A

Data from multiple randomized controlled trials (RCTs) or meta-analyses of RCTs.
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Data derived from a single large, well-designed RCT, or smaller RCTs with limitations due to experimental design.
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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.

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.

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

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 (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.

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.

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.

Protocolized lung protective ventilation for COVID-19 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 deviation from existing ARDS ventilation protocols in the care of COVID-19 patients.

Prophylactic-dose heparins 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. Most institutions recommend low molecular weight heparin rather than heparin or a novel oral anticoagulant.

Remdesivir in severely-ill COVID19 patients (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).

Steroids (systemic corticosteroids)

Guidelines and available data recommend the use of dexamethasone or an alternative equivalent corticosteroid for most patients hospitalized for 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. Some guidelines advise against use of dexamethasone in patients hospitalized for COVID-19 who have very low supplemental oxygen requirements; hover over individual recommendations for details.

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 inhbitor. See the baricitinib tile for more details about that medication.

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 instutitions, 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.

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.

Tofacitinib

Tofacitinib, like baricitinib, is an inhibitor of JAK proteins, and was developed as a treatment for rheumatoid arthritis. Because of its antiinflammatory 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).

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.

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.

Vaccine Booster

The protection from coronavirus vaccines decreases over time and against newer COVID-19 variants such as Omicron. Vaccine "boosters," help to ensure ongoing immune response against COVID-19 and its variants. Many global authorities now recommend booster shots to complete a primary series for most adults and some children. The selection, timing, and dosing of "booster" vaccines varies based on the type of vaccine used for the primary series, availability, country, and local guidance. Bivalent boosters include protection against the ancestral strain and Omicron subvariants depending on the region and are now the recommended booster for adults and some children who have completed their primary series or previously received monovalent booster. 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.

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.

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.

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

Intermediate-dose heparin in patients hospitalized for COVID-19 requiring ICU level care

Given concerns for hypercoagulability in critically ill patients with COVID-19, some institutions recommend "intermediate" (higher than prophylactic dosing, but lower than therapeutic dosing), but this is not supported by large randomized controlled trials.

Therapeutic-dose heparin in patients hospitalized with COVID-19 and not requiring ICU level care

The analysis of a platform of 3 large, international randomized controlled trials investigating therapeutic versus prophylactic-dose heparin in patients hospitalized with COVID-19 who do not have known VTE support that therapeutic-dose unfractionated heparin or LMWH may prevent progression of disease or death in patients with COVID-19 who are not requiring ICU level of care (receipt of high flow nasal cannula and beyond). All patients hospitalized with COVID-19 should receive some form of heparin for DVT/VTE prophylaxis. Most institutions prefer low molecular weight heparin (LMWH) rather than unfractionated heparin. Data has not supported use of a novel oral anticoagulants.

Remdesivir in critically-ill COVID19 patients (on 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).

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.

Convalescent plasma — Non-hospitalized patients

2/9/22. 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.

Empiric antimicrobials in critically ill patients

There are inadequate data regarding the use of empiric antibacterial agents in patients with critical COVID-19. Cohort studies show a low incidence of concurrent bacterial pneumonia in patients who present with COVID-19, but some 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.

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.

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.

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. Data on fluvoxamine is mixed and most guidelines do not recommend its use outside of the context of a clinical trial.

Favipiravir

Favipiravir is a viral RNA-polymerse inhibitor which has been used in China and Japan 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 in the United Kingdom.

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%. Additional trials have shown limited reduction in hospitalizations and mortality in high-risk vaccinated individuals, but may reduce duration of symptoms. Many institutions only conditionally recommend molnupiravir in individuals ≥ 18 years old with mild-moderate COVID-19 at high risk of disease progression when other therapies are not available, feasible to use, or clinically appropriate. Molnupiravir should be initiated within 5 days of symptom onset and not be used in individuals ≤ 18 years old or pregnant persons.

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.

GM-CSF Inhibitors, e.g. lenzilumab

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.

Metformin

Metformin, a common medication used for treatment of insulin resistance in Type 2 diabetes, may also have anti-inflammatory and antiviral properties, and some retrospective observational data has suggested lower rates of severe COVID-19 in persons who are taking metformin. Interest in metformin has increased since a trial published in NEJM in August, 2022, indicated potential promise of this medication to prevent emergency department visits, hospitalizations, or deaths in overweight or obese patients with mild-moderate COVID-19, although that was not the primary objective of the study. Additional randomized control trials TOGETHER and COVID-OUT did not demonstrate a benefit of reducing hospitalization or death in patients with COVID-19. Currently no major institutions recommend metformin for the treatment COVID-19 unless in a clincal trial.

