A

Data from multiple randomized controlled trials (RCTs) or meta-analyses of RCTs.
(This Level of Evidence Filter is in Beta testing)

B

Data derived from a single large, well-designed RCT, or smaller RCTs with limitations due to experimental design.
(This Level of Evidence Filter is in Beta testing)

C

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.
(This Level of Evidence Filter is in Beta testing)

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.

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 May 15, 2022

COVID-19 Guidelines Dashboard

This resource brings together guidelines for COVID-19 care from leading global health authorities and consolidates them into a single recommendation based on concordance.

By collaborators from:

Data from multiple randomized controlled trials (RCTs) or meta-analyses of RCTs.
(This Level of Evidence Filter is in Beta testing)
Data derived from a single large, well-designed RCT, or smaller RCTs with limitations due to experimental design.
(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.
(This Level of Evidence Filter is in Beta testing)

Hover over an indicator to view more detail about the recommendation. Click to open the full recommendation.

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Not Recommended

Not recommended unless in clinical trial

No recommendation

Click to see what the guidelines recommend.

Select a category above

Do
More than 1 guideline currently support this practice/therapy, and no guidelines currently oppose this practice/therapy.

Nirmatrelvir with ritonavir (Paxlovid)

Nirmatrelvir with ritonavir, named Paxlovid by its manufacturer, is a novel antiviral medication that has shown promise in clinical trials for prevention of progression in mild-moderate COVID-19. It is available as an oral preparation that combines a SARS-CoV2-specific protease-inhibitor (nirmatrelvir) with ritonavir, a known inhibitor of cytochrome P450-3A4, an enzyme that degrades protease inhibitors, to help slow the metabolism of the nirmatrelvir molecule. A large trial sponsored by the drug's manufacturer showed that Paxlovid significantly reduced hospitalizations when administered within 3 days of symptom onset in patients with mild-moderate COVID-19. Paxlovid is administered as three tablets (two tablets of nirmatrelvir and one tablet of ritonavir) taken together orally twice daily for five days, for a total of 30 tablets.

Patient Selection and Dosing

Neutralizing Monoclonal Antibodies – Non-Hospitalized Patients with COVID-19

Lab-generated SARS-CoV-2-specific antibodies have been investigated as a therapy to prevent progression of mild-moderate COVID-19 in non-hospitalized patients at high risk for clinical progression. Some trials have shown decreased viral load with use of these therapies and lower rates of progression of disease, but the robustness and clinical significance of these findings remains uncertain. Several institutions offer guidance on the use of monoclonal antibodies, and how to select appropriate patients for use. WHO acknowledges that due to the high cost and limited availability of monoclonal antibodies, and their requirement for parenteral administration, ""obstacles to ensuring access to low-to-middle income countries may prove formidable."" Recent data suggests that bamlanivimab-etesevimab and casirivimab-imdevimab do not retain activity against the Omicron variant, and sotrovimab may have poor efficacy against the Omicron BA.2 variant. Bebtolovimab, a newer monoclonal antibody, is predicted to remain effective against Omicron, including the BA.2 variant.
See separate topics on this dashboard for information about neutralizing antibodies for outpatient prophylaxis or for hospitalized patients.

Patient Selection and Dosing

Remdesivir in non-hospitalized patients

Remdesivir, an intravenous, non-COVID specific antiviral medication, has been recommended for certain patients with severe or critical COVID-19 since late 2019. A recent clinical trial investigated the use of remdesivir in outpatients with mild-moderate COVID-19 who are at high risk for progression to severe COVID-19. The trial, which was sponsored by remdesivir's maker, found that a 3-day course of IV remdesivir in the outpatient setting resulted in an 87% lower risk of hospitalization or death from COVID-19 when compared to placebo.

Patient Selection and Dosing

Molnupiravir

Molnupiravir is a prodrug to a nucleoside analog which interrupts viral replication, and is available in an oral form. A trial on unvaccinated, unhospitalized patients with mild-moderate COVID-19 sponsored by the drug's maker showed that it may reduce death or hospitalization by ~30%. A prior trial on molnupiravir in hospitalized patients was stopped after interim analysis in April 2021 showed that the drug was "unlikely to demonstrate a clinical benefit in hospitalized patients." In November 2021, molnupiravir was approved by the United Kingdom's Medicines and Healthcare products Regulatory Agency (MHCA) for use in outpatients with mild-moderate COVID-19 and at least one risk factor for developing severe disease. The US FDA approved an emergency use authorization for molnupiravir on December 23, 2021.

