Coronavirus Disease 2019 (COVID-19) Guidelines: Guidelines Summary, Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing by the Infectious Diseases Society of America, Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023) by the Infectious Diseases Society of America (IDSA)

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Coronavirus Disease 2019 (COVID-19)

Guidelines

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:

COVID-19 Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers (FDA, 2020): 2020 COVID-19 guidance for industry and FDA staff
OSHA Guidance on Preparing the Workplace for COVID-19 (2020): 2020 guidance on preparing the workplace for coronavirus disease 2019 (COVID-19) by the Occupational Safety and Health Administration (OSHA)
COVID-19 Breast Cancer Patient Triage Guidelines (CPBCC): Guidelines on surgical triage of patients with breast cancer by the COVID 19 Pandemic Breast Cancer Consortium
Procedures in Known/Suspected COVID-19 (ASA, 2020): 2020 guidelines on performing procedures on patients with known or suspected COVID-19 by the American Society of Anesthesiologists (ASA)
COVID-19–Related Airway Management Clinical Practice Guidelines (SIAARTI/EAMS, 2020): 2020 clinical practice guidelines from the SIAARTI Airway Research Group and the European Airway Management Society on coronavirus disease 2019 (COVID-19)–related airway management.
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19): Panel consisting of 36 experts from 12 countries compiled 54 evidence-based statements for clinicians caring for patients with severe COVID-19 infection. (Updated January 29, 2021)
Belgium Task Force on Supportive Care and Antiviral/Immunologic Treatment of Hospitalized Patients With Suspected or Confirmed COVID-19 (2020): 2020 interim clinical guidance by the Belgium Task Force for supportive care and antiviral/immunologic therapy for adults with suspected or confirmed coronavirus disease 2019 (COVID-19). (Updated April 2022)
COVID-19 Ventilation Clinical Practice Guidelines (2020): COVID-19 ventilation clinical practice guidelines by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine
Guidance on Obstetric COVID-19 (ISUOG, 2020): Guidance on the management of COVID-19 infection during pregnancy, childbirth, and the neonatal period, from the International Society of Ultrasound in Obstetrics and Gynecology
Control of COVID-19 in Nursing Homes Guidelines (2020): 2020 guidelines on infection control and prevention of COVID-19 in nursing homes by the Centers for Medicare & Medicaid Services (CMS)
FDA Face Mask and Respirator Policy in COVID-19 (2020): 2020 guidelines on enforcement policy for face masks and respirators by the US Food and Drug Administration (FDA)
Rapid COVID-19 Clinical Practice Guidelines (2020): Rapid COVID-19 clinical practice guidelines by Wuhan University Novel Coronavirus Management & Research Team and China International Exchange & Promotive Association for Medical and Health Care.
Guidance on Cardiac Implications of COVID-19 (ACC, 2020): 2020 guidance by the American College of Cardiology regarding the cardiac implications of COVID-19
COVID-19 Guidance for Ophthalmologists (AAO, 2020): 2020 COVID-19 guidance for urgent and nonurgent patient care in ophthalmology.
Guidance on Containing Spread of COVID-19 (CMS, 2020): Guidance for hospitals on how to identify at-risk patients, screen for COVID-19, and monitor or restrict health care facility staff, from the Centers for Medicare & Medicaid Services
COVID-19 Sample Collection and Testing: Clinical Practice Guidelines (CDC, 2020): 2020 clinical practice guidelines from the Centers for Disease Control and Prevention on the collection, handling, and testing of specimens for the diagnosis of coronavirus disease 2019 (COVID-19).
Guidelines for Evaluating and Testing Persons Under Investigation for COVID-19 (CDC, 2020): 2020 clinical practice guidelines on evaluating and testing persons under investigation for coronavirus disease 2019 (COVID-19) by the Centers for Disease Control and Prevention (CDC)
Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic: a 2022 update to the 2020 clinical practice guidelines from the American Academy of Pediatrics provides discussion and resources for parents and caregivers of children with special needs regarding how to minimize infection risk, support from health and related service providers, and school decisions.

Please see Coronavirus Disease 2019 (COVID-19) in Children for additional guidance related to pregnant individuals, infants and children, and breastfeeding.

