DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
DEFINITION AND INTRODUCTION
- An infectious disease caused by SARS-CoV2 virus that can be complicated by severe respiratory impairment but can involve almost any body system
- Follow appropriate infection prevention measures in patients with confirmed or suspected COVID-19 infection
- Guidance, treatment and infection prevention strategies are regularly updated and affected by prevalence of COVID-19 and region - the latest local policies must be consulted
RECOGNITION AND ASSESSMENT
Symptoms and signs
- No single symptom or sign is diagnostic for COVID-19, and neither does the absence of any features rule out disease
- Contact with probable or confirmed case - although this may not be apparent
- Fever
- Flu like symptoms
- myalgia and arthralgia
- headache
- sore throat
- fatigue, malaise and anorexia
- sneezing and nasal congestion
- Cough
- dry/productive/haemoptysis
- Breathlessness
- Altered sense of smell/taste
- Chest pain and tightness
- Confusion and delirium
- Rash
- chilblains, urticaria
High risk characteristics
- Older age - aged ≥65 yr
- Male sex
- Ethnicity
- Obesity
- Unvaccinated
- Other comorbidities
- e.g. cancer; cardiovascular disease; chronic diseases of kidney, liver and lungs; and diabetes
- Immunosuppression
- Solid organ transplant
- Disability
- Frailty
- Pregnancy
Investigations
- FBC, U&E, LFT, CRP, blood glucose
- lymphopenia, leukocytosis, and thrombocytopenia may be present
- high neutrophil-to-lymphocyte ratio
- Real-time-reverse transcriptase polymerase chain reaction (RT-PCR)
- positive RT-PCR confirms COVID-19
- if COVID-19 is still clinically suspected, repeat 24-48 hr later
- Procalcitonin
- biomarker specific for bacterial infection that can support suspicion of secondary infection
- Extended spectrum respiratory atypical pneumonia swab
- Blood and sputum cultures
- PA chest X-ray
- ground-glass opacification; consolidation
DIFFERENTIAL DIAGNOSIS
- Community-acquired pneumonia
- Other viral infections
- influenza, RSV, common cold, MERS and avian flu
- Pneumocystis jirovecii pneumonia
- especially in presence of immunosuppression or HIV
- send sputum culture
- Febrile neutropenia
TREATMENT OF NON-HOSPITALISED PATIENT
- Manage patient at home unless:
- oxygen is required to maintain target saturations SpO2 ≥92%, ≥93% if pregnant unless risk of type 2 (hypercapnic)
- respiratory failure then target SpO2 88-92%
- respiratory rate (RR) ≥30 breaths/min (bpm) and using accessory muscles
- another medical condition or care issue necessitates admission
- high risk of deterioration and observation required - consider Virtual Oximetry@Home service
Infection prevention
- Provide isolation advice at home or healthcare institution on discharge
Management of breathlessness
- If severe shortness of breathlessness occurs implement escalation plan - see below
- Change body position
- Lying prone
Management of fever
- Paracetamol 1 g oral 6-hrly
- Ibuprofen 200-400 mg oral 8 hrly - only to be used at lowest effective dose for shortest period to control symptoms
- Encourage adequate fluid intake
- Only commence antibiotics if additional bacterial infection suspected
Management of cough
- Avoid lying on back
- less effective cough
Observe for signs of deterioration
- Advise patient and carers to observe for signs of deterioration that necessitate implementing escalation plan
severe shortness of breath
- coughing blood
- blue lips or face
- feeling cold and clammy
- pale and mottled skin
- collapse or faint and difficult to rouse
- new confusion
- reduced urine output
Virtual Oximetry@Home Service
Refer patients with confirmed COVID-19 infection who can be managed in the community with high risk characteristics and at risk of deterioration, but do not currently require oxygen, to the Virtual Oximetry@Home Service for monitoring of oxygen saturation
- Inclusion criteria
- confirmed COVID-19 infection
- patient registered with a GP in the Stoke-on-Trent or Staffordshire area
- aged ≥65 yr OR aged <65 yr and felt to be clinically vulnerable to COVID-19
- patient maintaining saturations on air of ≥95% on discharge
- Exclusion criteria
- service is for monitoring oxygen sats only, and not equipped to look after other active medical problems
- To refer to Virtual Oximetry@Home Service call Community Rapid Intervention Service (CRIS) on-call 0300 1230983, or send a referral email with patient details to CareCoordinationCentre@mpft.nhs.uk
COVID-19 treatments to prevent severe disease
To be initiated as soon as possible after SARS-CoV-2 positive result and within 5 days of symptom onset. Indicated if:
- Patient does not need oxygen
- Increased risk for progression to severe COVID-19, see section 5 of NICE’s technology appraisal - guidance on nirmatrelvir
- Diabetes
- Heart failure
Nirmatrelvir and ritonavir