Anakinra

Anakinra is an interleukin-1 antagonist that binds to IL-1 receptors and has been investigated to treat hyperinflammatory states in COVDI-19 given its great safety profile and use in other hyperinflammatory states such as Cytokine Release Syndrome (CRS). The FDA has issued an EUA for anakinra for treatment of COVID-19 in hospitalized adults with COVID-19 pneumonia requiring supplemental oxygen at risk for progressing to severe resrpiratory failure and elevated soluble urokinase plasminogen activator receptor (suPAR). Data supporting anakinra for COVID-19 was demonstrated in the SAVE-MORE trial which showed 70% decrease in relative risk of progression to severe respiratory failrue and 28d mortality with anakinra compared to standard of care. Most institutions do not make a recommendation on anakinra due to insufficient evidence and which patient population would benefit from anakinra given use of suPAR which is not widely available.

Vilobelimab

Patients with severe COVID-19 have been reported to have high levels of C5a which leads to inflammation and release of histamine that can result in tissue damage. Vilobelimab is a anti-C5a monoclonal antibody that has been shown to reduce immune system activation and inhibited lung injury in mice. A phase 3 double-blind, placebo-controlled, randomized control trial (PANAMO) showed 28-day mortality was lower in vilobelimab (when not stratified by study site), but analysis that stratified by study site did not show any difference in 28-day mortality. Based on these results, the FDA issued an EUA for use vilobelimab in patients hosptialized with COVID-19 when it is administered within 48 hours of mechanical ventilation or extracorporeal membrane oxygenation. The NIH notes that there is not enough information to either recommend for or against velobelimab use.

Neutralizing monoclonal antibodies – hospitalized COVID-19 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 WHO's decision in September 2021 to recommend antibody therapy to patients hospitalized with severe or critical COVID who are seronegative for antibodies at admission moves this topic into the "inconclusive" column.

Pre-exposure prophylaxis with neutralizing monoclonal antibodies for specific individuals

Lab-generated 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 adequte 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, but is no longer authorized by the FDA due to minimal activity against circulating Omicron subvariants. Currently, there are no other available monoclonal antibodies for pre-exposure prophylaxis.
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Don't
More than 1 guideline currently oppose this practice/therapy, and no guidelines currently support this practice/therapy.

Therapeutic-dose heparin in patients hospitalized for COVID-19 and requiring ICU level care

The analysis of a platform of 3 large, international randomized controlled trials investigating therapeutic versus prophylactic-dose heparin in patients hospitalized with COVID-19 who do not have known VTE support that therapeutic-dose unfractionated heparin or LMWH may prevent progression of disease or death in patients with COVID-19 who are not requiring ICU level of care (receipt of high flow nasal cannula and beyond), but may be harmful in patients requiring ICU level of care.

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.

Ivermectin for prevention or treatment 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.

Hydroxychloroquine (HCQ) 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.

Azithromycin

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

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.

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.

ACE inhibitor – Stopping chronic therapy on admission for COVID19

COVID-19 patients already on an ACEi or ARB for cardiovascular disease should continue these medications in the absence of other contraindications.

NSAID discontinuation

Guidelines to not recommend discontinuing or holding NSAIDs as antipyretic or analgesic therapy in patients with COVID-19 unless there are known contraindications for use of NSAIDs in individual patients.

Famotidine

There are inadequate data to recommend use of the H2-blocker famotidine as an antiviral therapy among patients 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. However, randomized clinical trial data has not supported its efficacy and guidelines do not recommend its routine use.

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.

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. Activity of anti-SARS-CoV-2 monoclonal antibodies vary on the circulating SARS-CoV-2 variant and as the pandemic has progressed have lost activity over time due to prevalence of Omicron and its subvariants. Currently, no monoclonal antibody has retained activity against circulating Omicron subvariants BQ.1, BQ.1.1, and XBB and not recommended for treatment at this time by multiple organizations.

Post-exposure prophylaxis with neutralizing monoclonal antibodies for specific individuals

See separate topics on this dashboard for information about neutralizing antibodies for outpatient prophylaxis or for hospitalized patients.

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.

PCR Testing for de-isolation of hospitalized patients

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), severity of illness (hypoxia), current symptoms, and time since the initial positive SARS-CoV2 test or symptom onset. Repeat testing to discontinue isolation is generally not recommended except for moderately or severely immunocompromised patients who may still have infectious virus beyond the typical isolation period.

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.
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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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