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Awaiting dx, decision on tx setting
In setting of COVID-19, screen and isolate pts at 1st point of contact, use PPE.1,2 Assess for pneumonia s/sx:3
- cough
- dyspnea, tachypnea
- fever (T ≥38.0°C), shivers, sweats
- pleural pain, generalized aches/pains
- new/localizing chest exam signs
Assess severity to determine outpt vs. inpt care setting. Imaging may not be feasible/available, esp. in COVID-19 settings. - Use PSI rather than CURB-65 to determine outpt vs. inpt setting, per ATS/IDSA;4 (PSI risk score available via epocrates search bar). Consistent evidence supports safety/effectiveness of PSI, but CURB-65 is simpler (based on confusion, urea, RR, BP, age >65 yo), doesn’t require labs/ABG.
- Severe CAP requiring inpt care2 in setting of COVID-19 = fever and/or suspected resp infection PLUS ≥1 of: RR >30, severe resp distress, SpO2 ≤93% on RA.
- Severe CAP requiring ICU care4 = pt in septic shock requiring pressors or resp failure requiring mechanical ventilation; or pts w/ ≥3 of: RR ≥30, PaO2/FiO2 ≤250, multilobe infiltrates, AMS, BUN ≥20, WBC <4K/uL, plt <100K/uL, T <36°C, hypotension.
Test early for COVID-19 in pts w/ fever, cough/dyspnea;1 consider flu,1,4 other coinfections.2 Absence of imaging shouldn’t delay empiric tx.3 - Use nasopharyngeal swab. PCR/NAAT more reliable than antigen tests. Follow algorithm5 for antigen testing (most POC tests).
o Symptomatic – If antigen test positive, isolate and treat as appropriate. If antigen test negative, repeat in 48h or perform PCR/NAAT. If 2nd antigen test negative, consider alternative dx.
- Most COVID-19 pts have mild dz; ~15% develop severe dz (e.g., pneumonia) requiring hospitalization and O2; ~5% require ICU care.2
- Mask/isolate pt upon 1st contact w/ health care setting. Repeatedly assess for droplet, contact, airborne precautions. Use PPE; if possible, use disposable/dedicated stethoscope, BP cuff, pulse-ox, thermometer, etc.—or disinfect between each pt.2
- Blood cx, sputum Gram stain/cx not routinely recommended at dx for outpt.3,4 Consider in select inpts, per ATS/IDSA.4 Obtain cx pre-tx.
- Reinfection w/ COVID-19 can occur w/in 90 days of the initial infection.1 Follow special testing considerations.1,5,6
o If 1st positive test w/in ≤30 days: Symptomatic – Use antigen test. If negative, repeat in 48h. If 2nd test negative, consider PCR/NAAT or repeat antigen test. Asymptomatic – Testing not recommended to detect new infection.
o If 1st positive test w/in 31-90 days: Symptomatic – Use antigen test. If negative, repeat in 48h. If 2nd test negative, consider PCR test or repeat antigen test in 48h. Asymptomatic w/ new exposure – Use antigen test. If negative, repeat in 48h. If 2nd test negative, repeat in 48h (total 3 tests). If negative x3 and concern, consider PCR/NAAT. - Influenza rapid NAAT test4 (w/ prompt tx w/in 48h) recommended (vs. RIDT) when flu circulating.3,4 May consider testing pts w/ ILI during periods of low flu activity.4
- Consider RSV, esp. during RSV season.1 Use rRT-PCR RSV test (not antigen test) in older children/adults.1
- Legionella urine test if severe CAP (or if local outbreak or travel-related).4
- CRP can strengthen dx/exclusion, per ACCP,3 though evidence low. CRP >30 mg/L w/ suggestive s/sx: CAP likely cause of acute cough. CAP less likely if CRP <10 mg/L or if pt w/o dyspnea/fever has CRP <50 mg/L.3
