Coronavirus Disease 2019 (COVID-19) Guidelines

Updated: Jun 12, 2023
  • Author: David J Cennimo, MD, FAAP, FACP, FIDSA, AAHIVS; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines Summary

Numerous clinical guidelines have been issued for COVID-19. The following guidelines have been summarized at Medscape's COVID-19 Clinical Guidelines center:

Information regarding COVID-19 is rapidly emerging and evolving. For the latest information, see the following:


CDC Evaluating and Testing Persons Under Investigation (PUI) for COVID-19 Clinical Guidelines

COVID-19 Terminology and Definitions

There are many different technical and legal terms that have been utilized in official governmental guidance, media reports, and throughout the general public with respect to the 2019-nCoV (2019 Novel Coronavirus) and the resulting COVID-19 (Coronavirus Disease 2019).

Patient Status Definitions

  • Confirmed: The patient meets all the criteria necessary to be considered a Patient Under Investigation (PUI), including signs, symptoms and travel history. A lab sample was collected and tested by a CDC-qualified laboratory and the result is positive.
  • Suspected: The patient meets all the criteria necessary to be considered a Patient Under Investigation (PUI), including signs, symptoms and travel history. A lab sample was collected and sent to a CDC-qualified lab, but the results are still pending.
  • Exposed: The person meets the criteria established by the CDC with regards to travel history and/or close contact with a confirmed case, but the individual is not exhibiting any additional signs or symptoms consistent with infection.

Protective Action Definitions

  • Treatment: A person is currently receiving active medical treatment for their COVID-19 symptoms and/or related complications.
  • Isolation: This involves separating ill persons from well persons.
  • Quarantine: This involves separating well persons, who have been exposed to the infection, from other well persons during the incubation period of an illness.
  • Monitoring: A state or local public health authority establishes regular communication with a person or group of people who were potentially exposed to the virus by virtue of travel history to identified locations or close contact with confirmed cases. The person is instructed to monitor for and report certain signs and symptoms of potential illness to the health authority.  There are no movement restrictions applied to this individual.

Legal Status Definitions

  • Voluntary: The person has voluntarily agreed to comply with legally enforceable directives issued under the authority of a relevant federal, state, or local entity that, when applied to a person or group, may place restrictions on the activities undertaken by that person or group, potentially including movement restrictions or a requirement for monitoring by a public health authority, for the purposes of protecting the public’s health.
  • Involuntary: The person has been compelled by a court order to abide by legally enforceable directives issued under the authority of a relevant federal, state, or local entity that, when applied to a person or group, may place restrictions on the activities undertaken by that person or group, potentially including movement restrictions or a requirement for monitoring by a public health authority, for the purposes of protecting the public’s health.
  • Non-legal: The person is not subject to any legally enforceable directives. The person voluntarily agrees to adhere to non-binding guidance provided by public health or healthcare officials.

Supervision Level Definitions

  • Direct Medical: The person is under the direct continuous clinical care of a healthcare provider in a clinical setting (e.g. inpatient at a hospital or isolated to a government facility).
  • Public Health Supervision: The person is monitored directly by local public health authorities, in-person or remotely, on a regular basis (e.g. daily).
  • Delegated Supervision: The local public health authority has delegated oversight to an appropriate occupational health or infection control program at a trusted organization (e.g. healthcare, higher education, corporation). The delegated supervisor maintains coordination with the public health department of local jurisdiction.
  • Self: The person is instructed to monitor themselves for and report certain signs and symptoms of potential illness to the healthy authority.

Location Definitions

  • Hospital: The patient is admitted to a hospital.
  • Government: The person has been relocated to a government-controlled facility.
  • Congregate: The person has been relocated to any other congregate type setting (e.g. long term care facility, public housing, university housing) administered by routine operating authorities.

CDC Sample Collection and Testing Guidelines for COVID-19

In March 2020, the CDC published interim guidelines regarding the collection, handling, and testing of clinical specimens for the diagnosis of COVID-19. [314]

Collection and evaluation of an upper respiratory nasopharyngeal swab (NP) is recommended for initial COVID-19 testing.

If an oropharyngeal swab (OP) is collected, it should be combined in the same tube as the NP; however, OPs are a lower priority than NPs.

Only patients with a productive cough should undergo sputum collection. Sputum induction is not recommended.

If lower respiratory tract specimens are available, they should also be tested.

If clinically indicated (eg, if the patient is undergoing invasive mechanical ventilation), collection and testing of a lower respiratory tract aspirate or bronchoalveolar lavage sample should be performed.

