Home Guidelines & Resources Management of Patients with COVID-19 Infection

Management of Patients with COVID-19 Infection

Ryan C. Maves, MD, FCCP; and Vikram Mukherjee, MD

Dr. Maves is Program Director, Infectious Diseases Fellowship;Faculty Physician, Critical Care Medicine Service;Naval Medical Center, San Diego, CA; and Dr. Mukherjee is Director, Medical ICU, Bellevue Hospital Center; Director, Special Pathogens Unit, Bellevue Hospital Center; and Assistant Professor, NYU School of Medicine, New York, NY.

Isolation

On March 11, 2020, the World Health Organization (WHO) declared the worldwide outbreak of the novel coronavirus disease 2019 (COVID-19) to be a pandemic.1 First reported in the city of Wuhan, Hubei Province, China, this infection has now spread widely from China to many other countries around the world, with the largest number of cases in mainland China, Italy, Iran, and the Republic of Korea. The virus is contagious with well-documented human to human spread; prompt identification and isolation of infected individuals are paramount in preventing further transmission.2 The first confirmed instance of person to person spread of COVID-19 in the United States was reported on January 30, 2020, in a household contact of a traveler from China.

Currently, not all the routes of spread have been clearly defined. There is concern, though, that the virus can spread via respiratory droplets and direct contact, as well as potentially through airborne routes of spread.3 For these reasons, it is recommended that patients with confirmed or suspected COVID-19 be cared for using a combination of standard, contact and airborne precautions, including the use of eye protection. Personal protective equipment (PPE) should include a gown (that does not need to be fluid-impermeable), gloves, and either an N95 respirator (if fit-tested) and face shield or a powered air-purifying respirator (PAPR).4 Given the elevated risk of nosocomial transmission, health-care workers must be well trained in proper donning and doffing practices of appropriate PPE prior to entering the room.

Patients who are at risk for having COVID-19 illness should be considered as “persons under investigation” (PUI). The CDC’s PUI criteria are under regular revision as more information is learned; clinicians are recommended to review current guidelines at CDC https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html. As of March 11, 2020, CDC recommends that patient testing should be based on clinical symptoms (including cough, dyspnea, or fever), local disease epidemiology, as well as any potential high-risk exposures, such as travel to areas with high rates of transmission or close contact with a confirmed case of COVID-19.

Recommendation

Continue to routinely ask patients about international travel, including specific information about the country, city, and dates of travel. Have heightened vigilance for COVID-19 based on the travel history (both international and within the United States), any exposure history to known persons with COVID-19, and the patient’s signs and symptoms of illness.

For patients meeting PUI criteria:

  • Instruct patient to wear surgical mask. Patient should immediately be placed in a negative airflow room (preferred) or private room with the door closed.
  • Isolation precautions: Airborne, contact, and eye protection is required.
  • Contact your local or state public health department and your facility’s infection prevention department.

PUIs for COVID-19 do not always require admission to a biocontainment unit. Hospital admission is only required when clinically indicated. The vast majority of patients who demonstrate mild illness can be safely discharged on home isolation.

US citizens, residents, and their immediate family members who have been in high-risk countries may be subject to health monitoring and possible quarantine for up to 14 days. Most persons will be asked to stay on home isolation, whereas others with higher risk exposures may be directed to federal quarantine facilities for observation during the 14-day incubation period.

Epidemiology and clinical features

The 2019 novel coronavirus also recently known as “SARS-CoV-2” per the International Committee on Taxonomy of Viruses, is a beta-coronavirus, strongly homologous to a bat coronavirus and closely related to the original SARS-CoV responsible for the severe acute respiratory syndrome (SARS) responsible for over 8,000 infections in 2003-2004. Although virologically similar, the disease caused by this novel virus, COVID-19, appears to be comparatively less deadly than SARS, with an overall mortality of 2% to 3% in currently reported cases (and likely to be lower as less-severe infections are identified).