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

Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing by the Infectious Diseases Society of America

Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing (December 2023) by the Infectious Diseases Society of America (IDSA) are as follows^[278]:

NAAT in Symptomatic Individuals - The IDSA panel recommends a SARS-CoV-2 NAAT in symptomatic individuals suspected of having COVID-19 (strong recommendation, moderate certainty evidence).

Anatomic Site of Specimen Collection - The panel advises collecting and testing swab specimens or saliva from various regions (NP, AN, OP, or MT) or mouth gargle for symptomatic individuals suspected of having COVID-19.

Self-Collection of Swab Specimens - The panel suggests that, for symptomatic individuals suspected of having COVID-19, AN and MT swab specimens may be collected for SARS-CoV-2 RNA testing by either patients or healthcare providers (conditional recommendation, moderate certainty evidence).

The panel recommends that symptomatic individuals suspected of having COVID-19 can collect AN and MT swab specimens for SARS-CoV-2 RNA testing, either by themselves or by healthcare providers.

Rapid Versus Standard Laboratory-Based NAATs in Symptomatic Individuals - The panel recommends utilizing rapid or standard laboratory-based NAATs for testing symptomatic individuals suspected of having COVID-19.

Single Versus Repeat NAAT - The panel recommends conducting a single NAAT and avoiding routine repeat testing in symptomatic or asymptomatic individuals suspected of having COVID-19 if the initial NAAT result is negative.

NAAT in Asymptomatic Individuals Who Are Exposed to SARS-CoV-2 - The panel recommends SARS-CoV-2 RNA testing for asymptomatic individuals with clinical or epidemiological factors that may indicate the need for testing, especially those who are known or suspected to have been in contact with COVID-19.

Rapid Versus Laboratory-Based NAATs in Asymptomatic Individuals - The panel recommends utilizing either rapid or laboratory-based NAATs for testing asymptomatic individuals with known exposure to SARS-CoV-2 infection who have clinical or epidemiologic factors that may indicate the need for testing.

NAAT in Asymptomatic Individuals Before Hospital Admission - The panel advises against routine SARS-CoV-2 NAAT in asymptomatic individuals with no known COVID-19 exposure who are being hospitalized.

NAAT in Asymptomatic Individuals Undergoing Procedures - The panel advises against routine SARS-CoV-2 NAAT of asymptomatic individuals with no known COVID-19 exposure who are undergoing a medical or surgical procedure.

Repeat Testing in COVID-19 Patients Requiring Procedures - The panel advises against routinely repeating NAAT before medical or surgical procedures in patients with a recent COVID-19 history.

NAAT to Remove Patients With SARS-CoV-2 Infection From Isolation - The panel advises against routinely repeating NAAT in patients with COVID-19 to guide release from isolation.

Molecular Testing at Home - The panel advises neither for nor against home testing for SARS-CoV-2.

Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023) by the Infectious Diseases Society of America (IDSA)

Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023) by the Infectious Diseases Society of America (IDSA) are as follows^[279]:

Antigen Testing Versus No Testing in Symptomatic Individuals - For symptomatic persons suspected of having COVID-19, the panel advises a single Ag test over no test.

Antigen Testing Versus Standard NAAT in Symptomatic Individuals - For symptomatic persons suspected of having COVID-19, the panel advises using standard NAAT (ie, rapid RT-PCR or laboratory-based NAAT) over a rapid Ag test.

Repeat Rapid Antigen Testing Versus Single Standard NAAT in Symptomatic Individuals - For symptomatic persons suspected of having COVID-19, the panel advises using a single standard NAAT (ie, rapid RT-PCR or laboratory-based NAAT) rather than a strategy of 2 consecutive rapid Ag tests.

Antigen Testing Versus No Testing in Asymptomatic Individuals With Known SARS-CoV-2 Exposure - For asymptomatic individuals with known exposure to SARS-CoV-2 infection, the panel advises using a single (ie, one-time) Ag test over no testing in specific situations.

