Skip to main content

Pharmacologic Interventions

Last Updated: June 25, 2020

Antiviral Therapy

Recommendations

  • The COVID-19 Treatment Guidelines Panel (the Panel) recommends the investigational antiviral agent remdesivir for treatment of COVID-19 in hospitalized patients with SpO2 ≤94% on room air (at sea level) or those who require supplemental oxygen (AI).
  • The Panel recommends remdesivir for treatment of COVID-19 in patients who are on mechanical ventilation or extracorporeal membrane oxygenation (BI).

See the Remdesivir section for a detailed discussion of these recommendations.

Immune-Based Therapy

Several immune-based therapies that are expected to modify the course of COVID-19 infection, including corticosteroids, are currently under investigation or are already in use. These agents may target the virus (e.g., convalescent plasma) or modulate the immune response (e.g., interleukin [IL]-1 or IL-6 inhibitors). Recommendations regarding immune-based therapy can be found in Immune-Based Therapy Under Evaluation for Treatment of COVID-19.

Corticosteroids

Preliminary clinical trial data from a large, randomized, open-label trial suggest that dexamethasone reduces mortality in hospitalized patients with COVID-19 who require mechanical ventilation or supplemental oxygen.1 The recommendations for using corticosteroids in patients with COVID-19 depend on the severity of illness. Before initiating dexamethasone, clinicians should review the patient’s medical history and assess the potential risks and benefits of administering corticosteroids to the patient.

Recommendations

  • The Panel recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated (AI) and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated (BI).
  • The Panel recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen (AI).

Rationale

See the Panel’s guidance on the use of dexamethasone for a detailed discussion of these recommendations.

Empiric Broad-Spectrum Antimicrobial Therapy

Recommendations

  • In patients with COVID-19 and severe or critical illness, there are insufficient data to recommend empiric broad-spectrum antimicrobial therapy in the absence of another indication (BIII).
  • If antimicrobials are initiated, the Panel recommends that their use should be reassessed daily in order to minimize the adverse consequences of unnecessary antimicrobial therapy (AIII).

Rationale

There are no reliable estimates of the incidence or prevalence of co-pathogens with COVID-19 at this time.

For patients with COVID-19, some experts routinely administer broad-spectrum antibiotics to all patients with moderate or severe hypoxemia. Other experts administer antibiotics only for specific situations, such as the presence of a lobar infiltrate on a chest x-ray, leukocytosis, an elevated serum lactate level, microbiologic data, or shock.

Gram stain and cultures or testing of respiratory specimens are often not available due to concerns about aerosolization of the virus during diagnostic procedures or when processing specimens.

There are no clinical trials that have evaluated the use of empiric antimicrobial agents in patients with COVID-19 or other severe coronavirus infections.

With influenza, empiric antibacterial treatment is strongly recommended for patients with initial severe disease (i.e., those with extensive pneumonia, respiratory failure, hypotension, and fever) and those who deteriorate after initial improvement.2 These recommendations are based on observations that bacterial superinfections, especially those due to Staphylococcus aureus and Streptococcus pneumonia, are not uncommon and have dire consequences if not treated promptly.

Whether moderate or severe COVID-19 disease should be approached like severe influenza will remain uncertain until more microbiologic and clinical data become available.

References

  1. Horby P, Shen Lim W, Emberson J, et al. Effect of dexamethasone in hospitalized patients with COVID-19: preliminary report. medRxiv. 2020;[Preprint]. Available at: https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1.
  2. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical practice guidelines by the Infectious Diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenza. Clin Infect Dis. 2019;68(6):e1-e47. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30566567.