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Inpatient COVID-19 Management

Aisha Suara

Testing

  • Test patients with any new fever, cough, shortness of breath, loss of taste/smell, diarrhea/vomiting, or flu-like symptoms
  • Asymptomatic testing for SARS-COV-2 is no longer required for routine admissions or pre-procedures
  • Exceptions:
    • Admission to 10 CCT, 11N, MCE6, and MCE7
    • Pre-transplant pre-procedure planning
    • May also be required by post-acute care facility prior to discharge
  • Would avoid retesting those with confirmed COVID-19 within the last 30 days unless they develop symptoms or fall within the exceptions due to risk of lingering detection without contagiousness or recurrent infection

Evaluation of Admitted Patients with Symptomatic Acute COVID-19

  • Please refer to the hospital’s current maximum oxygen requirement allowed on the floor to ensure patient is appropriately triaged
  • Basic admission workup for symptomatic, confirmed COVID-19
    • Labs: CBC with diff, CMP, D-dimer, Ferritin, CRP, ESR, PT/INR, PTT, procalcitonin
    • Imaging: Portable CXR. Consider CTA PE if sudden or rapid worsening of hypoxia
    • Nursing: Strict I/O’s to avoid pulmonary edema
    • Enhanced precautions (contact, airborne, eye protection)

Management

  • Fluid balance goal slightly net negative to even
  • Anticoagulation/DVT prophylaxis:
    • Current guidelines suggest DVT ppx on admission
    • Would only initiate treatment dose anticoagulation if confirmed DVT/PE

Pharmacologic therapies

  • Note: Therapies, indications, and contraindications are frequently changing, please see latest VUMC/VA guidelines for specific indications for these medications or others. For VUMC, RedCap form is required prior to ordering Paxlovid or Remdesivir
  • Nirmatrelvir/ritonavir (Paxlovid)
    • For use in symptomatic patients within 5 days of symptoms at high risk for progression to severe disease without significant drug interactions
    • Contraindications:
      • Risk of HIV resistance in patients with uncontrolled or undiagnosed HIV-1 infection
    • Dosing:
      • eGFR > 60: nirmatrelvir 300 mg (two 150 mg tablets) + ritonavir 100 mg (one 100mg tablet) BID x 5 days
      • eGFR 30 to <60 mL/min: nirmatrelvir 150 mg (one 150 mg tablet) + ritonavir 100 mg (one 100 mg tablet) BID x 5 days
      • eGFR <30 mL/min: use is not recommended
    • Significant drug interactions
  • Remdesivir
    • For use in patients hospitalized with COVID within 7 days of symptoms at high risk for progression to severe disease
    • Contraindications: known hypersensitivity, ALT >/= 10x ULN, on mechanical ventilation or ECMO
    • Dosing:
      • Mild to moderate COVID-19 who may be admitted for other indications but are at high risk of progression to severe COVID 19: loading dose 200mg IV x1 then 100mg IV q24h x 2 days. Course can be extending for a total of 5 days if patient progresses to severe COVID-19 (requiring supplemental oxygen)
      • Severe COVID-19 requiring supplemental oxygen: loading dose 200mg IV x1 then 100mg daily x 4 days
    • Monitoring: baseline CBC, INR, q48h CMP
    • Do not need to remain in the hospital to complete course of Remdesivir
  • Dexamethasone
    • For inpatient management of COVID-19 who require supplemental respiratory support (NC, non-invasive ventilation, mechanical ventilation, or ECMO)
    • Dosing
      • 6mg PO/IV x 10 days; consideration of longer taper if no clinical improvement or persistently elevated CRP
      • 12mg Po/IV daily can be considered in those requiring >=10L who are clinically worsening despite 6 mg and who are not eligible for baricitinib or tocilizumab
    • Contraindications: no hard contraindications, use clinical judgement if concomitant serious bacterial/fungal infection
  • Baricitinib (JAK inhibitor)
    • Eligibility determined by ID and/or Pulm/Crit
    • Use in those requiring >=6L or >40% FiO2, <=7 days since admission to the hospital, and/or clinical worsening despite steroids and supportive care
    • Contraindications: hypersensitivity, concurrent treatment with tocilizumab, dialysis, ESRD, or acute anuric kidney injury, ALT>= 10x ULN, active TB or systemic fungal infection, or pregnancy
    • Dosing:
      • Would discuss with pharmacist if patient is taking an OAT3 inhibitor, otherwise dosing is based on eGFR
      • For patients with eGFR > 60 ml/min: baricitinib 4 mg po daily
      • For patients with eGFR 30-59 ml/min, baricitinib 2 mg po daily
      • For patients with eGFR 15-29 ml/min, baricitinib 1 mg po daily
    • To be administered for 14 days or until hospital discharge
    • Monitoring: CBC w/ diff and CMP at baseline
    • Adverse events: thrombosis, elevated LFTs, severe infection 2/2 lymphopenia and neutropenia
  • Tocilizumab (IL-6 inhibitor)
    • Eligibility determined by ID and/or Pulm/Crit
    • Adjunctive therapy for those who are not eligible with baricitinib
    • Contraindications: hypersensitivity, recent hx of diverticulitis, history of bowel perforation, demyelinating disorders, ALT>= 5x ULN, ANC <500, Plt <50k, active bacterial, fungal, or viral infection other with COVID-19
    • DOSING: 8mg/kg, up to max of 800mg IV, once
    • Adverse events: Bowel perforation, elevated lipids, elevated LFTs, serious infections
  • Antibiotics:
    • Consider CAP coverage if evidence of PNA on imaging or lack of improvement despite supportive care
    • Can also use procalcitonin to guide decision though procal may be elevated in severe COVID-19 infection without concomitant bacterial infection

Discharge Recommendations

  • Typical discharge criteria for respiratory illness requiring supplemental oxygen
  • If patient was hospitalized FOR COVID-19, Patients should self-isolate x 20 days after the test was obtained AND until improving and fever-free x 24 hours
    • If hospitalized WITH COVID-19 (i.e. hospitalized for other indications and required remdesivir and/or steroids), would isolate for 10 days after test was obtained
  • Consider telehealth PCP f/u
  • May be seen in-person at clinic after they have completed the required isolation
  • Consider a referral to home health

Multisystem Inflammatory Syndrome in Adults (MIS-A)

  • Consider in those with fever with unclear etiology, history of previous COVID-19 diagnosis 2-8 weeks prior, and laboratory evidence of organ dysfunction
  • See VUMC COVID-19 Guidance for MIS-A for full diagnostic criteria
  • Treatment: IVIG, steroids, and DVT ppx