Once a possible COVID-19 case has been identified, specimen collection should be performed as soon as possible, regardless of when the individual’s symptoms began.

Proper infection control must be maintained during specimen collection.

Lower respiratory tract specimens

Bronchoalveolar lavage, tracheal aspirate

Two to 3 mL should be collected in a sterile, leak-proof, screw-cap sputum collection cup or sterile, dry container.


The patient should rinse their mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile, dry container.

Upper respiratory tract specimens

Nasopharyngeal swab/oropharyngeal swab

Only synthetic fiber swabs with plastic shafts should be used. Calcium alginate swabs or swabs with wooden shafts—both of which may contain substances that inactivate some viruses and inhibit PCR testing—should not be used. Swabs should be placed immediately in sterile tubes containing 2-3 mL of viral transport media. In general, the CDC recommends that only an NP should be collected. If an OP is collected as well, it should be combined at collection with the NP in a single vial.

To collect an NP, the swab should be inserted into the nostril parallel to the palate, reaching a depth equal to the distance from the nostrils to the ear’s outer opening. To absorb secretions, the swab should be left in place for several seconds. It should then be slowly removed while the clinician rotates it.

In collecting an OP (eg, a throat swab), the posterior pharynx should be swabbed, with avoidance of the tongue.

Nasopharyngeal wash/aspirate or nasal aspirate

Two to 3 mL should be collected in a sterile, leak-proof, screw-cap sputum collection cup or sterile, dry container.


Specimens should be stored at 2-8°C for up to 72 hours after collection. If testing or shipping may be delayed, the specimens should be stored at -70°C or below.


Packaging, shipping, and transportation of specimens must be performed as designated in the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations. Specimens should be stored at 2-8°C and shipped overnight to the CDC on ice pack. Specimens frozen at -70°C should be shipped overnight to the CDC on dry ice.


Guidance for Hospitals on Containing Spread of COVID-19

The guideline on coronavirus disease (COVID-19) infection control and prevention for hospitals was released on March 4, 2020 by the Centers for Medicare & Medicaid Services. [315]

Hospitals should monitor the CDC website ( for up-to-date information and resources.

Hospitals should contact their local health department if they have questions or suspect a patient or healthcare provider (HCP) has COVID-19.

Hospitals should have plans for monitoring healthcare personnel with exposure to patients with known or suspected COVID-19. Additional information about monitoring healthcare personnel is available at .

Risk assessment and screening

Older adults and those with underlying chronic medical conditions or immunocompromised state may be at highest risk for severe outcomes. This should be considered in the decision to monitor the patient as an outpatient or inpatient.

Hospitals should identify visitors and patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility. They should ask patients about the following:

  • Fever or symptoms of a respiratory infection, such as a cough and sore throat
  • International travel within the last 14 days to restricted countries (For updated information on restricted countries, visit
  • Contact with someone with known or suspected COVID-19

For patients identified as at-risk, implement respiratory hygiene and cough etiquette (ie, placing a face mask over the patient’s nose and mouth) and isolate the patient in an examination room with the door closed.

If the patient cannot be immediately moved to an examination room, ensure they are not allowed to wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, medically stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when they can be evaluated.

Inform infection prevention and control services, local and state public health authorities, and other healthcare facility staff as appropriate about the presence of a person under investigation for COVID-19.

Additional guidance for evaluating patients in the United States for COVID-19 can be found on the CDC COVID-19 Web site.

Provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS), tissues, no-touch receptacles for disposal, facemasks, and tissues at healthcare facility entrances, waiting rooms, patient check-ins, etc.

Monitoring or restriction of healthcare facility staff

The same screening performed for visitors should be performed for hospital staff.

HCP who have signs and symptoms of a respiratory infection should not report to work.

Any staff that develop signs and symptoms of a respiratory infection while on the job should do the following:

  • Immediately stop work, put on a facemask, and self-isolate at home.
  • Inform the hospital’s infection prevention specialist and include information on individuals, equipment, and locations with which the person came into contact.
  • Contact and follow the local health department recommendations for next steps (eg, testing, locations for treatment).

Refer to the CDC guidance for exposures that might warrant restricting asymptomatic health care personnel from reporting to work (

Hospitals should contact their local health department for questions and frequently review the CDC website dedicated to COVID-19 for health care professionals:

Patient placement and infection prevention and control for known or suspected COVID-19 cases

Patient placement and other detailed infection prevention and control recommendations regarding hand hygiene, transmission-based precautions, environmental cleaning and disinfection, managing visitors, and monitoring and managing health care personnel are available in the CDC Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons under Investigation for COVID-19 in Healthcare Settings.