Antigen Testing Versus Standard NAAT in Asymptomatic Individuals With Known Exposure to SARS-CoV-2 - For asymptomatic persons with known SARS-CoV-2 exposure, the panel advises using a single standard NAAT (ie, rapid RT-PCR or laboratory-based NAAT) rather than a single rapid Ag test.

Repeat Antigen Testing Versus Single Standard NAAT in Asymptomatic Individuals With Known Exposure to SARS-CoV-2 - In asymptomatic persons with a known SARS-CoV-2, if timely standard NAAT testing or results are not available and a first Ag test is negative, perform repeat Ag testing.

Repeat Antigen Testing Versus No Testing in Asymptomatic Students in Educational Settings and Employees in Workplaces - Among students in educational settings or employees in workplaces for whom SARS-CoV-2 testing is desired, the panel advises neither for nor against 2 consecutive Ag tests rather than no testing for the diagnosis of SARS-CoV-2 infection.

Antigen Testing Versus No Testing in Asymptomatic Individuals Planning to Attend Large Gatherings - For asymptomatic persons planning to attend a large gathering (eg, concert, conference, party, sporting event), the panel advises neither for nor against Ag testing rather than no testing.

Observed Versus Unobserved Self-Collection of Specimens for Antigen Testing - The panel advises either observed or unobserved self-collection of swab specimens for Ag testing if self-collection is performed.

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).^[145] Refer to the IDSA guidelines for the most recent version.

Hydroxychloroquine/Chloroquine + Azithromycin

The IDSA guideline panel advises against using hydroxychloroquine in patients with COVID-19. Remark: Chloroquine is considered to be class equivalent to hydroxychloroquine.The panel advises against using hydroxychloroquine plus azithromycin in hospitalized patients with COVID-19. Note: Chloroquine is considered to be class equivalent to hydroxychloroquine.

Hydroxychloroquine for Prophylaxis

In individuals exposed to COVID-19, the panel advises against hydroxychloroquine.

Lopinavir/Ritonavir

In individuals exposed to COVID-19, the panel advises against post-exposure prophylaxis with lopinavir/ritonavir.
Among ambulatory patients with mild-to-moderate COVID-19, the panel advises against the use of lopinavir/ritonavir.
Among hospitalized patients with COVID-19, the panel advises against the use of the combination lopinavir/ritonavir.

Glucocorticoids

Among hospitalized critically ill patients* with COVID-19, the panel advises giving dexamethasone rather than no dexamethasone. Remark: If dexamethasone is unavailable, equivalent total daily doses of alternative glucocorticoids may be used. Dexamethasone 6 mg IV or PO for 10 days (or until discharge) or equivalent glucocorticoid dose may be substituted if dexamethasone is unavailable. Equivalent total daily doses of alternative glucocorticoids to dexamethasone 6 mg daily are methylprednisolone 32 mg and prednisone 40 mg.
Among hospitalized individuals with severe**, but non-critical, COVID-19, the panel suggests giving dexamethasone rather than no dexamethasone. Remark: Dexamethasone 6 mg IV or PO for 10 days (or until discharge) or equivalent glucocorticoid dose may be substituted if dexamethasone is unavailable. Equivalent total daily doses of alternative glucocorticoids to dexamethasone 6 mg daily are methylprednisolone 32 mg and prednisone 40 mg.
Among hospitalized patients with mild-to-moderate*** COVID-19 without hypoxemia requiring supplemental oxygen, the panel suggests against the use of glucocorticoids.

*Critical illness is defined as patients on mechanical ventilation and extracorporeal mechanical oxygenation (ECMO). Critical illness includes end organ dysfunction as is seen in sepsis/septic shock. In COVID-19, the most commonly reported form of end organ dysfunction is ARDS.

**Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen.

*** Mild-to-moderate illness is defined as patient with a SpO2 >94% not requiring supplemental oxygen.

Inhaled Corticosteroids

For ambulatory patients with mild-to-moderate COVID-19, the panel suggests against inhaled corticosteroids. Remark: Patients who are using inhaled corticosteroids for other indications may continue them.

††The guideline panel determined that the negative effects outweigh the positive effects, despite existing uncertainties, and while the majority of well-informed individuals would opt for the recommended action, a significant number may choose otherwise.

