Coronavirus

Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

When SARS-CoV-2 and influenza viruses are co-circulating, clinicians should consider both viruses, as well as co-infection, in patients with acute respiratory illness symptoms because of similar signs and symptoms. Testing and treatment guidance in priority groups is available. For more information on influenza and Covid-19 see the NIH Treatment Guidelinesexternal icon.Revisions were made on November…

When SARS-CoV-2 and influenza viruses are co-circulating, clinicians should consider both viruses, as well as co-infection, in patients with acute respiratory illness symptoms because of similar signs and symptoms. Testing and treatment guidance in priority groups is available. For more information on influenza and Covid-19 see the NIH Treatment Guidelinesexternal icon.

Revisions were made on November 3, 2020, to reflect the following:

  • New information for Laboratory and Radiographic Findings
  • New information for Pediatric Considerations
  • Revisions for clarity and significant updates to footnotes throughout
  • Influenza alert box
  • Information on FDA approval of remdesivir

Revisions were made on October 27, 2020, to reflect the following:

  • Updated content to Reinfection

Revisions were made on September 10, 2020, to reflect the following:

  • Updated content to Reinfection

Revisions were made on June 20, 2020, to reflect the following:

Revisions were made on May 29, 2020, to reflect the following:

Revisions were made on May 25, 2020, to reflect the following:

Revisions were made on May 20, 2020, to reflect the following:

Revisions were made on May 12, 2020, to reflect the following:

  • New information about COVID-19-Associated Hypercoagulability
  • Updated content and resources to include new NIH Treatment Guidelines
  • Minor revisions for clarity

This document provides guidance on caring for patients infected with SARS-CoV-2, the virus that causes COVID-19. The National Institutes of Health (NIH) have published guidelines for the clinical management of COVID-19external icon prepared by the COVID-19 Treatment Guidelines Panel. The recommendations are based on scientific evidence and expert opinion and are regularly updated as more data become available.

For guidance related to children with COVID-19, please see the Pediatric Considerations section below.

Clinical Presentation

Incubation period

The incubation period for COVID-19 is thought to extend to 14 days, with a median time of 4-5 days from exposure to symptoms onset.(1-3) One study reported that 97.5% of people with COVID-19 who have symptoms will do so within 11.5 days of SARS-CoV-2 infection.(3)

Presentation

The signs and symptoms of COVID-19 present at illness onset vary, but over the course of the disease many people with COVID-19 will experience the following:(1,4-9)

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Symptoms may differ with severity of disease. For example, shortness of breath is more commonly reported among people who are hospitalized with COVID-19 than among people with milder disease (non-hospitalized patients).(10, 11) Atypical presentations of COVID-19 occur often, and older adults and people with medical comorbidities may experience fever and respiratory symptoms later during the course of illness than people who are younger or who do not have comorbidities.(12, 13) In one study of 1,099 hospitalized patients, fever was present in only 44% at hospital admission but eventually 89% of patients had a fever sometime during hospitalization.(1) Fatigue, headache, and muscle aches (myalgia) are among the most commonly reported symptoms in people who are not hospitalized, and sore throat and nasal congestion or runny nose (rhinorrhea) also may be prominent symptoms. Many people with COVID-19 experience gastrointestinal symptoms such as nausea, vomiting or diarrhea, sometimes prior to having fever and lower respiratory tract signs and symptoms.(9) Loss of smell (anosmia) or taste (ageusia) has been commonly reported, in a third of patients in one study, especially among women and younger or middle-aged patients.(14)

Asymptomatic and Presymptomatic Infection

Several studies have documented infection with SARS-CoV-2, the virus causing COVID-19, in patients who never have symptoms (asymptomatic) and in patients not yet symptomatic (presymptomatic).(15-29) Since people who are asymptomatic are not always tested, the prevalence of asymptomatic infection and detection of presymptomatic infection is not yet well understood. Current data, based on reverse transcription-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 and on serologic studies, suggest asymptomatic infections can be common and that the total number of infections is likely greater than the number of cases reported.(15,22-24,30,31) Patients may have abnormalities on chest imaging before the onset of symptoms.(16)

Asymptomatic and Presymptomatic Transmission

Increasing numbers of epidemiologic studies have documented SARS-CoV-2 transmission during the presymptomatic incubation period.(19,28,29,32) Studies using RT-PCR detection have reported low cycle thresholds, indicating larger quantities of viral RNA, among people with asymptomatic and presymptomatic SARS-CoV-2 infection. Likewise in viral culture, viral growth has been observed in specimens obtained from patients with asymptomatic and presymptomatic infection.(22,24,27,33) The proportion of SARS-CoV-2 transmission due to asymptomatic or presymptomatic infection compared with symptomatic infection is not entirely clear; however, recent studies do suggest that people who are not showing symptoms may transmit the virus.(22,24,34)

Clinical Course

Illness Severity

The largest cohort reported to date, including more than 44,000 people with COVID-19 from China, showed that illness severity can range from mild to critical:(35)

  • Mild to moderate (mild symptoms up to mild pneumonia): 81%
  • Severe (dyspnea, hypoxia, or more than 50% lung involvement on imaging): 14%
  • Critical (respiratory failure, shock, or multiorgan system dysfunction): 5%

In this study, all deaths occurred among patients with critical illness, and the overall case fatality ratio (CFR) was 2.3%.(35) The CFR among patients with critical disease was 49%.(35) Among children in China, illness severity was lower than in adults, with 94% of affected children having asymptomatic, mild, or moderate disease; 5% having severe disease; and less than 1% having critical disease.(13) Among U.S. COVID-19 cases reported January 22–May 30, 2020, overall the proportion of people who were hospitalized was 14%, including 2% admitted to the intensive care unit (ICU).  Overall 5% of patients died.(36)

Clinical Progression

Among patients in multiple early studies from Wuhan, China who had severe COVID-19 illness, the median time from their onset of illness to the time they experienced dyspnea was 5–8 days; the median time from onset of illness to acute respiratory distress syndrome (ARDS) was 8–12 days; and the median time from onset of illness to ICU admission was 9.5–12 days.(5,6,37,38) Clinicians should be aware of the potential for some patients with COVID-19 to rapidly deteriorate about one week after illness onset. Among all hospitalized patients, 26%–32% of patients were admitted to the ICU.(6,8,38) Among all patients, 3%–17% had ARDS compared with 20%–42% for hospitalized patients and 67%–85% for patients admitted to the ICU.(1,4-6,8,38) Mortality among patients admitted to the ICU ranged from 39% to 72% depending on the study and characteristics of patient population.(5,8,37,38) The median length of hospitalization among survivors was 10–13 days.(1,6,8)

Risk Factors for Severe Illness

Age is a strong risk factor for severe illness, complications, and death.(1,6,8,13,34,35,39-42) Among the cohort of more than 44,000 confirmed cases of COVID-19 in China, the CFR increased with advancing age, and was highest among the oldest cohort.  Mortality among people 80 years and older was 14.8%; 70–79 years, 8.0%; 60–69 years, 3.6%; 50–59 years, 1.3%; 40–49 years, 0.4%; and for those younger than 40 years, 0.2%.(35) Based on U.S. epidemiologic data through March 16, 2020, CFR was highest in people aged 85 years or older (range 10%–27%), followed by people aged 65–84 years (3%–11%), aged 55–64 years (1%–3%), and was lower in people younger than 55 years (

About the author

cvxgBWcuFA

Leave a Comment