Managing COVID-19 in adults
Introduction
Initial clinical assessment for potential COVID-19 in all patients should be guided by t
he Screening tool. Further guidelines on
infection control precautions, bed management etc. are also found at the same link.
This guideline has been adapted from the
Australian National COVID-19 Clinical Evidence Taskforce and Counties Manukau
District Health Board management guideline and has been revised by Infectious Diseases, for use at the Auckland District
Health Board. It refers to ongoing clinical management
FOR ADULTS ONLY in the following patient groups:
Confirmed COVID-19
Probable COVID-19
(SARS-CoV-2 test positive during current illness)
(tested negative, but ID decision to treat as COVID)
i.e. does not apply to those with ‘Suspected’, ‘High risk criteria’, ‘Acute respiratory infections’ or ‘contact’ groups.
Initial Management
MILD
MODERATE
SEVERE / CRITICAL
No symptoms
Stable adult patient presenting with
Adult patients meeting any of the
OR URTI symptoms only
shortness of breath and/or systemic
following criteria:
OR cough, new myalgia or
symptoms or signs.
DEFINITION
• Respiratory rate ≥30/min
asthenia without new
Able to maintain oxygen saturation
• Oxygen saturation <92% on 4L/min
shortness of breath or
≥92% (or ≥90% for patients with
oxygen via nasal prongs
reduction in oxygen
chronic lung disease) with up to 4
• Clinically deteriorating
saturation
L/min oxygen via nasal prongs.
FBC, Creat, electrolytes, LFTs, CRP
FBC, Creat, electrolytes, LFTs, CRP
ECG
ECG only if specific indication
Chest x-ray
Chest x-ray
ABG
ABG if saturations <92%
Investigations for CAP (urinary
BASELINE TESTING
Only as clinically indicated.
Investigations for CAP (urinary
antigen for
S. pneumoniae, sputum
Low value testing is
antigen for
S. pneumoniae, sputum
culture and PCR panel) if CXR shows
& WORK-UP
discouraged.
culture and PCR panel) if CXR shows
focal consolidation.
focal consolidation.
Blood cultures if febrile or shocked
Blood cultures if febrile or shocked
Coag screen, d-dimer, LDH, ferritin,
d-dimer & ferritin
BNP, troponin, consider
HIV test
echocardiogram
HIV test
Assess ability to manage in
Early decision & documentation of ceiling of therapy (including respiratory
TREATMENT
a quarantine (hotel) setting.
support modalities). Involve ICU and Respiratory early.
Consider & document risk
Consider & document risk factors for poor COVID outcome.
ESCALATION
factors for severe COVID.
Complete th
e ADHB Goals of Care form for all patients
PLANNING
NOTE – any new deterioration >7 days post onset of illness requires careful assessment, observation &
judgement. Severe COVID-19 frequently develops with a rapid deterioration.
Admit to Ward 7A under the COVID
DISPOSITION
Encourage discharge
CBU.
Admit to Ward 7A or ICU.
(discuss with JetPark via ID).
Liaise with Respiratory if requiring
Discuss with ICU and/or Respiratory
DECISION
Liaise with Public Health.
oxygen >2L/min and/or comorbid
regarding destination.
respiratory disease e.g., NIV for OSA
PROBABLE ONLY
Collect serum sample in acute phase, repeat ≥2 weeks later, for ‘COVID serology’
Monitor for progressive respiratory failure and sepsis, especially on days 5 to 10 after onset of symptoms.
Only repeat CXR in people with suspected or confirmed COVID-19 if clinically indicated (e.g. in cases of clinical
MONITORING
deterioration or recent intubation).
&
Do not routinely perform CT scanning - only if clinically indicated.
MARKERS OF
Anticipate complications such as pulmonary embolism, other thromboembolism, arrhythmias, cardiac
CLINICAL
impairment, acute kidney injury, sepsis, shock and multi-organ dysfunction, and address using existing
DETERIORATION
standards of care. Also be aware of potential complications from trial drugs, if applicable.
Repeat baseline investigations (see above) periodically in patients who are not clearly improving, in order to
detect & manage the above complications.
Discuss all cases with the COVID SMO or on call ID physician at the earliest opportunity
NOTIFICATION
If not already notified, send e-ref to Auckland Regional Public Health AND notify by telephone (09 623 4600)
Version 2: 23 August 2021
Document Owner: Service Clinical Director, Infectious Diseases
Authors: Mark Hobbs, Annabelle Donaldson, Rebekah Lane, Mitzi Nisbet, Eamon Duffy, Colin McArthur
Approved by: Ian Dittmer, Clinical Lead COVID and Alex Pimm Auckland DHB Incident Controller 25 August 2021
All patients should be screened for eligibility for one of two clinical trials currently recruiting at ADHB
CLINICAL TRIALS
‘REMAP-CAP’ is recruiting patients admitted to ICU, and ‘ASCOT-ADAPT’ is recruiting hospitalised patients
outside of ICU. Discuss with ID in the first instance.