- Nirmatrelvir is a peptidomimetic inhibitor of coronavirus 3C-like protease which prevents multiplication of SARS-CoV-2. Nirmatrelvir concentration is increased by ritonavir inhibition of CYP3A-mediated metabolism
- Firstline
- If confirmed or suspected co-infection with HIV 1, discuss with microbiology and infectious disease consultant
- For patients either of:
- aged ≥70 yr or
- BMI ≥35 kg/m2
- Nirmatrelvir 300 mg (two pink tablets) and ritonavir 100 mg (one white tablet) twice daily for 5 days, to be taken together
- reduce dose to 150 mg nirmatrelvir (one pink tablet) and 100 mg ritonavir (one white tablet) twice daily in moderate renal impairment (eGFR 30-60 mL/min)
- Avoid:
- if severe renal impairment (eGFR <30 mL/min)
- if severe hepatic failure
- in pregnancy
- Do not breastfeed during treatment and until 7 days after last dose
Sotrovimab
- Human immunoglobulin monoclonal antibody that binds to the spike protein receptor binding domain of SARS-CoV-2, which prevents the virus from entering human cells
- Only use if nirmatrelvir plus ritonavir contraindicated or unsuitable
- For patients weighing ≥40 kg
- 500 mg for 1 dose diluted in 50 mL or 100 mL glucose 5% or sodium chloride 0.9% and administered over 30 min through an in-line 0.2 micron filter
Antimicrobials
- Antibiotics not indicated unless secondary bacterial infection suspected - see appropriate guideline
Care planning
- Complete care plan for deterioration in consultation with patient and carers to collaboratively establish appropriate escalation plan and how to access:
- a move to secondary care
- other community-based support (virtual ward, hospital-at-home or palliative care)
TREATMENT OF HOSPITALISED PATIENT
Infection prevention
- Admit patient to suitably isolated bed
Care plan
- Complete COVID-19 care plan in addition to admission care plans
- latest version of care plan is available on Trust intranet site at A-Z > COVID-19 (Coronavirus) > COVID-19 Care plan and ward round guidance
Respect documentation
- Complete respect form to document escalation of treatment decisions
- document stability of underlying health conditions
- assess frailty using Clinical Frailty Score (CFS) available online
- do not use in younger people, those with long-term disability, learning disability or autism, who require individualised assessment
- discuss treatment goals with patient (if possible) and relatives
- include decisions about CPR, CPAP, non-invasive ventilation and intubation and critical care management
COVID-19 treatments to prevent severe disease
To be initiated as soon as possible after SARS-CoV-2 positive result and within 5 days of symptom onset. Indicated if:
- Patient does not need oxygen
- Increased risk for progression to severe COVID-19, see section 5 of NICE's technology appraisal - guidance on nirmatrelvir
- Diabetes
- Heart failure
Nirmatrelvir and ritonavir
- Nirmatrelvir is a peptidomimetic inhibitor of coronavirus 3C-like protease which prevents multiplication of SARS-CoV-2. Nirmatrelvir concentration is increased by ritonavir inhibition of CYP3A-mediated metabolism
- Firstline
- If confirmed or suspected co-infection with HIV 1, discuss with microbiology and infectious disease consultant
- For patients either of:
- aged ≥70 yr or
- BMI ≥35 kg/m2
- Nirmatrelvir 300 mg (two pink tablets) and ritonavir 100 mg (one white tablet) twice daily for 5 days, to be taken together
- reduce dose to 150 mg nirmatrelvir (one pink tablet) and 100 mg ritonavir (one white tablet) twice daily in moderate renal impairment (eGFR 30-60 mL/min)
- Avoid:
- if severe renal impairment (eGFR <30 mL/min)
- if severe hepatic failure
- in pregnancy
- during breast feeding
- Do not breastfeed during treatment and until 7 days after last dose
Sotrovimab
- Human immunoglobulin monoclonal antibody that binds to the spike protein receptor binding domain of SARS-CoV-2, which prevents the virus from entering human cells
- Only use if nirmatrelvir plus ritonavir is contraindicated or unsuitable
- For patients weighing ≥40 kg
- Can be given if pregnant
- 500 mg for 1 dose diluted in 50 mL or 100 mL glucose 5% or sodium chloride 0.9% and administered over 30 min through an in-line 0.2 micron filter
Awake prone positioning
- Indications
- SpO2 <94% and RR >22 bpm
- patients on oxygen supplementation, NIV, and CPAP
- patient must be alert and able to safely self-prone
- Technique
- Proning leaflet is available online
- Contraindications
- need for immediate intubation
- respiratory exhaustion
- reduced consciousness
- haemodynamic instability
- trauma and recent surgery causing discomfort or musculoskeletal instability
- pregnancy: second and third trimester
Oxygen
- See Hypoxaemia guideline
- SpO2 88-92% for non-critical patients at risk of type 2 (hypercapnic) respiratory failure
- SpO2 92-96% for all other patients with COVID-19
Critical care referral
- If it has been agreed that escalation to critical care would be appropriate, refer to critical care on call if patient:
- requires ≥40% oxygen to maintain SpO2 ≥90%
- is in respiratory distress with respiratory rate (RR) ≥30 bpm, using accessory muscles or is exhausted
- rapid increase in oxygen requirement or decline in NEWS score
Enhanced respiratory support on respiratory ward
- Patients to be offered high flow nasal oxygen (HFNO) or CPAP if normocapnic or NIV if hypercapnic if:
- not suitable for or do not wish to escalate to critical care or
- are appropriate for enhanced support but not intubation or
- are likely to respond to enhanced respiratory support and are not likely to need intubation
- Call respiratory HDU (ward 222) and respiratory support unit (ward 128) to discuss administration of HFNO, CPAP and NIV and discuss with consultant on call for NIV and CPAP
Corticosteroids
- If patient requires oxygen or ventilatory support and is not pregnant administer dexamethasone 6 mg daily or if unable to take medication orally, dexamethasone 1.8 mL (5.94 mg) of 3.3 mg/mL injection IV once daily for 10 days or until discharge if sooner
- if pregnant give prednisolone 40 mg once daily, or if unable to take medication orally hydrocortisone 80 mg IV twice daily for 10 days or until discharge if sooner
Tocilizumab
- Recombinant humanised monoclonal antibody that binds to interleukin-6 receptors thereby blocking the activity of pro-inflammatory cytokines
- In patient with confirmed active COVID-19 infection and all of:
- patient already taking dexamethasone or steroids contraindicated
- patient on oxygen and CRP ≥75 or within first 48 hr of starting invasive ventilation, NIV or CPAP
- Prescribe and dispense using brand name, 8 mg/kg (max. per dose 800 mg) for 1 dose diluted in 100 mL of normal saline and given as IV infusion over 1 hr
- IL-6 inhibitors must be prescribed on a separate prescription form/checklist which can be found via: Intranet > A-Z > COVID-19 (Coronavirus) > COVID-19 Care plan > Request Forms
- IL-6 inhibitors are contraindicated if ANY of the following;
- ALT or AST >5x upper limit of normal
- neutropenia (<2.0)
- thrombocytopenia (cut-off platelets <50 for tocilizumab)
- Use caution in patients who may be otherwise immunosuppressed or if clear evidence of a bacterial, fungal, viral or other infection besides COVID-19, including active tuberculosis, HIV or viral hepatitis. If serious infection occurs, interrupt treatment
- Women of child-bearing age should take contraception for 3 months post-dose
- Hypersensitivity/allergic reactions are possible, report any adverse events to the MHRA by the dedicated COVID-19 Yellow Card Reporting Site
Antimicrobials
- Antibiotics not indicated for COVID-19 pneumonitis unless secondary bacterial infection suspected
- purulent sputum
- raised procalcitonin
- deterioration after biomarker and clinical improvement
- CXR changes suggest pneumonic consolidation
- See Community acquired pneumonia and Hospital acquired pneumonia guidelines
Prophylactic and therapeutic anticoagulation for venous thromboembolic disease
Prophylactic treatment
- For non-hypoxic patients, patients with an increased bleeding risk or those requiring advanced oxygen support (e.g. high-flow, CPAP/NIV or IMV)
- Omit if platelets <30, otherwise administer according to table below:
Dose | Weight | |||
Dalteparin | <45 kg | 45-100 kg | 101-150 kg | 150 kg |
eGFR >30 mL/min | 2500 units S/C once daily | 5000 units S/C once daily | 5000 units S/C twice daily | 7500 units S/C twice daily |
eGFR ≤30 mL/min | 2500 units S/C once daily | 2500 units S/C once daily | 5000 units S/C once daily | 7500 units S/C once daily |
- Stop prophylactic LMWH once patient is discharged unless significantly high risk of thrombosis (see below) and prolonged VTE prophylaxis for a total of 7 days - refer to district nurses:
- past history of VTE
- significant immobility
- significant obesity
- other comorbid conditions increasing VTE risk
Therapeutic anticoagulation
- Commence all hypoxic patients on low-flow oxygen (i.e. nasal cannula or venturi masks) who do not have an increased bleeding risk (HASBLED score >3 due to irreversible factors - see Atrial fibrillation guideline) on therapeutic dalteparin - see Dalteparin for VTE guideline
- Continue for maximum of 14 days and stop on discharge
- If platelets <100 or patient is pregnant, discuss with haematology before prescribing
- If care escalated to CPAP, NIV, HFNO or invasive mechanical ventilation convert back to prophylactic dose
- Check platelets, eGFR and liver function and review patient risk daily
DISCHARGE AND FOLLOW-UP
- People are usually infectious for 10 days after developing symptoms
- Provide infection control advice
- Before patient discharged, request CXR for 6-8 weeks
- Arrange follow-up in outpatients to ensure continued recovery. If on review continued shortness of breath arrange:
- lung function tests and refer to respiratory department
- echocardiogram
- if CXR not resolved, arrange CT chest