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.
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 - high-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 (confirmed or strong suspicion on the basis of chest imaging and clinical history) in patients requiring oxygen therapy as per targets, non-invasive ventilation or invasive ventilation. 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 with uncontrolled hyperglycaemia, please discuss with the diabetes team 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:
Patients on long term corticosteroid therapy, the decision to switch corticosteroid therapy to dexamethasone or hydrocortisone should be taken by the lead clinician bearing in mind corticosteroid equivalencies as follows:
Dexamethasone 6mg ≈ hydrocortisone 160mg ≈ prednisolone 40mg (equivalencies take no account of mineralocorticoid effects, nor duration of action)
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 for patients hospitalised due to COVID-19 guideline for clinical indications in patients hospitalised due to symptomatic COVID-19 and full inclusion and exclusion criteria, and dosing, supply, administration and monitoring guidance. For further information, see the manufacturer's Summary of Product Characteristics.
Tocilizumab is an immune modulating drug that is a humanised monoclonal antibody against the interleukin-6 (IL-6) receptor. The REMAP-CAP and RECOVERY trials have reported a survival benefit with the use of this agent 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 in adults who are receiving systemic corticosteroids and require supplemental oxygen or mechanical ventilation. See the tocilizumab for hospitalised patients with COVID-19 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.
Tocilizumab is a potent immunosuppressant drug. Patients are at risk of opportunistic infection following administration. It will suppress C-reactive protein for several weeks and this should therefore not be relied upon as an indicator of infection / inflammation.
A RoActemra® (tocilizumab) Patient Alert Card should be provided to patients when administered or, if not appropriate at the time, prior to discharge from level 2 or level 3 care. In addition to this, women of child-bearing potential should be advised to use effective contraception for 3 months following administration.
Baricitinib (a JAK inhibitor) is an anti-inflammatory used for rheumatoid arthritis and atopic dermatitis which has been shown in the RECOVERY study to have added benefits to dexamethasone and an IL-6 inhibitor (e.g. tocilizumab).
Note, baricitinib use in the context of COVID-19 is off-label. See the baricitinib guideline for full inclusion and exclusion criteria, and dosing and administration guidance.
An Olumiant® (baricitinib) Patient Alert Card should be provided to patients when baricitinib is being administered or, if not appropriate at the time, prior to discharge from level 2 or level 3 care if this is within 1 week of the last dose being administered (patients should be advised to keep the card for one week after the end of treatment).
These include Ronapreve® (casirivimab and imdevimab combined) or sotrovimab. There are currently no nMABs recommended or commissioned for use in patients hospitalised for the treatment of COVID-19 pneumonitis other than in clinical trials.
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 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 | 15/05/2023 |
| Page updated | 04/02/2025 |