Patients may not require hospitalization and can be managed at home if they are able to comply with monitoring requests. More information is available at

Patients with known or suspected COVID-19 should continue to receive the intervention appropriate for the severity of their illness and overall clinical condition. Because some procedures create high risks for transmission (eg, intubation), additional precautions include the following:

  • HCP should wear all recommended personal protective equipment (PPE).
  • The number of HCP present should be limited to essential personnel.
  • The room should be cleaned and disinfected in accordance with environmental infection control guidelines.

Additional information about performing aerosol-generating procedures is available at

The decision to discontinue transmission-based precautions for hospitalized patients with COVID-19 should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. This decision should consider disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens.

More detailed information about criteria to discontinue transmission-based precautions are available at

Visitation rights

Medicare regulations require a hospital to have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation, such as infection control concerns.

Patients must be informed of their visitation rights and the clinical restrictions or limitations on visitation.

The development of such policies and procedures require hospitals to focus efforts on preventing and controlling infections, not just between patients and personnel, but also between individuals across the entire hospital setting (for example, among patients, staff, and visitors), as well as between the hospital and other healthcare institutions and settings and between patients and the healthcare environment.

Hospitals should work with their local, state, and federal public health agencies to develop appropriate preparedness and response strategies for communicable threats.

Hospital discharge

The decision to discharge a patient from the hospital should be based on the clinical condition of the patient. If transmission-based precautions must be continued in the subsequent setting, the receiving facility must be able to implement all recommended infection prevention and control measures.

Although patients COVID-19 who have mild symptoms may be managed at home, the decision to discharge to home should take into account the patient’s ability to adhere to isolation recommendations, as well as the potential risk of secondary transmission to household members with immunocompromising conditions. 

Medicare’s Discharge Planning Regulations (updated in November 2019) require that the hospital assess the patient’s needs for post-hospital services and the availability of such services. When a patient is discharged, all necessary medical information (including communicable diseases) must be provided to any post-acute service provider. For patients with COVID-19, this must be communicated to the receiving service provider prior to discharge/transfer and to the healthcare transport personnel.


American Academy of Pediatrics Guidance on Management of Infants Born to Mothers with COVID-19

The American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases has issued guidance on the management of infants born to mothers with COVID-19. [316, 317]

Early evidence has shown low rates of peripartum SARS-CoV-2 transmission and uncertainty concerning in utero viral transmission.

Neonates can be infected by SARS-CoV-2 after birth. Because of their immature immune systems, they are vulnerable to serious respiratory viral infections. SARS-CoV-2 may be able to cause severe disease in neonates.

Precautions during delivery

A gown and gloves should be worn by birth attendants, along with an N95 respiratory mask plus goggles or an air-purifying respirator that protects the eyes.

Delayed cord clamping

Transplacental viral transmission from mother to newborn has not been clearly demonstrated, so delayed cord clamping can continue per normal center practices. The mother can briefly hold the newborn during delayed cord clamping if infection-control precautions are observed.

Room-in of mother and well newborn

This is controversial. Some information has shown good outcomes among most newborns exposed to mothers with COVID-19, although some infants have developed severe illness. The safest approach is to minimize the infection risk via separation, at least temporarily, allowing time for the mother to become less infectious. If the mother chooses against separation or other factors preclude separation, infection risks should be minimized with distancing (at least 6 feet between mother and newborn) and provision of hands-on care to the infant by a noninfected caregiver. Mothers who provide hands-on care should wear a facemask and observe proper hand hygiene.


Breastfeeding is strongly supported as the best choice for infant feeding. Breastmilk is unlikely to transmit SARS-CoV-2. Mothers with COVID-19 may express breast milk after appropriate hand and breast hygiene to be fed to the newborn by caregivers without COVID-19. Mothers who opt for nursing should observe strict precautions, including use of a facemask and breast and hand hygiene.

Neonatal intensive care

If the newborn requires intensive care and respiratory support, admission to a single-patient room with negative room pressure is optimal. If multiple newborns with exposure to COVID-19 must be treated in the same room, they should be kept at least six feet apart and/or kept in temperature-controlled isolettes.

Care providers should wear gowns and gloves, along with an N95 respiratory mask plus goggles or an air-purifying respirator that protects the eyes to treat infants who require supplemental oxygen at more than 2 LPM, continuous positive airway pressure, or mechanical ventilation.