- Not recommended: routine sputum Gram stain/cx3 except in certain4 hospitalized pts (e.g., severe, intubated, tx for MRSA/P. aeruginosa infection, prior hospitalization w/in 90 days), procalcitonin level,3,4 pneumococcal urine antigen.4
- Infiltrate on CXR confirms or rules out CAP, esp. in pts w/ abnormal vitals.3 CXR/CT alone not recommended to diagnose COVID-19 but might be helpful in assessing and managing COVID-19 pts.1
Footnotes 1 CDC 2023. Clinical Care Considerations. Clinical considerations for care of children and adults with confirmed COVID-19. Centers for Disease Control and Prevention. Updated August 4, 2023. Accessed September 12, 2023
2 WHO 2021. Living guidance for clinical management of COVID-19. World Health Organization. Updated November 23, 2021. Accessed November 28, 2021
3 CHEST 2019. Hill AT, et al. Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. Chest. 2019 Jan;155(1):155-167. PDF
4 ATS/IDSA 2019. Metlay JP, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. Full-text article
5 CDC 2023. Considerations for SARS-CoV-2 Antigen Testing for Healthcare Providers Testing Individuals in the Community. Centers for Disease Control and Prevention. Updated May 11, 2023. Accessed September 12, 2023
6 FDA 2022. At-Home COVID-19 Antigen Tests-Take Steps to Reduce Your Risk of False Negative Results: FDA Safety Communication. U.S. Food and Drug Administration. Updated November 17, 2022. Accessed September 12, 2023
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Start empiric antimicrobials if imaging (+), or if imaging not available but CAP suspected.1,2 Use antibacterials in CAP, even if flu test (+),1 but not in COVID-19.3 - Abx duration: until stabilized for ≥5 days.1
- If no high-risk comorbidity1/MRSA/Pseudomonas infection risk:1 amoxicillin, doxycycline; macrolides OK if local resistance <25%.
- If high-risk comorbidity (chronic heart, lung, liver, or renal dz; DM; alcoholism; malignancy; asplenia):1 combo tx w/ 1 of these: amoxicillin/clavulanate, cefpodoxime, cefuroxime PLUS 1 of these: azithromycin, clarithromycin, doxycycline. Or use mono-tx w/ levofloxacin, moxifloxacin, or gemifloxacin.1
- MRSA/Pseudomonas infection risk: rare in outpt setting, but consider coverage, if present.1
- If influenza suspected or test (+): Start antiviral w/in 48h of sx onset, per ACCP.2 ATS/IDSA suggests flu tx for CAP pts w/ (+) flu test, regardless of sx duration.1
- If flu test (+) in CAP w/ (+) CXR: Empiric antibacterials should still be used.1
- Routine f/u CXR for CAP not recommended if sx resolved in 5-7 days,1 per ATS/IDSA.
For mild to moderate suspected or confirmed COVID-19, use home isolation, supportive care.4 Prioritize COVID-19 testing.4,5 Avoid routine abx.3 Offer tx to high-risk pts.4 - Home isolation suitable; educate about when to seek care; pts who are older, have underlying conditions, or are immunocompromised are at higher risk, so they should contact physician early, even for mild sx,3 and warrant closer monitoring.3,5
- If high risk, offer specific tx (e.g., antivirals/monoclonal Ab) to decrease risk of hospitalization and death.4 Monitor closely. If immunocompromised, consider convalescent plasma w/in 8 days of sx onset (low certainty of evidence). Pts who aren’t immunocompromised would likely place a lower value on the uncertain benefits of convalescent plasma (reductions in need for mechanical ventilation, hospitalization, and death).6
- Follow most-recent guidance for postexposure ppx or tx; see epocrates resource: Consensus Guidelines for COVID-19 Drug Therapies in Adults.