Patient Selection and Dosing

Pre-exposure prophylaxis with neutralizing monoclonal antibodies for specific individuals

Infusion of lab-created COVID-specific monoclonal antibodies can provide temporary ""passive immunity"" against acquisition of the SARS-CoV2 virus. This protection is called pre-exposure prophylaxis, and may be beneficial for individuals who not expected to develop adequate immunity after vaccination or individuals with medical contraindications to vaccination. Tixagevimab-cilgavimab is a long-acting neutralizing antibody developed for pre-exposure prophylaxis against SARS-CoV2 infection. The drug's manufacturer reports that tixagevimab-cilgavimab reduced risk of developing COVID by up to 78%, but this data is not yet publicly available. The United States FDA granted Emergency Use Authorization to tixagvimab-cilgamivab for pre-exposure prophylaxis among individuals who may not mount an adequate response to COVID vaccination or individuals who have had a prior severe adverse reaction to COVID vaccination. The majority of organizations recommend a dosage of 300mg tixagevimab and 300mg cilgavimab.

Patient Selection and Dosing

Prophylactic-dose Anticoagulation for DVT/VTE Prophylaxis

The analysis of 3 large, international randomized controlled trials investigating therapeutic versus prophylactic anticoagulation in patients hospitalized with COVID-19 who do not have known VTE suggest that higher dose heparin or LMWH therapy may prevent progression of disease or death in certain patients with COVID-19 who are not in the ICU. Guidance continues to evolve on this topic, and some institutions now suggest specific circumstances in which patients with non-critical COVID may benefit from therapeutic anticoagulation in absence of confirmed venous thromboembolism. All patients hospitalized with COVID-19 should receive some form of heparin for prophylaxis or treatment in absence of contraindicatons. Most institutions recommend low molecular weight heparin rather than heparin or a novel oral anticoagulant.

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.

Multiple high-quality clinical trials have shown that a 5-10 day course of 6-20mg dexamethasone (or equivalent corticosteroid) reduces mortality in patients with COVID-19 who require supplemental oxygen, including those who are mechanically ventilated. Accordingly, all major guidelines currently recommend this practice. Guidelines and available evidence do not support the use of doses higher than 20mg dexamethasone (or equivalent) per day or recurrent courses of systemic steroids for progressive or resistant critical COVID-19.

Patient Selection and Dosing

Vaccine boosters

The protection from coronavirus vaccines may decrease over time. Vaccine "boosters," help to ensure ongoing immune response against COVID-19. Many global authorities now recommend booster shots to complete a primary series for most adults and some children. The selection, timing, and dosing of 3rd and 4th dose "booster" vaccines varies based on the type of vaccine used for the primary series, availability, country, and local guidance. Available data suggests that booster doses improve immunity and protect against bad outcomes.

Vaccination in children and adolescents

While every major global public health organization recommends vaccination for adults, some organizations remain hesitant to recommend vaccination in children due to less available data and lower risk of COVID-19 to infected children. We anticipate guidance will change as complete efficacy and safety data for various vaccines in children become available, and adequate supplies of vaccines are available. Please note that some organizations have different recommendations for children under age 11-12 and children age 12 and older ("adolescents"). Which vaccines are approved for use and are being used varies by country; for example, in the United States and England, the Pfizer vaccine is currently approved for children and adolescents; in India, the ZyCov-D vaccine has been approved for adolescents but a vaccination program has not yet been rolled out.

IL-6 Inhibitors (e.g. tocilizumab or sarilumab)

Agents that interfere with IL-6 signaling pathways, such as tocilizumab or sarilumab, have been investigated in severe COVID-19 because of their potent anti-inflammatory properties, and authorities we follow now largely support the use of tocilizumab and/or sarilumab as an additional treatment to corticosteroids in patients with severe and critical COVID-19 pneumonia. Multiple clinical trials that examined adding IL-6 inhibitors to corticosteroids have now been published; results are mixed but largely signal benefit in patients who have severe and critical COVID with high inflammatory markers and who are still within a few days of onset of symptoms. Baricitinib, another strong anti-inflammatory medication, has been used for similar patients and is recommended by several authorities as an alternative to tocilizumab or sarilumab. Baricitinib should not be used in addition to an IL-6 inhibitor. Some institutions specify that tocilizumab should be used in place of baricitinib in patients receiving invasive mechanical ventilation. See the baricitinib tile for more details about that medication.