Treatment
NOTE:- the standard-of-care for patients with COVID-19 is to be offered enrolment in one of our clinical trials.
This table indicates which treatment modalities are affected if the patient is enrolled in a trial:
MODALITY
PATIENT SUB-GROUPS
RECOMMENDATION
Switch nebulisers to metered dose inhalers via spacer if
possible.
All patients
Encourage self-proning in patients who are able to follow
verbal instructions if safe and feasible
Administer dry oxygen (0.5-3 L/min) via standard nasal
prongs
Aim for SpO2 90-92% (>86% for those at risk of
RESPIRATORY SUPPORT
SpO2 <92% or significantly below baseline
hypercapnic respiratory failure or known COPD)
Use Hudson mask (5-10 L/min) if higher flow rates
required
Consider High Flow Nasal Oxygen (HFNO, eg ‘Airvo”) or
NIV
Unable to maintain SpO2 ≥92% on
Discussion with ICU and Respiratory SMO
conventional oxygen at 6 L/min
Note that these are potential aerosol-generating
procedures
Discuss with Resp regarding Non-Invasive Ventilation
Hypercapnic patients with underlying
(NIV)
COPD or OHS
Note that this is a potential aerosol-generating procedure
Use IV fluids as you would in any unwell patient
FLUID MANAGEMENT
Avoid: ‘maintenance’ IV fluids, high volume enteral nutrition, and repeated fluid boluses for
hypotension.
Involve ICU for consideration of vasopressor therapy if not responding after 2-3 boluses
Patients with any of the following signs of deterioration should be discussed with ICU:
Increasing oxygen requirement (requiring FiO2 of 0.4 to maintain SpO2 >92% on HFNO, or 10-15L/min
conventional O2 therapy)
ICU CARE
Increased work of breathing with impending respiratory failure
Haemodynamically unstable and non-responsive to fluid bolus therapy
Rapidly worsening tachypnoea or hypoxaemia
Detailed clinical guidelines for ICU care of COVID-19 is beyond the scope of this guideline.
Do not use oral steroids to treat mild COVID-19. Consider
inhaled budesonide (800 micrograms bd for 14 days) in
Adults who do not require oxygen
patients over 65 years or those over 50 years with
comorbidities.
Adults requiring oxygen and/or ventilatory
STEROIDS
Dexamethasone 6mg daily IV/PO until discharge OR up to
support to maintain oxygen saturation
10 days (whichever sooner).
≥92%
Adults with another evidence-based
indication for steroids (e.g. asthma/COPD
Steroids as per usual practise.
exacerbations)
Enoxaparin 1mg/kg SC bd if eGFR >30 mL/min/1.73m2
Adults with mild or moderate COVID-19
Reduce to 1mg/kg daily if eGFR <30mL/min/1.73m2
AND no contra-indication to
THROMBOSIS
Liaise with Haematology if low platelet count (<50 x109),
anticoagulation e.g. risk for major bleeding
MANAGEMENT
or low fibrinogen level (<1.0g/L)
Heparin 5000U SC 8 or 12 hourly or enoxaparin 40mg SC
daily
Adults with severe COVID-19 (ICU
Patients on the ward on therapeutic-dose enoxaparin
required)
who deteriorate and require ICU care need discussion
with Haematology and COVID team
Consider enrolment in REMAP-CAP for dosing options
Version 2: 23 August 2021
Document Owner: Service Clinical Director, Infectious Diseases
Authors: Mark Hobbs, Annabelle Donaldson, Rebekah Lane, Mitzi Nisbet, Eamon Duffy, Colin McArthur
Approved by: Ian Dittmer, Clinical Lead COVID and Alex Pimm Auckland DHB Incident Controller 25 August 2021
Pregnant or postpartum women with any
Enoxaparin as above
severity of COVID-19
NOTE:- Discuss dosing & duration with Obstetrics
There are no trials of immune modulation therapies currently recruiting at ADHB
Adults with COVID-19:
Give tocilizumab:
AND receiving oxygen + steroids
Apply to PHARMAC (NPPA) or local HMC for rapid
AND evidence of severe systemic
IMMUNE MODULATION
access
inflammation (raised CRP, ferritin or
THERAPY
8mg/kg (actual body weight) rounded to nearest 200mg
procalcitonin)
(max dose 800mg), as a single dose
AND there is not another active, severe
secondary infection
COVID-19 not meeting the criteria above
Do not use immune modulation therapy
All patients enrolled in ASCOT-ADAPT
As per trial protocol & randomisation (in addition to
trial (anti-viral domain)
remdesivir, if indicated below)
Do not use remdesivir or any other anti-viral outside of a
Adults with mild COVID-19
clinical trial
Adults with moderate to severe COVID-19
Consider Remdesivir to reduce time to recovery, see the
who do not require ventilation with
ANTI-VIRAL THERAPY
eligibility criteria for access to remdesivir
oxygen saturations of <92% on room air
200mg IV on day 1, then 100mg q24h for a further 4
and do not fulfil criteria for immune
days. Dose made up in 250mL 0.9% NaCl, infuse over
