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COVID-19 Management
Bridging Clinical Gaps in COVID-19 Management: Evolving Guidelines and Treatment Strategies

Released: November 21, 2024

Expiration: November 20, 2025

Payal K. Patel
Payal K. Patel, MD, MPH, FIDSA
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Key Takeaways
  • Inpatient COVID-19 management guidelines, which are often guided by local antimicrobial stewardship programs, should be tailored to individual settings using the latest national guideline recommendations and clinical data. 

The overnight resident reports to the incoming medicine ward team that a patient is being transferred from the emergency department with COVID-19. In the current era, how does the medicine team approach management of inpatient COVID-19?

Evolving Treatments
In recent years, numerous antiviral therapeutics have been available for COVID-19 with varying efficacy. However, many of these agents, including previously available monoclonal antibodies, have been retired as COVID-19 variants have evolved.

Current inpatient management guidelines for COVID-19 are often guided by local antimicrobial stewardship programs in accordance with national guideline recommendations. Given the rapid evolution of treatment recommendations during the past few years, it is important to consult the latest guidance and clinical data. Guidance is available from professional societies, such as Infectious Diseases Society of America (IDSA), and from government guidance sources such as the National Institutes of Health (NIH); however, the last version of the NIH COVID-19 treatment guidelines was published in March 2024 and have recently been archived. 

Local COVID-19 Treatment Guidelines
In addition to evolving treatment, the way patients present with COVID-19 to the hospital has evolved. Although treatment recommendations are based on COVID-19 severity, healthcare professionals should consider the patient’s primary reason for admission: either (1) a COVID-19 admission or (2) a non–COVID-19 admission, where COVID-19 was an incidental finding.

Often, we are seeing patients admitted with mild COVID-19 and alternative reasons for admission; this differs from patients enrolled in prior clinical trials, who were primarily admitted for COVID-19, that have shaped current guidelines. Because of this, we must adapt current recommendations and create local guidance tailored to specific healthcare settings (eg, inpatient, outpatient) based on COVID-19 severity.

The IDSA and the Centers for Disease Control and Prevention COVID-19 Real-Time Learning Network initially developed the “COVID-19 Outpatient Treatment Road Map,” which was last updated in April 2024, to assist in outpatient management. However, these recommendations or other locally tailored outpatient COVID-19 antimicrobial stewardship guidelines may be useful when considering inpatient management for patients admitted for an alternative medical reason (eg, trauma from a fall or small bowel obstruction). Inpatient COVID-19 guidance often addresses cases where COVID-19 is the primary reason for admission, especially those with more severe disease.

Mild to Moderate COVID-19
For patients with mild or moderate COVID-19 (oxygen saturation >94%, not requiring oxygen), either in the outpatient settings or among those hospitalized for COVID-19—often for non–COVID-19 reasons—local antimicrobial stewardship guidance may recommend remdesivir or nirmatrelvir/ritonavir for patients with risk factors for severe disease progression. At my site, we consider using antiviral therapy in patients who are severely immunocompromised (eg, hematopoietic stem cell transplant recipients, solid organ transplant recipients on antirejection drugs, those within 1 year of receiving B-cell–depleting agents), or older patients (aged 65 years or older) with multiple comorbidities.

Severe to Critical COVID-19
In those admitted to the hospital with severe (oxygen saturation ≤94%, including those receiving supplemental oxygen) or critical (requiring mechanical ventilation, extracorporeal membrane oxygenation, and/or with end organ dysfunction) COVID-19, remdesivir or other agents such as immunomodulators (eg, dexamethasone, baricitinib, tocilizumab) are considered.

Back to Our Case
The medicine team meets the patient on rounds and finds that the patient is 82 years of age with multiple comorbidities, including diabetes mellitus, cardiovascular disease, and chronic kidney disease, who was admitted for small bowel obstruction. The patient reports mild symptoms of an upper respiratory infection that began 3 days ago. In addition, the patient’s most recent COVID-19 vaccination was more than 2 years ago.

According to IDSA guidance, the patient meets criteria for mild COVID-19. In assessing the patient’s risk factors and primary reason for admission (small bowel obstruction), the team considers age (65 years or older), multiple comorbidities, and vaccination status, and determines that the patient is at higher risk for severe COVID-19 progression.

After reviewing local antimicrobial stewardship guidance, the team decides to initiate antiviral therapy. The patient is discharged a few days later with improved bowel status and recovery from the upper respiratory infection.

Your Thoughts?
What factors do you consider most important when deciding whether to treat mild to moderate COVID-19 in patients admitted for non–COVID-19 reasons? What guidance do you use to make these decisions? Join the discussion by posting a comment.