Interleukin-6 Inhibitors

For hospitalized adults with progressive severe* or critical** COVID-19 who have elevated markers of systemic inflammation, the panel suggests tocilizumab added to standard of care (ie, steroids) rather than standard of care only. Remarks: Patients, particularly those who respond to steroids alone, who put a high value on avoiding possible adverse events of tocilizumab and a low value on the uncertain mortality reduction, would reasonably decline tocilizumab. In the largest trial on the treatment of tocilizumab, criterion for systemic inflammation was defined as CRP ≥75 mg/L.
When tocilizumab is unavailable, for patients who otherwise would qualify for tocilizumab, the panel suggests sarilumab added to standard of care (ie, steroids) rather than standard of care only. Remark: Patients, especially those who show improvement with steroids alone, who prioritize avoiding potential adverse effects of sarilumab over uncertain mortality reduction, may justifiably choose not to receive sarilumab.

Severity definitions:

*Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen.

**Critical illness is defined as patients on mechanical ventilation and ECMO. Critical illness includes end organ dysfunction as is seen in sepsis/septic shock. In COVID-19, the most commonly reported form of end organ dysfunction is ARDS.

†The guideline panel concluded that the desirable effects outweigh the undesirable effects, though uncertainty still exists, and most informed people would choose the suggested course of action, while a substantial number would not.

Convalescent Plasma

(UPDATED 2/22/2023): For immunocompetent patients hospitalized with COVID-19, the panel advises against COVID-19 convalescent plasma.
(NEW 2/22/2023): For immunocompromised patients hospitalized with COVID-19, the panel suggests against routinely using COVID-19 convalescent plasma. Remark: Patients, especially those ineligible for alternative treatments, who prioritize uncertain mortality reduction over potential adverse effects of convalescent plasma, may justifiably choose to receive convalescent plasma.
(UPDATED 2/22/2023): For ambulatory patients with mild-to-moderate COVID-19 at high risk for progression to severe disease who have no other treatment options*, the panel suggests FDA-qualified high-titer COVID-19 convalescent plasma within 8 days of symptom onset rather than no high-titer COVID-19 convalescent plasma. Remarks: In the United States, FDA emergency use authorization (EUA) only authorizes use in patients with immunosuppressive disease or receiving immunosuppressive treatment. Patients, particularly those who are not immunocompromised, who place a low value on the uncertain benefits (reduction in the need for mechanical ventilation, hospitalization, and death) and a high value on avoiding possible adverse events associated with convalescent plasma would reasonably decline convalescent plasma.

Other options for treatment and management of ambulatory patients include nirmatrelvir/ritonavir and 3-day treatment with remdesivir Patient-specific factors (eg, symptom duration, renal insufficiency or other contraindications, drug interactions) as well as logistical challenges, infusion capacity, and product availability should drive decision-making regarding choice of agent. Data for combination treatment do not exist in this setting.

Remdesivir

For individuals (ambulatory or hospitalized) with mild-to-moderate COVID-19 at high risk for progression to severe disease, the panel suggests remdesivir be initiated within 7 days of symptom onset rather than no remdesivir. (Conditional recommendation†, Low certainty of evidence) Remarks: Dosing for remdesivir in mild-to-moderate COVID-19 is 200 mg on day 1 followed by 100 mg on days 2 and 3. Pediatric dosing is 5 mg/kg on day 1 and 2.5 mg/kg on subsequent days. Options for treatment and management of ambulatory patients include nirmatrelvir/ritonavir, 3-day treatment with remdesivir, molnupiravir, and neutralizing monoclonal antibodies. Patient-specific factors (eg, patient age, symptom duration, renal function, drug interactions), product availability, and institutional capacity and infrastructure should drive decision-making regarding choice of agent. Data for combination treatment do not exist in this setting.
For patients receiving supplemental oxygen but not mechanical ventilation or ECMO, the panel suggests treatment with 5 days of remdesivir rather than 10 days of remdesivir.
For hospitalized patients with severe* COVID-19, the panel suggests remdesivir over no antiviral treatment.
For patients with COVID-19 on invasive ventilation and/or ECMO, the panel suggests against routinely initiating remdesivir.