modulation therapy
30-120min
Note – must have ALT <5 x ULN and/or
Monitor LFTs
daily; discuss with ID if eGFR <30 or AKI
ALT <3 x ULN and bilirubin <2 x ULN
Adults with critical COVID-19 who require
Do not use remdesivir or any other anti-viral outside of a
ventilation (invasive or non-invasive)
clinical trial
Mild or moderate COVID-19 without
specific evidence of concurrent bacterial
Do not use antibiotics
infection (which is rare in the first 7 days
of illness)
ANTIBIOTIC THERAPY
Any severity of COVID-19 AND specific
evidence of concurrent bacterial infection
(not routinely indicated to
Calculate CURB-65 score
(e.g. positive culture/antigen, purulent
treat COVID-19)
Treat as per SCRIPT guidelines
sputum, focal/unilateral consolidation,
unilateral pleural effusion, neutrophilia)
Severe/critical COVID-19, especially with
Discuss with ID (in hospitalised COVID-19 it is common to
any deterioration occurring >7 days post
develop late, severe, secondary bacterial sepsis)
onset
ACE-inhibitors / ARBs
Oral contraceptive pill (with or without
Usual care (i.e. may be continued in COVID-19 unless
oestrogen)
otherwise contra-indicated)
THERAPIES FOR EXISTING
Antenatal steroids for high risk of
preterm birth
INDICATIONS
Corticosteroids for asthma/COPD
Usual care
(inhaled or oral, with or without
Do not use a nebuliser
bronchodilators)
Oral menopausal hormone therapy / HRT Consider stopping until after recovery
Do not routinely perform elective surgery within eight weeks of recovery from COVID-19 infection,
SURGERY
unless outweighed by the risk of deferring surgery, such as disease progression or clinical priority.
PREGNANCY & PERINATAL
Out of scope for this local guideline; detailed guidance is included in t
he Australian COVID-19
guidelines
CARE
Input from Obstetrics, in discussion with ID and/or other relevant specialties, is essential.
Version 2: 23 August 2021
Document Owner: Service Clinical Director, Infectious Diseases
Authors: Mark Hobbs, Annabelle Donaldson, Rebekah Lane, Mitzi Nisbet, Eamon Duffy, Colin McArthur
Approved by: Ian Dittmer, Clinical Lead COVID and Alex Pimm Auckland DHB Incident Controller 25 August 2021
Discharge Planning:
Patients with Suspected, Probable or Confirmed COVID-19 who are being considered for discharge need to have specific
decisions made about the following aspects of post-discharge care:
1. Further investigations (for Suspected)
2. Discharge destination:
Suspected cases being discharged before results are available should be notified to the Medical Officer of
Health, who may request discharge to a quarantine facility.
Ensure an e-referral to ARPHS has been made, with correct mobile phone numbers to ensure patient
notification of result
Most Probable/Confirmed cases who remain in isolation will be discharged to Jet Park.
3. Clearance from isolation:
Mild cases can be released from isolation after ≥10 days have passed since the onset of symptoms AND there
has been resolution of the acute symptoms for ≥72 hours.
Most hospitalised moderate & severe cases will require a further 10 days of isolation after discharge.
Patients with prolonged illness, long hospital stay, or major immunosuppression will require case-by-case
review by ID.
Note – repeat swabs are generally discouraged (but may be requested by ID on a case-by-case basis).
4. Appropriate follow-up:
Patients who have had significant respiratory failure and/or persistent dyspnoea or hypoxia may require
respiratory follow up and support on discharge e.g. pulmonary rehabilitation, short-term oxygen.
All confirmed COVID-19 cases with pneumonitis requiring treatment with oxygen and/or corticosteroids
should be referred to the Infectious Diseases Clinic on discharge so a follow-up appointment can be arranged
approximately 8/52 post-discharge. Please send an electronic referral and request:
Pulmonary function tests with DLCO ~6/52 post-discharge
A CXR, which could be done on the day of the PFTs (please indicate in the CXR ROERS request that the patient
will have an appointment for PFTs and the CXR could occur on the same day)
Please consider referring other confirmed COVID-19 patients who would benefit from ID follow-up.
5. All cases should be discussed with ID in advance to individualise the plan.
Version 2: 23 August 2021
Document Owner: Service Clinical Director, Infectious Diseases
Authors: Mark Hobbs, Annabelle Donaldson, Rebekah Lane, Mitzi Nisbet, Eamon Duffy, Colin McArthur
Approved by: Ian Dittmer, Clinical Lead COVID and Alex Pimm Auckland DHB Incident Controller 25 August 2021