Patient Selection and Dosing

New update

Baricitinib (JAK inhibitor)

Many guideline authorities recommend the use of the antiinflammatory JAK-2 inhibitor baricitinib in addition to steroids in patients who are admitted to the hospital with severe to critical COVID pneumonia and have increasing oxygen requirements or other evidence of widespread inflammation. Most institutions recommend 4mg PO daily for up to 14 days, with dose-adjustment based on renal function. IL-6 inhibitors like tocilizumab or sarilumab may be used as an alternative to baricitinib; most institutions do not recommend one agent over another due to lack of data directly comparing them, but some institutions, like UCSF, favor a particular medication as first line (baricitinib, in the case of UCSF). Baricitinib and IL-6 inhibitors should not be used concurrently. Some data additionally support baricitinib in place of steroids if there is a strong contraindication to the use of steroids (such cases are rare). Some institutions specify that tocilizumab should be used in place of baricitinib in patients receiving invasive mechanical ventilation. See institution guideline links for details.

Patient Selection and Dosing

Protocolized Lung Protective Ventilation in COVID19 ARDS

Lung protective ventilation should be pursued for all ARDS patients undergoing mechanical ventilation. This includes targeting tidal volumes of 4-6mL/kg Ideal Body Weight, targeting Plateau Pressure < 30cmH2O, and titrating FiO2 and PEEP per ARDSnet protocols. Available guidelines do not support significant deviations from existing ARDS ventilation protocols in the care of COVID-19 patients.

Vaccination

Vaccination against SARS-CoV2 is recommended for all adults. Existing guidelines recommend prioritizing healthcare workers and vulnerable populations for allocation of vaccine doses if vaccine scarcity is present. Several different vaccines have been developed and vaccine availability differs by region and country. Efficacy data is similarly variable depending on the individual vaccine. Data collection on adverse reactions to various vaccines is ongoing but all authorities surveyed here agree that benefits of the SARS-CoV2 vaccine outweighs possible risks. Most organizations now recommend extending vaccination to children and adolescents. Please see the topics "Vaccine Boosters" for more information regarding "booster" vaccines and/or extensions of the COVID vaccine primary series, and the topic "Vaccination in children and adolescents" for more details.

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. The recent RECOVERY-RS trial studied HFNO in comparison to conventional nasal oxygen and CPAP, and found that CPAP, but not HFNO, reduced need for intubation compared to conventional oxygen therapy.

Prone Positioning (Intubated Patients)

For mechanically ventilated patients with moderate to severe ARDS (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. Guideline support for this therapy is largely based on its efficacy in trials on non-COVID hypoxemic respiratory failure.

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.

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.

Home pulse oximetry for monitoring symptomatic patients with high risk of disease progression

For patients with mild COVID-19 who are not admitted to the hospital but are at elevated risk for disease progression, home monitoring of arterial blood oxygen saturation with a hand-held pulse oximeter may help alert patients to seek care if disease is progressing or reassure patients if disease is stable. The optimal use of pulse oximetry in the outpatient setting for COVID19 is an evolving area of practice. Patients and caregivers should only utilize certified and approved devices by their local healthcare authority to ensure quality. Some pulse oximeters may provide false reassurance or false alarms in patients with darker skin pigmentation.

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.

N95 or Equivalent for Healthcare Workers

N95 or equivalent grade respirators (including powered respirators), 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. Many health authorities also recommend that respirators be used in routine care for patients with COVID-19 if adequate supplies are available.

Wearing a mask in public

Combined with other measures, masking is an important tool to decrease community transmission of the SARS-CoV2 virus. Masks should be well-fitting and comfortable, and worn over both the nose and mouth. Surgical masks may be more effective than cloth masks, and N95, KN95 or similar respirators are most effective to protect individuals from getting or spreading COVID-19.

