Management of Persons with COVID-19
Last Updated: June 11, 2020
Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can experience a range of clinical manifestations, from no symptoms to critical illness. This section of the Guidelines discusses the clinical management of patients according to illness severity. Currently, the Food and Drug Administration has not approved any drugs for the treatment of COVID-19. However, an array of drugs approved for other indications, as well as multiple investigational agents, are being studied for the treatment of COVID-19 in several hundred clinical trials around the globe. Some drugs can be accessed through Emergency Use Authorization, expanded access programs, or compassionate use mechanisms. Available clinical data for these drugs under investigation are discussed in Antiviral Therapy and Immune-Based Therapy.
In general, adults with COVID-19 can be grouped into the following severity of illness categories, although the criteria in each category may overlap or vary across guidelines and clinical trials:
- Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 by virologic testing using a molecular diagnostic (e.g., polymerase chain reaction) or antigen test, but have no symptoms.
- Mild Illness: Individuals who have any of the various signs and symptoms of COVID 19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.
- Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SpO2) ≥94% on room air at sea level.
- Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%
- Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children, thus hypoxia should be the primary criteria to define severe illness, especially in younger children.
Asymptomatic or Presymptomatic Infection
Asymptomatic SARS-CoV-2 infection can occur, although the percentage of patients who remain truly asymptomatic throughout the course of infection is variable and incompletely defined. It is unclear at present what percentage of individuals who present with asymptomatic infection may progress to clinical disease. Some asymptomatic individuals have been reported to have objective radiographic findings consistent with COVID-19 pneumonia. Over time, the availability of widespread virologic testing for SARS-CoV-2 and the development of reliable serologic assays for antibodies to the virus will help determine the true prevalence of asymptomatic and presymptomatic infections.1
Persons who test positive for SARS-CoV-2 by molecular diagnostic or antigen testing (see Testing for SARS-CoV-2) and who are asymptomatic should self-isolate at home. If they remain asymptomatic, they can discontinue isolation 10 days after the date of their first positive SARS-CoV-2 test.2 Health care workers who test SARS-CoV-2 positive and are asymptomatic may obtain additional guidance from their occupational health service. See the Centers for Disease Control and Prevention COVID-19 website for detailed information. Individuals who become symptomatic should contact their health care provider for further guidance. Current CDC recommendations for individuals who develop symptoms are to self-isolate for at least 10 days from the onset of their symptoms and until they have no fever and improvement in respiratory symptoms for at least 3 days.
The Panel recommends no additional laboratory testing and no specific treatment for persons with suspected or confirmed asymptomatic or presymptomatic SARS-CoV-2 infection (AIII).
Patients may have mild illness defined by a variety of signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea on exertion, or abnormal imaging. Most mildly ill patients can be managed in an ambulatory setting or at home through telemedicine or remote visits.
All patients with symptomatic COVID-19 and risk factors for severe disease should be closely monitored. In some patients, the clinical course may rapidly progress.3,4
No specific laboratory evaluations are indicated in otherwise healthy patients with mild COVID-19 disease.
There are insufficient data to recommend either for or against any antiviral or immune-based therapy in patients with COVID-19 who have mild illness.
Moderate COVID-19 illness is defined as evidence of lower respiratory disease by clinical assessment or imaging with SpO2 ≥94% on room air at sea level. Given that pulmonary disease can rapidly progress in patients with COVID-19, close monitoring of patients with moderate disease is recommended. If bacterial pneumonia or sepsis is strongly suspected, administer empiric antibiotic treatment for community-acquired pneumonia, re-evaluate daily, and if there is no evidence of bacterial infection, de-escalate or stop antibiotics.