As of March 11, 2020, there have been more than 120,000 reported cases of COVID-19 and over 4,600 deaths, the majority of these occurring within mainland China but with high case numbers in Italy, Iran, and the Republic of Korea. Precise case counts are a challenge for a variety of reasons, including an unknown burden of subclinical disease, overlapping clinical syndromes with influenza and other respiratory viruses, and an evolving infrastructure for virologic testing and specific diagnosis. In the United States and Canada, a diagnosis of COVID-19 requires confirmation by real-time, reverse transcriptase polymerase chain reaction (rRT-PCR). Within Hubei Province in China, cases of probable infection based on syndrome and compatible chest imaging are included in the total case count; this is a valid epidemiologic approach, subject to confounding by influenza and other diseases but also reducing the risk of undercounting cases.

Transmission of COVID-19 appears to be primarily from symptomatic persons, although transmission from presymptomatic hosts cannot yet be excluded.3 The virus is spread via respiratory droplets like other coronaviruses (and influenza), with an estimated range of 2 meters (6.5 ft). The duration of persistence in the environment is unknown, although other coronaviruses can remain viable on surfaces for approximately 4 days at room temperature in a low-humidity environment. The typical period of time between exposure and symptom onset appears to be 5 to 6 days, although periods up to 12 to 14 days have been reported.5

Most patients with COVID-19 infection will present with an acute febrile syndrome with predominantly respiratory symptoms. Older patients and those with medical comorbidities are more likely to present with severe disease; these populations are at a higher risk of developing acute respiratory and multiorgan failure, are more likely to require critical care support, and, ultimately, have a higher likelihood of dying. Severe disease, including the acute respiratory distress syndrome (ARDS), appears to develop 1 to 2 weeks after symptom onset. Younger patients, on the contrary, appear to present with a milder form of illness and, in many cases, may be safely managed in a nonhospital setting.6,7

Management

As in most viral pneumonias, supportive care is crucial in managing a patient with COVID-19. Patients can develop ARDS, either from primary viral pneumonia or from a secondary bacterial infection. Regardless of the specific microbiology, respiratory support consists of invasive mechanical ventilation, following evidence-based guidelines for ARDS, such as low tidal volume ventilation, and the use of prone positioning or extracorporeal membrane oxygenation (ECMO) for severe, refractory cases.8 A low threshold should be maintained for initiating antibacterial therapy.

The use of glucocorticoid therapy is of uncertain benefit; a majority of hospitalized patients described by Wang and colleagues in Wuhan6 received glucocorticoids with an in-hospital mortality of 4.3%. Other experts have discouraged the use of glucocorticoids based on data derived from SARS and MERS. Pending further data, glucocorticoids such as methylprednisolone, may be considered on a case-by-case basis. As of now, there are no FDA-approved drugs for the treatment of COVID-19. Remdesivir, a novel viral RNA polymerase inhibitor, has demonstrated in vitro activity against coronaviruses and may be available through emergency investigational new drug (eIND) authorization; clinical trials using this and other novel agents are currently underway. As ARDS seems to be a late complication of infection, one can hypothesize that antiviral therapy would need to be administered early in COVID-19 to be effective, similar to neuraminidase inhibitors in influenza; however, this supposition is presently unconfirmed.

Health-care workers (HCWs) are at a high risk for contracting infection through nosocomial transmission routes. As of February 24, 2020, more than 3,000 HCWs have been infected, with six deaths reported. Experiences from the SARS and MERS-CoV outbreaks have shown that hospitals can act as amplification zones, with nosocomial transmission leading to rapid spread of disease.9