Non-invasive Positive Pressure Ventilation (aka NIPPV, NIV, CPAP)

In adults with acute hypoxemic respiratory failure, a trial of CPAP or NIPPV/BiPAP may be considered if mechanical ventilation is not indicated. Risks include delayed intubation and some experts believe NIPPV/BiPAP in patients with ARDS can cause direct pulmonary injury. Airborne precautions should be utilized. The RECOVERY-RS trial studied HFNO and CPAP in comparison to conventional nasal oxygen , and found that CPAP, but not HFNO, reduced need for intubation compared to conventional oxygen therapy.

Antigen (“Rapid”) Testing for Persons with Suspected Acute COVID-19

Rapid antigen tests have high specificity during acute symptomatic COVID-19, but sensitivity is variable. Available guidelines generally recommend use of antigen tests if NAAT is not available or in high-risk, high-prevalence settings. Rapid antigen testing is generally not recommended for testing asymptomatic individuals, especially if NAAT is available.

Inconclusive
Only 1 guideline addresses this topic in support or opposition or multiple guidelines make recommendations that are not in alignment.

New update

Convalescent plasma in non-hospitalized patients

Convalescent plasma has been investigated as a potential therapy for outpatients with mild-moderate COVID-19. So far, data is mixed, and as such, guidelines are currently inconclusive, with some institutions against, and some suggesting that plasma may be used if other outpatient therapies are not available. Some guidelines specify that convalescent plasma collected prior to the emergence of the Omicron variant should not be used in any circumstances, given that it is unclear that such a product has any neutralizing activity against the Omicron Variant.

Post-exposure prophylaxis with neutralizing monoclonal antibodies for specific individuals

Some reports have found that neutralizing monoclonal antibodies may prevent symptomatic infection in persons who had very close and prolonged contact with an individual with COVID-19. The antibodies studied for this indication, casirivimab plus imdevimab, are the same that are currently approved by the US FDA's Emergency Use Authorization for certain patients with mild-moderate COVID-19 with high risk for progression, and the US FDA extended this authorization to include post-exposure prophylaxis in July 2021. However, these antibodies are not effective against the Omicron variant. Data on the use of monoclonal antibodies for post-exposure prophylaxis is still limited, especially for the Omicron BA.1 and BA.2 variants, and the cost-effectiveness of prophylactic therapy is unknown.

Therapeutic anticoagulation in patients hospitalized for non-critical COVID-19

The analysis of 3 large, international randomized controlled trials investigating therapeutic (or "full-dose") anticoagulation in patients hospitalized with COVID-19 who do not have known VTE suggest that this therapy may prevent progression of disease or death in certain patients with non-critical COVID-19 who are not in the ICU. Guidance continues to evolve on this topic, and some institutions now suggest specific circumstances in which patients with non-critical COVID may benefit from therapeutic anticoagulation. All patients hospitalized with COVID-19 should receive some form of heparin for prophylaxis or treatment. Most institutions recommend low molecular weight heparin rather than heparin or a novel oral anticoagulant.

Intermediate Dose Anticoagulation for 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 in critically-ill patients in the ICU.

Fluvoxamine

Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) that has drawn interest in treatment of mild-moderate COVID-19 due to possible anti-inflammatory properties previously observed in mouse models of infection. Two randomized, placebo-controlled trial of fluvoxamine in outpatients with new-onset, mild COVID-19 show that it may prevent progression of mild disease. Current guidelines either do not address fluvoxamine or do not make a recommendation for or against its use due to insufficient data, although this may change given the results of the larger TOGETHER trial.

Neutralizing Monoclonal Antibodies – Hospitalized Patients

Certain lab-generated SARS-CoV-2-specific monoclonal antibodies, such as casirivimab-imdevimab (trade name REGEN-COV, commonly referred to as "Regeneron"), are recommended for use in patients with mild COVID-19 with elevated risk of progression. Initial studies did not support the efficacy of monoclonal antibodies in hospitalized patients, but more recent data from the adaptive RECOVERY trial suggests that hospitalized patients who are seronegative for endogenous SARS-CoV2 antibodies at admission may benefit from this therapy. Data and guidelines continue to evolve, and new updates from WHO and the United States NIH move this topic into the "inconclusive" column.