Hospital infection prevention and control measures include use of personal protective equipment for droplet and contact precautions along with eye protection (e.g., masks, face shields/goggles, gloves, gowns) and single-patient dedicated medical equipment (e.g., stethoscopes, blood pressure cuffs, thermometers).5,6 The number of individuals and providers entering the room of a patient with COVID-19 should be limited. If necessary, patients with confirmed COVID-19 may be cohorted in the same room. If available, airborne infection isolation rooms (AIIRs) should be used for patients who will be undergoing any aerosol-generating procedures. During these procedures, all staff should wear fit-tested respirators (N95 respirators) or powered, air-purifying respirators (PAPRs) rather than a surgical mask.7
The optimal pulmonary imaging technique for people with COVID-19 is yet to be defined. Initial evaluation may include chest x-ray, ultrasound, or if indicated, computerized tomography (CT). Electrocardiogram (ECG) should be performed if indicated. Laboratory testing includes a complete blood count (CBC) with differential and a metabolic profile, including liver and renal function tests. Measurements of inflammatory markers such as C-reactive protein (CRP), D-dimer, and ferritin, while not part of standard care, may have prognostic value.
Clinicians should refer to Antiviral Therapy and Table 2a and Immune-Based Therapy and Table 3a to review the available clinical data regarding investigational drugs being evaluated for treatment of COVID-19.
Patients with COVID-19 are considered to have severe illness if they have SpO2 <94% on room air at sea level, respiratory rate >30, PaO2/FiO2 <300 mmHg, or lung infiltrates >50%. These patients may experience rapid clinical deterioration and will likely need to undergo aerosol-generating procedures. They should be placed in AIIRs, if available. Administer oxygen therapy immediately using nasal cannula or high-flow oxygen.
If secondary bacterial pneumonia or sepsis is suspected, administer empiric antibiotics, re-evaluate daily, and, if there is no evidence of bacterial infection, de-escalate or stop antibiotics.
Evaluation should include pulmonary imagining (chest x-ray, ultrasound, or, if indicated, CT) and ECG, if indicated. Laboratory evaluation includes a CBC with differential and a metabolic profile, including liver and renal function tests. Measurements of inflammatory markers such as CRP, D-dimer, and ferritin, while not part of standard care, may have prognostic value.
For additional details, see Care of Critically Ill Patients with COVID-19.
Severe cases of COVID-19 may be associated with acute respiratory distress syndrome, septic shock that may represent virus-induced distributive shock, cardiac dysfunction, elevations in multiple inflammatory cytokines that provoke a cytokine storm, and/or exacerbation of underlying comorbidities. In addition to pulmonary disease, patients with COVID-19 may also experience cardiac, hepatic, renal, and central nervous system disease.
Because patients with critical illness are likely to undergo aerosol-generating procedures, they should be placed in AIIRs when available.
Most of the recommendations for the management of critically ill patients with COVID-19 are extrapolated from experience with other life-threatening infections.8 Currently, there is limited information to suggest that the critical care management of patients with COVID-19 should differ substantially from the management of other critically ill patients, although special precautions to prevent environmental contamination by SARS-CoV-2 is warranted.
The Surviving Sepsis Campaign (SSC), an initiative supported by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, issued Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) in March 2020.8 The Panel relied heavily on the SSC guidelines in making the recommendations in these Treatment Guidelines and gratefully acknowledges the work of the SSC COVID-19 Guidelines Panel.
As with any patient in the intensive care unit (ICU), successful clinical management of a patient with COVID-19 depends on attention to the primary process leading to the ICU admission, but also to other comorbidities and nosocomial complications.
- Wang Y, Liu Y, Liu L, Wang X, Luo N, Ling L. Clinical outcome of 55 asymptomatic cases at the time of hospital admission infected with SARS-coronavirus-2 in Shenzhen, China. J Infect Dis. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32179910.
- Centers for Disease Control and Prevention. Discontinuation of isolation for persons with COVID-19 not in healthcare settings (interim guidance). 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html. Accessed June 8, 2020.
- Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32109013.
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31986264.
- Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed June 8, 2020.
- Centers for Disease Control and Prevention. Strategies to optimize the supply of PPE and equipment. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Accessed June 8, 2020.
- Centers for Disease Control and Prevention. Approved respirator standards. 2006. Available at: https://www.cdc.gov/niosh/npptl/standardsdev/cbrn/papr/default.html. Accessed June 8, 2020.
- Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32224769.