CHESTGuidelines & Topic CollectionsCOVID-19 Resource CenterManagement of Patients With COVID-19 Infection

Management of Patients With COVID-19 Infection

Ryan C. Maves, MD, FCCP; and Vikram Mukherjee, MD
 Updated July 28, 2020; originally published March 11, 2020

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

First reported in the city of Wuhan, Hubei Province, China, the 2019 coronavirus disease (COVID-19) has since spread widely across the world, leading to more than 10 million cases and 500,000 deaths as of late June 2020.1 The United States has been particularly affected, with >2.5 million cases and 128,000 deaths from COVID-19 to date. The causative virus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is highly contagious with well-documented human to human spread; the prompt identification and isolation of infected individuals are paramount in preventing further transmission.2

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 the CDC website. Given widespread community transmission in the US, clinicians should have a low threshold to initiate testing based on clinical symptom and exposure history.

Recommendation

Since many parts of the United States are experiencing increasing community prevalence of disease, testing should be considered in the following populations:

  • Testing in individuals with signs and symptoms consistent with COVID-19
  • Testing asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission
  • Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification in special settings
  • Testing to determine resolution of infection
  • Public health surveillance for SARS-CoV-2

For patients meeting PUI criteria:

  • Instruct the patient to wear a surgical mask. The 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 facility’s infection prevention department.

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

Epidemiology and clinical features

SARS-CoV-2 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 June 28, 2020, there have been more than 500,000 reported cases of COVID-19 and over 128,000 deaths. 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); however a negative test should be interpreted with caution in the appropriate clinical scenario.

Transmission of COVID-19 appears to be primarily from symptomatic persons, although transmission from presymptomatic and asymptomatic hosts is well-described and may drive a large component of community spread.5 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.6

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.7, 8

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; the use of early, prolonged prone positioning; and the use of extracorporeal membrane oxygenation (ECMO) for severe, refractory cases.8 Clinicians should consider initiating antibacterial therapy in patients with severe disease, although the level of supportive evidence is currently limited.

Remdesivir, an inhibitor of viral RNA-dependent RNA polymerase, has shown promise as a therapeutic candidate for SARS-CoV-2 infection. It improves recovery time in hospitalized patients with COVID-19 and hypoxemia, although a significant mortality benefit is yet to be determined.9 Remdesivir is available through Federal Emergency Management Agency (FEMA) allocations to state and local public health departments; supplies of the drug have been limited, but remdesivir is recommended for severe COVID-19 pneumonia in hospitalized patients with room air oxygen saturations of 94% or less by both the National Institutes of Health (NIH) and Infectious Diseases Society of America (IDSA) COVID-19 treatment guidelines in the US.10 A 10-day course of therapy is recommended for patients requiring mechanical ventilation or extracorporeal membrane oxygenation (ECMO), although the manufacturer-sponsored SIMPLE trial suggests that a 5-day course of therapy may be equally effective in patients not requiring invasive support.11

Glucocorticoids may have a role to play in the treatment of severe COVID-19 as well. Despite discouraging data from experiences in SARS and MERS, the recent RECOVERY trial conducted in the United Kingdom reported a significant mortality benefit in patients with hypoxemia due to COVID-19 pneumonia, including patients requiring mechanical ventilation.12 The results of RECOVERY may be limited by a high baseline mortality, a lack of blinding, and uncertainties about patient allocation; however, given the magnitude of the reported mortality benefit, both the NIH and IDSA COVID-19 treatment guidelines have recommended dexamethasone 6 mg (either intravenous or oral dosing) for up to 10 days, with strong recommendations for patients requiring invasive mechanical ventilation and moderate recommendations for those requiring noninvasive supplemental oxygen.

Additional adjunctive therapies, including convalescent plasma, IL-1, and IL-6 antagonists, and interferon-beta remain under investigation. At this time, these therapies remain investigational, and usage of these agents may be best considered in the context of clinical trials. Some therapies that were considered and recommended earlier in the pandemic, including lopinavir-ritonavir and hydroxychloroquine, appear to be ineffective and are no longer recommended.13, 14

There is evolving evidence of the benefits of systemic anticoagulation among hospitalized patients with COVID-19. At the very least, providers must maintain a high index of suspicion for development of arterial and venous thrombi. While retrospective studies have suggested that therapeutic anticoagulation may be associated with improved survival, ongoing research will cast light on triggers for initiation, duration and side effects of this strategy. At a minimum, hospitalized patients with COVID-19 should receive appropriate venous thromboembolism prophylaxis, preferentially with enoxaparin, pending the results of ongoing randomized trials to investigate the role of more intensive anticoagulation strategies.

Health-care workers (HCWs) are at a high risk for contracting infection through nosocomial transmission routes. 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.

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 performed in airborne isolation rooms: patients requiring positive-pressure ventilatory support should be 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 isolation room (AIIR).15, 16

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 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.17, 18

Disclaimer

Given the rapidly-changing nature of this pandemic, clinicians in the United States are recommended to refer to www.cdc.gov and www.covid19treatmentguidelines.nih.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.

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