advice for women of child bearing age.
This is an anti-inflammatory used for rheumatoid arthritis which has been shown in the RECOVERY study to have added benefits to dexamethasone and IL-6 inhibitors.
Use of baricitinib in COVID-19 should be considered as an 'additive' to the use of IL-6 inhibitor (tocilizumab or sarilumab) rather than an alternative. In other words, a patient may be given an IL-6 inhibitor after treatment with baricitinib has been commenced (or vice versa), according to clinical management. It should not routinely be co-administered with an IL-6 inhibitor (i.e. co-administered simultaneously). However, in the situation of illness requiring critical care support or where a patient has deteriorated despite treatment, clinical judgement may deem co-administration appropriate. See the GGC Baricitinib guideline for full inclusion and exclusion criteria, and dosing and administration guidance.
These include Ronapreve® (casirivimab and imdevimab combined) or sotrovimab. There are currently no nMAB recommended or commissioned for use in patients hospitalised for the treatment COVID-19 pneumonitis other than in clinical trials. Please contact the GGC Principal Investigators of the RECOVERY trial to discuss further.
Vaccine responsive patients rarely develop COVID pneumonitis and bacterial co-infection with COVID-19 infection is rare. In hospitalised patients with COVID-19, antibiotics should not be routinely prescribed and only considered if there is additional clinical or radiological evidence of a bacterial infection. If bacterial infection is suspected, blood and other site specific cultures should be undertaken and NHSGGC empirical infection management guidelines should be followed.
It is important to initially withhold all oral anti-cancer medicines, including chemotherapy and biological modifiers, in hospitalised patients and discuss with their specialist 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).
In complex cases, multidisciplinary discussion should be sought and infectious disease or respiratory specialist can be contacted via the on-call consultant during office hours.
Back to main COVID-19 management guideline.
Guideline reviewed: 17/01/2023
Page last updated: 13/09/2023