Neonatal testing for COVID-19

Following birth, newborns born to mothers with COVID-19 should be bathed to remove virus from the skin. Newborns should undergo testing for SARS-CoV-2 at 24 hours and 48 hours (if still at the birth facility) after birth. Centers with limited testing resources can make testing decisions on a case-by-case basis.

Newborn discharge

Newborns born to mothers with COVID-19 should be discharged per the hospital’s normal criteria. Early discharge is not necessary.

Newborns who test positive for SARS-CoV-2 but are asymptomatic should undergo frequent outpatient follow-up (via phone, telemedicine, or office visit) through 14 days after birth. Infection-control precautions should be observed at home and in the outpatient office.

Infants who test negative for SARS-CoV-2 are likely to be discharged to the care of individuals who have COVID-19 or who have been exposed to COVID-19. All potential caregivers should receive infection-prevention instructions. Following hospital discharge, mothers with COVID-19 should stay at least 6 feet away from their newborns. If a closer proximity is required, the mother should wear a mask and observe hand hygiene for newborn care until (1) her temperature has normalized for 72 hours without antipyretic therapy and (2) at least 10 days has passed since the onset of symptoms. If the mother has asymptomatic SARS-CoV-2 infection (identified with obstetric screening tests), she should wait at least 10 days from the positive test or until two consecutive tests administered more than 24 hours apart show negative results.

Newborns who cannot undergo SARS-CoV-2 testing should be treated as infected for an observation period of 14 days. The mother should still observe the precautions detailed above.

NICU visitation

Access to NICUs during the COVID-19 pandemic is limited. Mothers and partners with confirmed or suspected COVID-19 (PUIs) should not enter the NICU until their status is resolved and transmission is no longer a risk.


NIH Coronavirus Disease 2019 (COVID-19) Treatment Guidelines

Pharmacologic management based on COVID-19 disease severity

Outpatient or hospitalized (but not requiring oxygen)

  • No specific antiviral or immunomodulatory therapy recommended
  • The Panel recommends against use of dexamethasone
  • Also see remdesivir for use in hospitalized patients with moderate COVID-19

Hospitalized and requires supplemental oxygen (but not by high-flow device, noninvasive ventilation, invasive mechanical ventilation, or ECMO)

  • Remdesivir 200 mg IV x 1, then 100 mg IV qDay for 4 days or until hospital discharge, whichever comes first, OR
  • Remdesivir plus dexamethasone 6 mg IV/PO qDay for up to 10 days or until hospital discharge, whichever comes first
  • If remdesivir cannot be used, dexamethasone may be used instead 

Hospitalized and requires oxygen by high-flow device or noninvasive ventilation

  • Dexamethasone plus remdesivir at doses and durations above OR
  • Dexamethasone 

Hospitalized and requires invasive mechanical ventilation or ECMO

  • Dexamethasone at doses and duration above OR
  • Dexamethasone plus remdesivir for patient recently intubated 

Antiviral therapy


Because remdesivir supplies are limited, the Panel recommends prioritizing remdesivir for use in hospitalized patients with COVID-19 who require supplemental oxygen, but who do not require oxygen delivery by high-flow device, noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).

Five days of remdesivir treatment is recommended in hospitalized patients with severe COVID-19 who are not intubated. The optimal duration of remdesivir treatment is undetermined in mechanically ventilated patients, patients on ECMO, and patients in whom improvement is inadequate after 5 days of therapy.

The data are insufficient to recommend for or against remdesivir in patients with mild or moderate COVID-19.

Chloroquine or hydroxychloroquine

The Panel recommends against chloroquine or hydroxychloroquine with or without azithromycin in the treatment of COVID-19 outside the context of a clinical trial.

The Panel recommends against the use of high-dose chloroquine (600 mg twice daily for 10 days) for the treatment of COVID-19. 

Other antivirals

The Panel recommends against (1) hydroxychloroquine plus azithromycin, (2) lopinavir/ritonavir, and (3) other HIV protease inhibitors except in a clinical trial.