- Consider home pulse-ox for pts at risk of deterioration.3 Home SpO2 <92% increases RR of hospitalization (7.0), ICU (9.8), ARDS (8.2), and septic shock (6.6)3 but may not detect occult hypoxemia in all pts, esp. in those w/ darker skin, and smart phone–based pulse oximeters may not accurately detect hypoxia.4
- Use outpt supportive care, e.g., antipyretics3 (NSAIDs not contraindicated, per FDA).7 Avoid steroids (inhaled or systemic)1,3,6 unless required for other indications (e.g., COPD exacerbation);4 weigh benefit/harm of antenatal steroids if pregnant and at risk for preterm labor. Don’t use anticoagulants/antiplatelets to prevent VTE (unless other indications for this tx).8
- Don’t routinely use empiric or prophylactic abx; bacterial coinfection rare in COVID-19 (only 8% of hospitalized COVID-19 pts).3 Consider abx in older adults (esp. those in long-term care facilities) and children <5 yo;3 use AWaRe Access abx vs. broad-spectrum abx in Watch and Reserve categories.3
Footnotes 1 ATS/IDSA 2019. Metlay JP, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. Full-text article
2 CHEST 2019. Hill AT, et al. Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. Chest. 2019 Jan;155(1):155-167. PDF
3 WHO 2021. Living guidance for clinical management of COVID-19. World Health Organization. Updated November 23, 2021. Accessed November 28, 2021
4 CDC 2023. Clinical Care Considerations. Clinical considerations for care of children and adults with confirmed COVID-19. Centers for Disease Control and Prevention. Updated August 4, 2023. Accessed September 12, 2023
Home care isolation guidance available from CDC.
Underlying Medical Conditions Associated with Higher Risk for Severe COVID-19: Information for Healthcare Professionals
5 IDSA 2020. COVID-19 Prioritization of Diagnostic Testing. Infectious Diseases Society of America. Updated March 17, 2020. PDF
6 IDSA 2023. COVID-19 Guideline: Treatment and Management. Infectious Diseases Society of America. June 26, 2023. Accessed September 18, 2023
7 FDA 2020. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. U.S. Food and Drug Administration. March 19, 2020. Accessed March 26, 2020
8 NIH 2023. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Updated August 22, 2023. Accessed September 20, 2023
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In the setting of COVID-19, screen and isolate pts at 1st point of
contact;1 use PPE.2 Use severity criteria for ICU decision. Start empiric antibacterials even if (+) flu test in CAP;3 give steroids in severe COVID-19.
- Mask/isolate pt upon 1st contact w/ health care setting.1,2 Repeatedly assess for droplet, contact, airborne precautions.1 Use PPE;2 if possible, use disposable/dedicated stethoscope, BP cuff, pulse-ox, thermometer, etc.—or disinfect between each pt.1
- Direct ICU admission for major severity criteria (e.g., septic shock needing pressors or resp failure requiring mechanical ventilation) or if 3+ of: RR ≥30, PaO2/FiO2 ≤250, multilobe infiltrates, AMS, BUN ≥20, WBC <4K/uL,1 plt <100K/uL, T <36°C, hypotension; per ATS/IDSA.3
Start empiric antimicrobials if imaging (+), or if imaging not available but CAP suspected. Use antibacterials even if (+) flu test in CAP.3 - Pre-tx blood/sputum cx for: severe CAP (esp. if intubated); treat pts empirically for MRSA or P. aeruginosa so abx can be de-escalated if cx (-). Conditionally recommended in pts previously infected w/ MRSA or P. aeruginosa, as well as pts exposed in past 90 days to hospitalization plus parenteral abx. Check nasal PCR for MRSA if available.3
- Abx duration: until stabilized for ≥5 days.3 Stabilized = T, HR, RR, BP, SpO2, eating, mentation all NL.
- If nonsevere CAP: combo tx w/ 1 of these: ampicillin/sulbactam, cefotaxime, ceftaroline, ceftriaxone PLUS azithromycin or clarithromycin. Or use mono-tx w/ levofloxacin or moxifloxacin.3 If both macrolides and fluoroquinolones contraindicated, could combine β-lactam w/ doxycycline.3
- If severe CAP: combo tx w/ 1 of these: ampicillin/sulbactam, cefotaxime, ceftaroline, ceftriaxone PLUS 1 of these: azithromycin, clarithromycin, levofloxacin, moxifloxacin.3
- If MRSA risk:3 If severe CAP or previous MRSA isolate hx, add vancomycin or linezolid; based on limited evidence, consider de-escalating at 48h based on cx/nasal PCR results. If nonsevere CAP w/o previous isolate hx, withhold until/if (+) cx and/or nasal PCR results.