In this context, a few principles apply to providing care to a person under investigation (PUI) or a confirmed patient with COVID-19. A minimal number of HCWs should be permitted entrance to the patient’s room. All staff entering the room should be competent in donning and doffing appropriate PPE. Consultative services should be provided remotely via telemedicine when possible. High-risk procedures that are known to generate aerosols, such as endotracheal intubation, bronchoscopy, and sputum induction, should be done by only experienced and trained staff. Interventions that are known to be aerosol generating, such as noninvasive ventilation (NIV) and nebulizer administration, should be avoided: patients requiring positive-pressure ventilatory support should be strongly considered for early intubation rather than the use of NIV, while metered-dose inhalers should be used preferentially in lieu of nebulized therapies. The role of high-flow nasal oxygen is controversial, but if it is employed, it should only be utilized within an airborne infection isoluation room (AIIR).10,11

Diagnostic testing should be minimized to the extent possible, and the laboratory should be notified well in advance to alert them that a specimen is from a PUI or confirmed COVID-19 case. Imaging should also be kept to a minimum. Obtaining a radiograph may be laborious given the likely need of training a radiology technician in PPE and decontaminating the machine. In practiced hands, point-of-care ultrasonography can serve as an excellent modality for imaging with comparable sensitivity and lower risk than conventional chest radiographs.

Support for health-care workers involved in the care of COVID-19 patients

Occupational health services should be involved early during care of a suspected COVID-19 patient for: (1) passive symptom monitoring of health-care workers who may have been exposed for 14 days after last exposure; (2) coordinating with state and national health agencies with regard to employee monitoring; (3) assessing the risk associated with PPE breeches or other exposures; (4) coordinating psychological support through established institutional resources; and (5) engaging with human resources to ensure compliance with internal policies and to make use of available employee resources for support.12,13

Disclaimer

Given the rapidly-changing nature of this pandemic, clinicians in the United States are recommended to refer to www.cdc.gov for the most recent updates on patient identification, infection prevention, and clinical management. The views expressed in this article are those of the authors and do not reflect neither the official policy or position of the Department of Health and Human Services, Department of the Navy, Department of Defense, nor the US Government. Dr. Maves is a US military service member. This work was prepared as part of his official duties. Title 17 USC §105 provides that Copyright protection under this title is not available for any work of the United States Government. Title 17 USC §101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.

References

  1. Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):514-523.
  2. Lipsitch M, Swerdlow DL, Finelli L. Defining the epidemiology of Covid-19—studies needed. N Engl J Med. 2020. doi: 10.1056/NEJMp2002125.
  3. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier transmission of COVID-19. Jama. 2020. doi: 10.1001/jama.2020.2565.
  4. Centers for Disease Control and Prevention. Guidance on personal protective equipment (PPE) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (PUIs) for ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in U.S. hospitals, including procedures for donning and doffing PPE. https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. Accessed March 14, 2020.
  5. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20–28 January 2020. Euro Surveil. 2020;25(5).
  6. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama. 2020. doi: 10.1001/jama.2020.1585.
  7. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513.
  8. MacLaren G, Fisher D, Brodie D. Preparing for the most critically ill patients with COVID-19: the potential role of extracorporeal membrane oxygenation. Jama. 2020. doi: 10.1001/jama.2020.2342.
  9. Chowell G, Abdirizak F, Lee S, et al. Transmission characteristics of MERS and SARS in the healthcare setting: a comparative study. BMC Med. 2015;13:210.
  10. Cheung JC, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med. 2020. doi: 10.1016/s2213-2600(20)30084-9
  11. Bouadma L, Lescure FX, Lucet JC, Yazdanpanah Y, Timsit JF. Severe SARS-CoV-2 infections: practical considerations and management strategy for intensivists. Intensive Care Med. 2020. doi: 10.1007/s00134-020-05967-x.
  12. Farmer JC, Wax R, Baldisseri MR. Preparing Your ICU for Disaster Response. Mount Prospect, IL: Society of Critical Care Medicine; 2012.
  13. Duan L, Zhu G. Psychological interventions for people affected by COVID-19 epidemic. Lancet Psychiatry. 2020. doi: 10.1016/S2215-0366(20)30073-0.