The Panel recommends use of tocilizumab (single IV dose of 8 mg/kg, up to 800 mg) in combination with dexamethasone in recently hospitalized patients who are exhibiting rapid respiratory decompensation caused by COVID-19. These patients include:

  • Recently hospitalized patients who have been admitted to the ICU within the prior 24 hours and who require invasive mechanical ventilation, noninvasive mechanical ventilation (NIV), or high-flow nasal canula (HFNC) oxygen (>0.4 FiO2/30 L/min of oxygen flow) (BIIa); or
  • Recently hospitalized patients (not in the ICU) with rapidly increasing oxygen needs who require NIV or HFNC and have significantly increased markers of inflammation (BIIa) (eg, C-reactive protein 75 mg/L or greater) 


The Panel recommends dexamethasone (6 mg/day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients who require supplemental oxygen but are not mechanically ventilated.

The Panel recommends against dexamethasone in patients with COVID-19 who do not require supplemental oxygen.

If dexamethasone is not available, the Panel recommends using alternative glucocorticoids such as prednisone, methylprednisolone, or hydrocortisone.

Convalescent plasma

The FDA granted emergency use authorization (EUA) on August 23, 2020 for use of convalescent plasma in hospitalized patients with COVID-19. Convalescent plasma contains antibody-rich plasma products collected from eligible donors who have recovered from COVID-19. 

The NIH COVID-19 Guidelines Panel further evaluated the Mayo Clinic’s expanded access (EA) program data and further reviewed subgroups. Among patients who were not intubated, 11% of those who received convalescent plasma with high antibody titers died within 7 days of transfusion compared with 14% of those who received convalescent plasma with low antibody titers. Among those who were intubated, there was no difference in 7-day survival. 

Based on the available evidence, the panel determined the following [250]

  • There are insufficient data to recommend either for or against the use of convalescent plasma for the treatment of COVID-19.
  • Adverse effects of COVID-19 convalescent plasma are infrequent and consistent with the risks associated with plasma infusions for other indications.
  • Convalescent plasma should not be considered standard of care for the treatment of patients with COVID-19.
  • Prospective, well-controlled, adequately powered, randomized trials are needed.

The NIH halted its trial of convalescent plasma in emergency departments for treatment of patients with mild symptoms as of March 2021. The second planned interim analysis of the trial data determined that while the convalescent plasma intervention caused no harm, it was unlikely to benefit this group of patients. 

NIH COVID-19 Treatment Guidelines [318]

Care of Critically Ill Patients with COVID-19

Potential Antiviral Drugs Under Evaluation for the Treatment of COVID-19

Immune-Based Therapy Under Evaluation for Treatment of COVID-19

Considerations for certain Concomitant Medications in Patients with COVID-19


Infectious Diseases Society of America (IDSA) Management Guidelines

The Infectious Diseases Society of America (IDSA) has formed a multidisciplinary guideline panel to provide treatment recommendations for coronavirus disease 2019 (COVID-19). [27]  Refer to the IDSA guidelines for the most recent version.



  • Remdesivir is approved the FDA for treatment of COVID-19 in hospitalized adults and pediatric patients aged 12 years and older who weigh at least 40 kg.
  • Emergency use authorization (EUA) has also been issued for use in hospitalized children aged 12 years or younger weighing 3.5 kg to less than 40 kg.
  • Consideration in contingency or crisis capacity settings (ie, limited remdesivir supply): Remdesivir appears to demonstrate the most benefit in those with severe COVID-19 on supplemental oxygen rather than in patients on mechanical ventilation or ECMO.


  • Insufficient data exist to recommend. 
  • Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19, in either ambulatory or hospitalized patients.

Strong recommendation against use 

  • Hydroxychloroquine or chloroquine with or without azithromycin: In patients with COVID-19, the panel recommends against hydroxychloroquine/chloroquine. Strong recommendation, moderate certainty of evidence. 
  • Lopinavir/ritonavir and other HIV protease inhibitors
  • Hydroxychloroquine/chloroquine plus azithromycin: In patients with COVID-19, the panel suggests against hydroxychloroquine/chloroquine plus azithromycin. Strong recommendation, low certainty of evidence. 
  • Combination of lopinavir/ritonavir: In hospitalized patients with severe COVID-19, the panel recommends against the combination of lopinavir/ritonavir. Strong recommendation, moderate certainty of evidence. 


Corticosteroids used in patients with COVID-19 include the following:

  • Hospitalized critically ill patients: The panel recommends glucocorticoids over no glucocorticoids (dexamethasone 6 mg IV or PO for 10 days, or until discharge). Strong recommendation, moderate certainty of evidence.
  • Hospitalized patients with severe, but noncritical COVID-19: The panel suggests corticosteroids rather than no corticosteroids. Conditional recommendation, moderate certainty of evidence.
  • Hospitalized patients with nonsevere COVID-19: The Panel suggests against use of glucocorticoids. Conditional recommendation, low certainty of evidence.



