A
(This Level of Evidence Filter is in Beta testing)
Data from multiple randomized controlled trials (RCTs) or meta-analyses of RCTs
B
(The Level of Evidence Filter is in Beta)
Data derived from a single large, well-designed RCT, or smaller RCTs with limitations due to experimental design.
C
(This Level of Evidence Filter is in Beta testing)
Data from observational, retrospective, cohort, or registry studies; or expert opinion if only case series, case studies, preclinical data, or data extrapolated from other diseases are available.
Do
More than 1 guideline currently support this practice/therapy, and no guidelines currently oppose this practice/therapy.
Inconclusive
Only 1 guideline addresses this topic in support or opposition; or multiple guidelines make recommendations that are not in alignment.
Don't
More than 1 guideline currently oppose this practice/therapy, and no guidelines currently support this practice/therapy.
Last updated January 14, 2021
COVID Guidelines Dashboard
By collaborators from:
This resource consolidates current guidelines regarding care of COVID-19 patients from leading global health authorities into a single recommendation to guide and improve care of COVID-19 patients worldwide.
Categorizations of recommendations are generated as noted below and do not necessarily reflect the views of UCSF, BWH, or other listed or collaborating institutions or authorities.
Do
What does it mean?
More than 1 guideline currently support this practice/therapy, and no guidelines currently oppose this practice/therapy.
Systemic Corticosteroids
Guidelines and available data recommend the use of dexamethasone or an alternative equivalent corticosteroid for hospitalized patients with COVID-19 who require supplemental oxygen, including those who are mechanically ventilated.
Recently moved from Inconclusive
High Flow Nasal Oxygen
High Flow Nasal Oxygen/Cannula (HFNO/HFNC) may be used to maintain SpO2 >90-94% in patients with hypoxemic respiratory failure who otherwise do not meet criteria for intubation and have escalating conventional oxygen requirements. HFNO/HFNC is considered an Aerosol Generating Procedure by many organizations; appropriate PPE and precautions should be used. Guideline support for this therapy is largely based on its efficacy in trials on non-COVID hypoxemic respiratory failure.
Protocolized Lung Protective Ventilation
Lung protective ventilation should be pursued for all ARDS patients undergoing mechanical ventilation. This includes targeting tidal volumes 4-6mL/kg Ideal Body Weight, maintaining target Plateau Pressure < 30mmHg, and titrating FiO2 and PEEP per ARDSnet protocols. Available guidelines do not support deviation from existing ARDS ventilation protocols in the care of COVID-19 patients.
Prone Positioning (Intubated Patients)
For mechanically ventilated patients with moderate to severe ARDS with hypoxemia (P:F<150) despite optimized mechanical ventilation, prone positioning for 12-16 hours per day may improve outcomes. Continuous infusions of neuromuscular blockade are not always required for proning.
N95 or Equivalent for Aerosol Generating Procedures in COVID-19+
N95/FFP2/FFP3-grade respirators (or equivalent powered devices), as opposed to surgical/medical masks, should be used in addition to other PPE when performing Aerosol Generating Procedures (AGPs) in the care of COVID19 patients.
NIPPV/CPAP for COVID-19 Respiratory Failure
In adults with acute hypoxemic respiratory failure, if HFNC is not available and intubation/mechanical ventilation is not indicated or available, a trial of CPAP or NIPPV/BiPAP may be considered. Many authorities support this practice only in mild to moderate ARDS patients or in subsets of patients with established indications for NIPPV (e.g. COPD or heart failure exacerbation). Risks include delayed intubation; some experts believe NIPPV/BiPAP may confer risk of direct pulmonary injury. Airborne precautions should be utilized.
Standard Dosing of DVT Prophylaxis
Chemical prophlyaxis with heparin or LMWH to prevent venous thromboembolism is recommended for all hospitalized patients with COVID-19 in absence of contraindications. Existing guidelines do not support the use of high-dose or "therapeutic" (in contrast to "prophylactic") dosing for routine DVT prophylaxis in patients hospitalized with COVID-19.
NSAID Use if Clinically Appropriate
Current evidence does not suggest any specific harm of NSAID use in patients with COVID-19 for antipyrexia or pain control. Most guidelines recommend that NSAIDs may be used if clinically appropriate and not otherwise contraindicated.
Vaccination
Vaccination against SARS-CoV2 is recommended for adults. Existing guidelines recommend prioritizing healthcare workers and vulnerable populations for initial allocation of vaccine doses. There are several vaccine trials ongoing, please see link for details.
PCR Testing (NAAT) for Persons with Suspected COVID-19
All individuals with symptoms consistent with COVID-19 should undergo testing for SARS-CoV2 infection. PCR-based testing, also known as NAAT (Nucleic Acid Amplification Test), is considered the gold standard diagnostic test for COVID-19, although false negative results are possible.
Antigen (“Rapid”) Testing for Persons with Suspected Acute COVID-19 if PCR Testing is Not Available
Rapid antigen tests have high specificity during acute symptomatic COVID-19, but sensitivity is low. Available guidelines generally recommend use of antigen tests if NAAT is not available or in high-risk, high-prevalence settings. Rapid antigen testing is not currently recommended for testing asymptomatic individuals.
Prone Positioning (Non-Intubated Patients)
Data for proning patients non-intubated patients is evolving, although case series and limited pre-COVID studies suggest feasibility and possible benefit of "awake" proning combined with oxygen therapy in avoiding intubation. Patients who are self-proned require close monitoring including pulse oximetry, telemetry, and frequent clinical observation.
Recently moved from Don't
Inconclusive What does it mean?
Only 1 guideline addresses this topic in support or opposition; or multiple guidelines make recommendations that are not in alignment.