Severity definition:

*Severe illness is defined as patients with SpO2 ≤94% on room air.

††The guideline panel concluded that the undesirable effects outweigh the desirable effects, though uncertainty still exists, and most informed people would choose the suggested course of action, while a substantial number would not.

Famotidine

For ambulatory patients with mild-to-moderate COVID-19, the panel suggests against famotidine for the treatment of COVID-19
For hospitalized patients with severe* COVID-19, the panel suggests against famotidine for the treatment of COVID-19.

Severity definition:

* Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen.

Neutralizing Antibodies for Pre-Exposure Prophylaxis

As of 1/26/2023, based on CDC Nowcast data, fewer than 10% of circulating variants in the United States are susceptible to tixagevimab/cilgavimab (Evusheld), the only product that has been available for pre-exposure prophylaxis. Tixagevimab/cilgavimab therefore is no longer authorized for use in the United States until further notice by FDA.

Neutralizing Antibodies for Post-Exposure Prophylaxis

The initial two anti-SARS-CoV-2 neutralizing antibody combinations authorized by the US FDA, bamlanivimab/etesevimab and casirivimab/imdevimab, were found to be ineffective against the Omicron BA.1 and BA.2 variants. Consequently, these products no longer are suitable for treatment or post-exposure prophylaxis. Therefore, Emergency Use Authorization for both bamlanivimab/etesevimab and casirivimab/imdevimab has been revoked by the US FDA, leaving no neutralizing antibody products available for post-exposure prophylaxis in the United States.

Neutralizing Antibodies for Treatment

Throughout 2022, various Omicron sub-variants with increasingly reduced susceptibility to several anti-SARS-CoV-2 neutralizing antibodies emerged. On November 30, 2022, the US FDA revoked Emergency Use Authorization for bebtelovimab, the only neutralizing antibody product that had maintained activity against the majority of earlier SARS-CoV-2 variants, hence resulting in no neutralizing antibody products being accessible in the United States for treating COVID-19.

Janus Kinase Inhibitors

For hospitalized adults with severe* COVID-19, the panel suggests baricitinib with corticosteroids rather than no baricitinib. Remarks: Baricitinib 4 mg per day (or appropriate renal dosing) up to 14 days or until discharge from hospital. Baricitinib appears to demonstrate the most benefit in those with severe COVID-19 on high-flow oxygen/non-invasive ventilation at baseline. Limited additional data suggest a mortality reduction even among patients requiring mechanical ventilation.
For hospitalized patients with severe* COVID-19 who cannot receive a corticosteroid (which is standard of care) because of a contraindication, the panel suggests using baricitinib with remdesivir rather than remdesivir alone. Remark: Baricitinib 4 mg daily dose for 14 days or until hospital discharge. The benefits of baricitinib plus remdesivir for persons on mechanical ventilation are uncertain.
For hospitalized adults with severe** COVID-19 but who are not receiving non-invasive or invasive mechanical ventilation, the panel suggests tofacitinib rather than no tofacitinib. Remarks: Tofacitinib appears to demonstrate the most benefit in those with severe COVID-19 on supplemental or high-flow oxygen. Patients treated with tofacitinib should be on at least prophylactic dose anticoagulant. Patients who receive tofacitinib should not receive tocilizumab or other IL-6 inhibitor for treatment of COVID-19. The STOP-COVID Trial did not include immunocompromised patients.

Severity definitions:

* Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen, oxygen through a high-flow device, or non-invasive ventilation.

**Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen or oxygen through a high-flow device.

Ivermectin

In hospitalized patients with COVID-19, the panel suggests against giving ivermectin.
For ambulatory individuals with COVID-19, the panel advises against ivermectin.

††The panel determined that the negative effects outweigh the positive effects, despite existing uncertainties. Whereas most well-informed individuals would opt for the recommended course of action, a significant number may choose otherwise.