  • Among hospitalized adults with severe COVID-19 having elevated inflammatory markers, but not on invasive mechanical ventilation, the IDSA panel suggests baricitinib rather than no baricitinib.  
  • Among hospitalized patients with severe COVID-19 who cannot receive corticosteroids because of a contraindication, the IDSA guideline panel suggests use of baricitinib with remdesivir rather than remdesivir alone.
  • The FDA issued and EUA for baricitinib for use in combination with remdesivir for treatment of COVID-19 in hospitalized patients aged 2 years and older who require supplemental oxygen, invasive mechanical ventilation, or ECMO.

Tocilizumab and other IL-6 inhibitors

  • Tocilizumab: In hospitalized adults with COVID-19 who have elevated markers of systemic inflammation, the panel suggests tocilizumab in addition to standard of care (ie, steroids) rather than standard of care alone. Conditional recommendation, low certainty of evidence. 
  • Sarilumab: Preliminary data (preprint) from a trial with 45 patients receiving sarilumab; data are limited to offer recommendation.   

Anti-SARS-CoV-2 antibody products

Monoclonal directed antibodies

  • The FDA issued EUAs for nonhospitalized patients with mild-to-moderate COVID-19 disease who are at high risk of disease progression. 
  • Consider local variant susceptibility when choosing of the most appropriate neutralizing antibody therapy.

Convalescent plasma

  • The FDA issued an EUA for use in hospitalized patients.
  • Hospitalized patients: IDSA guideline panel suggests against COVID-19 convalescent plasma (low certainty of evidence).
  • Ambulatory patients with mild-to-moderate disease: IDSA guideline panel recommends COVID-19 convalescent plasma only in the context of a clinical trial (knowledge gap)


Famotidine may also be administered to patients with COVID-19, as follows:

  • In hospitalized patients with severe COVID-19, the panel suggests against famotidine for the sole intent of COVID-19 treatment outside the context of a clinical trial
  • Conditional recommendation, very low certainty of evidence.

Thromboembolism Prevention and Treatment

American College of Chest Physicians

Guideline summary is as follows [319] :

  • In the absence of contraindications, all acutely hospitalized patients with COVID-19 should receive thromboprophylaxis therapy.
  • Low-molecular-weight heparin (LMWH) or fondaparinux should be used for thromboprophylaxis over unfractionated heparin and direct oral anticoagulants.
  • Data are insufficient to justify routine increased-intensity anticoagulant dosing in hospitalized or critically ill patients with COVID-19.
  • Recommend only inpatient thromboprophylaxis for patients with COVID-19.
  • In critically ill patients with COVID-19, suggest against routine ultrasonographic screening for asymptomatic deep vein thrombosis (DVT).
  • In critically ill patients with COVID-19 who have proximal DVT or pulmonary embolism, recommend parenteral anticoagulation therapy with therapeutic weight-adjusted LMWH or fondaparinux over unfractionated heparin.

International Society on Thrombosis and Haemostasis

Guideline summary is as follows [320] :

  • In hospitalized patients, measure D-dimers, prothrombin time, and platelet count (and possibly fibrinogen).
  • The guidelines include an algorithm for management of coagulopathy based on laboratory markers.
  • Monitoring for septic coagulopathy can be helpful in determining prognosis in patients with COVID‐19 requiring hospital admission.
  • Use of LMWH to protect critically ill patients against venous thromboembolism appears to improve prognosis. 

National Institutes of Health Antithrombotic Therapy in Patients with COVID-19

Guideline summary is as follows [321] :

  • Measure hematologic and coagulation parameters (eg, D-dimers, PT, platelet count, fibrinogen) in hospitalized patients.
  • Patients on anticoagulant or antiplatelet therapies for underlying conditions should continue these medications if they receive a diagnosis of COVID-19.
  • Hospitalized adults with COVID-19 should receive VTE prophylaxis per the standard of care for other hospitalized adults, unless contraindicated.
  • Hospitalized patients with COVID-19 should not routinely be discharged on VTE prophylaxis.
  • In hospitalized patients, the possibility of thromboembolic disease should be evaluated in the event of rapid deterioration of pulmonary, cardiac, or neurological function or of sudden localized loss of peripheral perfusion. 
  • Nonhospitalized patients with COVID-19: Anticoagulants and antiplatelet therapy should not be initiated for prevention of VTE or arterial thrombosis unless the patient has other indications for the therapy or is participating in a clinical trial.