- If Pseudomonas infection risk:3 If severe CAP or previous Pseudomonas isolate hx, add piperacillin/tazobactam, cefepime, ceftazidime, aztreonam, meropenem, or imipenem; based on limited evidence, consider de-escalating at 48h based on cx results. Otherwise, withhold until/if (+) cx results.
- If influenza suspected or test (+), start antiviral w/in 48h of sx onset, per ACCP.4 ATS/IDSA suggests flu tx for CAP pts w/ (+) flu test, regardless of sx duration.3 If flu test (+) in CAP w/ (+) CXR: Empiric antibacterials should still be used.
- Not recommended. Corticosteroids not recommended in CAP (except in severe COVID-19),5,6 influenza;3 if aspiration suspected, don't routinely add anaerobic coverage unless lung abscess/empyema suspected.3
For severe suspected or confirmed COVID-19, use isolation,3 ventilatory monitoring, and support w/ proning,5 corticosteroids, and other appropriate meds.5,6 Prioritize COVID-19 testing.3,4 - Corticosteroids for severe COVID-19: dexamethasone (6 mg/day x10 days) recommended if pt on supplemental O2, mechanical ventilation, ECMO.5,6 If dex unavailable, use equivalent daily steroid doses: methylprednisolone 32 mg, prednisone 40 mg.6
- Meds for COVID-19: See epocrates resource: Consensus Guidelines for COVID-19 Drug Therapies in Adults.
- Consider proning all severely ill pts requiring supplemental O2 (including HFNO) or noninvasive ventilation.
- Use early warning scores (e.g., NEWS2) to monitor for rapid deterioration in COVID-19.1
- Don’t use anticoag/antiplatelet tx to prevent arterial thrombosis outside usual standard of care.
- VTE ppx recommended for ALL nonpregnant pts hospitalized w/ COVID-19.1,5 Ppx-dose LMWH preferred over UFH preferred over oral anticoagulants. (Don’t use rivaroxaban. Insufficient evidence for/against apixaban.) Evaluate for thromboembolic dz if rapid deterioration.5 If high suspicion for VTE, treat w/ anticoagulation.5 If ECMO, CRRT, or thrombosis related to catheters/extracorporeal filters, treat w/ antithrombotic as per standard institutional protocol.5 If hospitalized on low-flow O2 (not ICU) w/ elevated d-dimer and no increased risk of bleeding, use tx-dose heparin.5 Contraindications: plt <50 x 10*9/L, Hgb <8 g/dL, need for dual antiplatelet tx, bleeding w/in 30 days requiring ED/hospital visit, hx of bleeding d/o, inherited/active acquired bleeding d/o. If transferred to ICU, change to ppx-dose heparin unless confirmed VTE.5
- Don’t continue VTE ppx on hospital d/c unless another indication exists.5
- Don’t use antiplatelet tx to prevent COVID-19 dz progression/death in noncritically ill pts. Evidence insufficient for use in critically ill pts.5
- D/c COVID-19 precautions based on CDC protocols.2
Provide adjunctive support, monitor closely (esp. in COVID-19). - Use O2 to target higher SpO2 (>94%) in pts w/ emergent signs or during resuscitation; once stable, target SpO2 >90% (≥92%-95% if pregnant), per WHO.1
- Failure to achieve clinical stability3 w/in 5 days should prompt eval for pathogen resistance or complications (empyema, lung abscess).3
- Routine f/u CXR not recommended by ATS/IDSA if sx resolved in 5-7 days.3
Footnotes 1 WHO 2021. Living guidance for clinical management of COVID-19. World Health Organization. Updated November 23, 2021. Accessed November 28, 2021
2 CDC 2023. Clinical Care Considerations. Clinical considerations for care of children and adults with confirmed COVID-19. Centers for Disease Control and Prevention. Updated August 4, 2023. Accessed September 12, 2023
Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
3 ATS/IDSA 2019. Metlay JP, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. Full-text article
4 CHEST 2019. Hill AT, et al. Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. Chest. 2019 Jan;155(1):155-167. PDF
5 NIH 2023. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Updated August 22, 2023. Accessed September 20, 2023
6 IDSA 2023. COVID-19 Guideline: Treatment and Management. Infectious Diseases Society of America. June 26, 2023.
Accessed September 18, 2023
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