Fluvoxamine

For ambulatory patients with COVID-19, the panel advises fluvoxamine only in the setting of a clinical trial. (knowledge gap)

Nirmatrelvir/Ritonavir

(UPDATED 4/12/2023): For ambulatory patients with mild-to-moderate COVID-19 who are at high risk of developing severe illness, the IDSA guideline panel recommends initiating nirmatrelvir/ritonavir within 5 days of symptom onset over not using this treatment. Remarks: Patients’ medications need to be screened for serious drug interactions

Dosing based on renal function: - Estimated glomerular filtration rate (eGFR) > 60 ml/min: 300 mg nirmatrelvir/100 ritonavir every 12 hours for 5 days - eGFR ≤60 mL/min and ≥30 mL/min: 150 mg nirmatrelvir/100 mg ritonavir every 12 hours for 5 days - eGFR < 30 mL/min: not recommended

Patients with mild-to-moderate COVID-19 who are at high risk of progression to severe disease admitted to the hospital may also receive nirmatrelvir/ritonavir

Options for treatment and management of ambulatory patients include nirmatrelvir/ritonavir, remdesivir for a 3-day course, molnupiravir, and neutralizing monoclonal antibodies. Patient-specific factors (eg, symptom duration, renal function, drug interactions) as well as product availability should drive decision-making regarding choice of agent. Data for combination treatment do not exist in this setting.

†The guideline panel determined that the benefits outweigh the risks, despite existing uncertainties. While a majority of well-informed individuals would opt for the recommended action, a significant number may choose otherwise.

Molnupiravir

For ambulatory persons (aged 18 years and older) with mild-to-moderate COVID-19 at high risk for severe illness and who have no other treatment options*, the panel advises initiating molnupiravir within 5 days of symptom onset over not using molnupiravir.

* Treatment and management choices for ambulatory patients may also include nirmatrelvir/ritonavir, three-day remdesivir treatment, and decisions should be guided by patient-specific factors such as symptom duration, renal function, drug interactions, and product availability. Data for combination treatment do not exist in this setting.

Remarks:

Patients who are most likely to benefit from antivirals are those with risk factors for progression to severe disease (eg, elderly, those with high-risk comorbidities, incomplete vaccination status, or immunocompromised). Those without risk factors are less likely to benefit.
Patients who place a higher value on concerns regarding mutagenesis, adverse events, or reproductive effects and a lower value on uncertain benefits may reasonably decline molnupiravir.
Hospitalized patients with mild-to-moderate COVID-19 at high risk for progression to severe disease for reasons other than COVID-19 may also receive molnupiravir.
Molnupiravir is not authorized for use in patients younger than 18 years by the FDA EUA due to potential effects on bone and cartilage growth.
Use of molnupiravir is not recommended during pregnancy under the FDA EUA.
Molnupiravir is not authorized under the FDA EUA for pre-exposure or post-exposure prevention of COVID-19 or for initiation of treatment in hospitalized COVID-19 patients, as the benefits of treatment have not been observed when started post-hospitalization.

†The guideline panel determined that the benefits outweigh the risks, despite lingering uncertainty, and whereas the majority of well-informed individuals would opt for the recommended course of action, a significant number may choose otherwise.

Colchicine

In hospitalized individuals with COVID-19, the panel advises against colchicine for treatment of COVID-19.
In ambulatory persons with COVID-19, the panel suggests against colchicine for treatment of COVID-19.

Anakinra

(NEW 5/4/2023): In hospitalized persons with severe* COVID-19, the panel suggests against routinely using anakinra.

Severity definitions:

*Severe illness is defined as patients with SpO2 ≤94% on room air, including patients on supplemental oxygen.

The panel initially aimed to enroll patients in ongoing trials to gather essential evidence on the effectiveness and safety of COVID-19 therapies, with many trials conducted since then. Although progress has been made, there are still unanswered questions as the pandemic evolves. The panel found that, when weighing uncertain benefits against potential harm, the net benefit of certain therapeutic agents may not be positive and could even be negative. Recognizing that enrolling patients in randomized controlled trials may not always be feasible for frontline providers, the panel suggests establishing local or collaborative registries to systematically assess drug efficacy and safety. Clinicians are encouraged to contribute to understanding the disease by participating in local registries or data collection efforts.