Inhaled Corticosteroids

The use of inhaled corticosteroids, such as budesonide or ciclesonide, has been explored as a treatment to prevent progression of disease in non-hospitalized patients with mild-moderate COVID-19. So far, results are mixed on the efficacy of this treatment at preventing hospitalization or improving symptoms. As a result, most organizations do not address or are inconclusive regarding inhaled corticosteroids.

Tofacitinib

Tofacitinib, like baricitinib, is an inhibitor of JAK proteins, and was developed as a treatment for rheumatoid arthritis. Because of its anti-inflammatory properties, it has attracted attention for use in patients hospitalized with severe COVID-19 pneumonia. A medium-sized randomized controlled trial was published on tofacitinib for hospitalized patients with COVID-19 in July 2021 which suggested benefit from adding this medication to standard of care (which in almost all patients included systemic corticosteroids).

Patient Selection and Dosing

Remdesivir in severe COVID-19 (on O2 but not on a ventilator)

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 and the Dashboard has broken this category into 2 topics: Remdesivir for patients requiring supplemental oxygen but not mechanically ventilated (severely ill), and Remdesivir for patients who are mechanically ventilated (critically ill).

Patient Selection and Dosing

Remdesivir in critical COVID-19 (on ventilator or ECMO)

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 and the Dashboard has broken this category into 2 topics: Remdesivir for patients requiring supplemental oxygen but not mechanically ventilated (severely ill), and Remdesivir for patients who are mechanically ventilated (critically ill).

Patient Selection and Dosing

Favipiravir

Favipiravir is a viral RNA-polymerse inhibitor which has been used to treat influenza. It has been the subject of many smaller, methodologically-limited trials investigating its utility in the treatment of COVID-19 and results have been mixed. To date, no major international guidelines have addressed its use. In April 2021, a favipiravir arm was added to the PRINCIPLE adaptive trial on COVID therapeutics in the United Kingdom.

GM-CSF inhibitors

GM-CSF is a pro-inflammatory growth factor and cytokine that plays a part in mediating the inflammatory response to SARS-CoV2 infection in the lungs. Blockade of this pathway is under investigation in COVID-19 pneumonia, and trial data so far, as released in peer-reviewed journals or in pre-print form, show varying results based on the specific population studied. Until more data is available, it is unlikely that any guideline organization will recommend the use of this class of medications outside of a clinical trial.

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.

Don't
More than 1 guideline currently oppose this practice/therapy, and no guidelines currently support this practice/therapy.

New update

Ivermectin for Treatment or Prevention of COVID-19

Ivermectin is an anti-parasitic agent that has been investigated for anti-viral treatment of patients with COVID-19 or infection prophylaxis in high-risk patients. Several large trials have failed to show benefit of this medication for treatment of mild-moderate COVID-19, or for post-exposure prophylaxis. No guidelines surveyed by the COVID Guidelines Dashboard currently recommend ivermectin as prophylaxis against or treatment for COVID-19.

Therapeutic anticoagulation in ICU patients with critical COVID-19

The analysis of 3 large, international randomized controlled trials investigating therapeutic (or "full-dose") anticoagulation in patients hospitalized with COVID-19 suggest that this therapy does not prevent progression of disease or death in patients with critical COVID-19 who are in the ICU, and may be associated with increased rates of significant bleeding. Most existing guidelines do not recommend therapeutic anticoagulation in absence of known DVT/PE, but do recommend prophylactic anticoagulation for all patients with COVID-19 in the ICU. Full results are now published and linked below.

New update

Convalescent Plasma — Hospitalized Patients

Most randomized clinical trials have not shown a benefit of convalescent plasma (from prior survivors of COVID-19 infection) in patients hospitalized with moderate to severe COVID-19. The titer of anti-SARS-CoV2 antibodies in units of convalescent plasma may play a role in its success or failure as a therapy, and ongoing trials are largely focused only on high-titer convalescent plasma. Most guidelines currently recommend against use of convalescent plasma for hospitalized patients outside of clinical trials, and some explicitly recommend against convalescent plasma in certain populations. Some guidelines specify that convalescent plasma collected prior to the emergence of the Omicron variant should not be used in any circumstances, given that it is unclear that such a product has any neutralizing activity against the Omicron Variant.