Remdesivir
Guidelines on the use of remdesivir are mixed. The ACTT-1 trial revealed improved time to recovery with remdesivir, but another large RCT (SOLIDARITY, funded by WHO) found that remdesivir did not improve mortality. Current guidelines stratify recommended use of remdesivir based on illness severity; for example, some guidelines and institutions recommend use in hospitalized patients who require supplemental oxygen, but are not on mechanical ventilation.
Baricitinib (JAK inhibitor)
There are inadequate data to recommend routine use of the anti-JAK1/JAK2 drug baricitinib in hospitalized patients with COVID-19, although newer trial data suggest improvement in time to recovery in patients who received remdesivir and baricitinib. As such, guidelines are evolving. Current guideline recommendations depend on whether steroids are available, whether remdesivir is available, and whether patients are on supplemental oxygen.
Intermediate Dosing of DVT/VTE Prophylaxis in Critically Ill Patients
Given concerns for hypercoagulability in critically ill patients with COVID-19, some institutions recommend "intermediate" (higher than standard dosing, but lower than full-dose therapeutic dosing) anticoagulation dosing n critically-ill patients in the ICU. Data regarding the optimal dose of prophylactic anticoagulation is forthcoming.
Surgical/Medical Masks for Routine COVID-19+ Patient Care
Multiple guidelines suggest that the use medical/surgical masks provides adequate protection during routine care (that is, no AGPs are ordered or expected) of COVID19 patients, but many institutions encourage the use of respirators instead of medical/surgical masks at all times when providing direct care for COVID19 patients if adequate supplies of respirators are available.
Recently moved from Do
Empiric Antimicrobials in Critically Ill Patients
There are inadequate data regarding the use of empiric antibacterial agents in patients with severe COVID-19. Cohort studies show a low incidence of concurrent bacterial pneumonia in patients who present with COVID-19, but many guidelines recommend empiric antibiotics for critically ill or hypotensive patients admitted with COVID-19, and prompt de-escalation of therapy if no clinical evidence of bacterial infection is found.
Recently moved from Do
Don't What does it mean?
More than 1 guideline currently oppose this practice/therapy, and no guidelines currently support this practice/therapy.
Hydroxychloroquine
Existing guidelines recommend against the use hydroxychloroquine (HCQ) outside of clinical trials. Published randomized trials have not shown efficacy for treatment, or pre- or post-exposure prophylaxis. In June 2020, the US FDA revoked emergency use authorization of hydroxychloroquine for COVID-19.
Recently moved from Inconclusive
Azithromycin
Multiple guidelines recommend against using azithromycin as a monoagent or in combination with hydroxychloroquine as part of routine therapy for COVID-19.
Recently moved from Inconclusive
ACEi Inhibitor – Stopping Chronic Therapy on Admission for COVID-19
COVID-19 patients already on an ACEi or ARB for cardiovascular disease should continue these medication in the absence of other contraindications.
NSAID Discontinuation
There are inadequate data to recommend discontinuation or holding NSAIDs as antipyretic therapy in patients with COVID-19 (i.e. don't discontinue) in the absence of other known contraindications for use of NSAIDs.
Lopinavir/Ritonavir
Several large trials indicate that the antiviral agent lopinavir alone or in combination with ritonavir among patients with COVID-19 is an ineffective therapy. All major guidelines currently recommend against the use of lopinavir/ritonavir as treatment for COVID-19.
Antibody (Serology) Testing for Persons with Suspected Acute COVID-19
Testing for antibodies against SARS-CoV2 virus to diagnose acute COVID-19 is generally not recommended, but may be used in patients presenting >7-14 days after initial symptoms who have had multiple negative PCR tests but still have high clinical suspicion of COVID-19. Data are lacking to establish whether that a positive test for SARS-CoV2 antibodies confers immunity from recurrent infection.
Convalescent Plasma
Data and guidelines are evolving for the use of convalescent plasma (from prior survivors of COVID-19 infection) in patients hospitalized with COVID-19 infection. Most randomized clinical trials have not shown a benefit of convalescent plasma to-date.
Recently moved from Inconclusive
New update
Ivermectin
Most guidelines currently do not address the use of the anti-parasitic agent ivermectin for treatment of patients with COVID-19.
Recently moved from Inconclusive
IL-6 Inhibitors
Examples include tocilizumab, sarilumab, and siltuximab. Current guidelines largely suggest against the routine use of agents that inhibit IL-6 among patients with COVID-19 due to a number of negative randomized clinical trials, although evidence is evolving.
Recently moved from Inconclusive
ACE Inhibitor as Treatment for COVID-19
There are inadequate data to inform guidelines on the Initiation of ACE inhibitor (ACEi) or Angiotensin Receptor Blocker (ARB) therapy among patients hospitalized with COVID-19. Patients already on an ACEi or ARB for cardiovascular disease should continue these medication in the absence of other contraindications.
Recently moved from Inconclusive
Famotidine
There are inadequate data to recommend use of the H2-blocker famotidine as an antiviral therapy among patients with COVID-19.
Recently moved from Inconclusive
Neutralizing Monoclonal Antibodies – Hospitalized Patients
There are inadequate data to recommend routine use of lab-generated SARS-CoV-2-specific antibodies, such as bamlanivimab or casirivimab-imdevimab, in hospitalized patients.
Recently moved from Inconclusive
Empiric Antimicrobials in Non-Critically Ill Patients
There are inadequate data regarding the use of empiric antibacterial agents in patients with mild or moderate COVID-19. Most guidelines recommend against use of empiric antimicrobials in patients admitted to the hospital with non-severe COVID-19.