CDC Sample Collection and Testing Guidelines for COVID-19

On June 4, 2024, the CDC updated interim guidelines regarding the collection and handling of clinical specimens for the diagnosis of COVID-19.^{[280, 281]}

Key points include the following^[280]:

The selection of specimen for testing SARS-CoV-2 infection depends on the test being used and the manufacturer's instructions, with different specimen types being suitable for different tests.
Before collecting a specimen, verify with the testing laboratory that they can accept the type of specimen to be collected.
For diagnostic testing for current SARS-CoV-2 infections, the CDC advises collecting and testing an upper respiratory specimen.
This guidance is designed for healthcare providers or health department staff who will be gathering specimens from individuals in healthcare facilities or at the point-of-care, with separate guidance available for self-collection of specimens.

For collecting specimens from patients suspected of SARS-CoV-2 infection^[280]:

Ensure proper infection control and use recommended personal protective equipment, such as N95 respirators, eye protection, gloves, and gowns, for healthcare providers working within close proximity of potentially infected patients.
The selection of specimen type for COVID-19 testing depends on the specific test being used, and not all specimen types are suitable for every test. Confirm with the testing laboratory that they can accept the specimen type you plan to collect.
The CDC recommends collecting an upper respiratory specimen for diagnostic testing of current COVID-19 infections. This applies to healthcare providers and staff collecting specimens in healthcare settings or at the point-of-care.
Proper specimen collection is essential for accurate diagnosis. Choose appropriate upper respiratory specimens (such as nasopharyngeal or oropharyngeal swabs) for diagnostic testing following standardized procedures.
Nasopharyngeal and oropharyngeal swabs should be collected by trained healthcare providers for diagnostic testing. Self-collected samples are not recommended for these specimen types.
Lower respiratory tract specimens, such as bronchoalveolar lavage and sputum, may be considered for patients with severe disease, but caution is advised due to potential aerosol generation.
Maintain infection control precautions at all times during specimen collection, including wearing face masks, gloves, and gowns. Minimize use of personal protective equipment by keeping distance from patients while they self-collect specimens.
Follow specific guidelines for proper specimen collection, handling, and transportation to ensure the accuracy and integrity of test results. Consult the testing laboratory's recommendations and manufacturer instructions for guidance on specimen types and collection protocols.

Storage

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.^[281]

Shipping

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.^[281]

Thromboembolism Prevention and Treatment

The following are thromboembolism prevention and treatment clinical guideline summaries. Please see the complete guidelines for additional information.

A summary of guidelines by the American College of Chest Physicians is as follows^[282]:

In hospitalized patients with COVID-19 and a prior acute coronary syndrome (ACS), continue antiplatelet therapy unchanged.
In hospitalized patients with COVID-19 and confirmed ACS, consider dual antiplatelet therapy (DAPT) to reduce the risk of recurrent ACS or death.
In hospitalized patients with COVID-19 and myocardial injury without ACS, avoid initiating DAPT.
For hospitalized COVID-19 patients on DAPT for recent ACS receiving prophylactic-dose anticoagulants, continue DAPT.
For hospitalized COVID-19 patients on DAPT for recent ACS and on therapeutic-dose anticoagulants, decide individually considering bleeding risk.
In outpatients with COVID-19 on antiplatelet therapy for a previous stroke, avoid changing to anticoagulation.
For hospitalized non-ICU COVID-19 patients on antiplatelet therapy for stroke, continue antiplatelet and add prophylactic LMWH.
For hospitalized ICU COVID-19 patients on antiplatelet therapy for stroke, continue antiplatelet and add prophylactic LMWH.
For hospitalized COVID-19 patients with acute ischemic stroke requiring recanalization therapy, administer indicated therapy.
For hospitalized COVID-19 patients with acute stroke or TIA of unknown cause, treat with antiplatelet therapy following non-COVID-19 patient recommendations.