Aspirin

Aspirin has attracted attention for use in patients with COVID-19 due to its anti-platelet and anti-inflammatory properties. The adaptive, randomized controlled trial RECOVERY tested aspirin against placebo in over 14,000 patients hospitalized with COVID-19 infection and did not find any difference in mortality, progression to mechanical ventilation, or other clinically relevant endpoints. Most guidelines do not address aspirin or advise against its use outside of a clinical trial. Patients with COVID-19 who are on aspirin for a separate indication, e.g. coronary artery disease, should continue taking aspirin.

Hydroxychloroquine for prevention or treatment of COVID-19

Most existing guidelines recommend against the use hydroxychloroquine (HCQ) for treatment or prevention of COVID-19 in hospitalized patients and outpatients 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. In March 2021, WHO extended its recommendation against HCQ to specifically advise against its use as a preventative medication.

Nitazoxanide

Nitazoxanide is an anti-parasitic agent which has previously been investigated as an anti-viral medication for patients with influenza, and it has garnered interest as a potential therapy in early COVID-19 disease. However, a randomized, controlled trial of nitazoxanide for treatment of early COVID (within 3 days of symptom onset) did not show efficacy of this medication, and no major guideline organization currently support the use of nitazoxanide for inpatients or outpatients with COVID-19.

Colchicine

Colchicine, a medication that inhibits many different inflammatory pathways via disruption of microtubule formation, has garnered interest as a potential therapeutic option for patients with COVID-19. Its efficacy is not yet supported by randomized, clinical trial data, and guidelines do not recommend its routine use outside of a clinical trial. In March 2021, an interim analysis of the multinational RECOVERY trial failed to show benefit of colchicine in hospitalized adults with COVID-19 with respect to mortality, so recruitment to this arm of the study was stopped.

Azithromycin

Multiple guidelines recommend against using azithromycin alone or in combination with hydroxychloroquine as part of therapy for COVID-19.

Empiric Antimicrobials in Non-Critically Ill Patients

Most guidelines recommend against use of empiric antimicrobials in patients admitted to the hospital with non-severe COVID-19.

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) specifically as therapy for COVID-19 among hospitalized patients.

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 medications in the absence of other contraindications.

PCR Testing for de-isolation of patients in non-healthcare settings

Authorities typically recommend one of two strategies for releasing patients with symptomatic or asymptomatic SARS-CoV2 infection from isolation: 1. Repeat PCR testing or 2. Clinical criteria that include patient risk factors (such as immunocompromised state), current symptoms, and time since the initial positive SARS-CoV2 test or symptom onset. This category addresses the question "do guidelines recommend repeat PCR testing prior to releasing non-hospitalized patients from isolation?" Testing availability is generally included in institutional decision making.

Famotidine

There are inadequate data to recommend use of the H2-blocker famotidine as an antiviral therapy among patients with COVID-19.

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.

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* This dashboard presents published guidelines and is not an interpretation of primary data. Content is categorized as "do", "don't", or "inconclusive", based on the criteria described in the next section. Categorizations of recommendations do not necessarily reflect the views of UCSF, BWH, NEJM Group or other institutions collaborating with or presented in this Dashboard. Information presented here is intended to be educational in nature and is not a substitute for clinical decision making based on the medical condition presented. It is the responsibility of the user to ensure all information contained herein is current and accurate by using published references.

Categorization criteria:
Do: More than 1 guideline currently support this practice/therapy, and no guidelines currently oppose this practice/therapy.
Don't: More than 1 guideline currently oppose this practice/therapy, and no guidelines currently support this practice/therapy.
Inconclusive: Only 1 guideline addresses this topic in support or opposition; or multiple guidelines make recommendations that are not in alignment.
Topics categorized as 'Not recommended outside a clinical trial' are counted as equivalent to a recommendation against.

(WHO - World Health Organization; CDC - Centers for Disease Control and Prevention; SCCM - Society for Critical Care Medicine; ESICM - European Society of Intensive Care Medicine; NIH - National Institutes for Health; IDSA - Infectious Diseases Society of America; UCSF - University of California, San Francisco Medical Center, San Francisco, USA; BWH - Brigham and Women's Hospital, Boston, USA; AIIMS - All India Institute of Medical Science, New Delhi).

Categorizations of recommendations are generated as outlined above and do not necessarily reflect the views of UCSF, NEJM Group, or other institutions on this Dashboard.

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