A summary of guidelines by the International Society on Thrombosis and Haemostasis is as follows^[283]:

For nonhospitalized patients with symptomatic COVID-19, antiplatelet therapy or direct oral anticoagulant therapy does not reduce the risk of hospitalization, thromboembolism, or mortality. Oral sulodexide therapy within 3 days of symptoms may be considered for higher-risk patients, but low-molecular-weight heparin thromboprophylaxis is not effective in reducing progression.
In noncritically ill hospitalized patients, low-dose LMWH or UFH is recommended to reduce the risk of thromboembolism and potentially death. Therapeutic-dose LMWH or UFH is beneficial in selected patients to decrease the risk of thromboembolism, end-organ failure, and death. Intermediate-dose LMWH or UFH, add-on antiplatelet treatment, and apixaban therapy should be avoided.
For critically ill hospitalized patients, prophylactic dose LMWH or UFH is preferred over intermediate dose to reduce adverse events. Therapeutic-dose LMWH or UFH is not recommended over usual-care doses. Adding an antiplatelet agent to prophylactic LMWH/UFH is not advised.
Upon discharge from the hospital, routine prophylactic dose direct oral anticoagulant is not recommended for low-risk patients. High-risk patients may receive prophylactic-dose rivaroxaban post-discharge to reduce the risk of major thromboembolism.
Prophylaxis with anticoagulants or antiplatelet agents is not recommended for nonhospitalized patients with thrombophilia who receive a COVID-19 vaccine. Diagnostic use of antiplatelet factor 4 enzyme immunoassays is recommended for suspected VITT. Rapid heparin-induced thrombocytopenia assays are not recommended for diagnosing VITT. Treatment with UFH or LMWH is reasonable for VITT patients without nonheparin anticoagulant options. Intravenous immune globulin may be considered to reduce the risk of death for patients with VITT.

Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 by the CDC

Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 by the CDC are as follows^[284]:

In general, asymptomatic healthcare personnel (HCP) who have had a higher-risk exposure do not require work restriction, regardless of vaccination status, if they do not develop symptoms or test positive for SARS-CoV-2.

Evaluating healthcare personnel with symptoms of SARS-CoV-2 Infection

Healthcare providers experiencing even mild symptoms of COVID-19 should be given priority for viral testing using nucleic acid or antigen detection assays.

In individuals showing symptoms of COVID-19, a negative result from at least one viral test generally indicates that the person is unlikely to have an active SARS-CoV-2 infection at the time of sample collection.

For molecular testing (NAAT), a single negative test is usually adequate. However, if there is a strong clinical suspicion of SARS-CoV-2 infection, it may be advisable to maintain work restrictions and confirm with a second negative NAAT result.

If an antigen test yields a negative result, it should be validated by either a negative molecular test or a second negative antigen test conducted 48 hours after the initial negative test.

In cases where healthcare providers were initially suspected to have COVID-19 but are later diagnosed with another condition, decisions regarding their return to work should be based on the alternative diagnosis rather than their previous COVID-19 suspicion.

Return to work criteria for HCP with SARS-CoV-2 infection

Healthcare providers with SARS-CoV-2 infection should meet specific criteria to determine when they can safely return to work, which are influenced by the severity of their symptoms and the presence of any immunocompromising conditions. Upon returning to work, healthcare providers should monitor their symptoms and promptly seek reevaluation form occupational health if symptoms reappear or worsen. If symptoms return or worsen, these providers should refrain from work and follow infection prevention measures to avoid transmitting the virus to others until they once again meet the healthcare criteria for returning to work, unless an alternative diagnosis is established.

Healthcare providers with mild to moderate illness who are not moderately to severely immunocompromised may resume work once they meet the following criteria:

At least 7 days have elapsed since symptom onset if a negative viral test was obtained within 48 hours before returning to work (or 10 days if testing is not done or if a positive test was received at day 5-7)
At least 24 hours have passed since the last recorded fever without the use of fever-reducing medications
Improvement in symptoms (eg, cough, shortness of breath)

*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later.

Healthcare providers who remained asymptomatic during their infection and do not have moderate to severe immunocompromising conditions may resume work once they meet the following criteria:

A negative viral test obtained within 48 hours before returning to work (or 10 days if testing is not conducted or if a positive test was received at day 5-7) should be presented after at least 7 days have elapsed since the date of their initial positive viral test.

*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later.

HCP with severe to critical illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:

At least 10 days and up to 20 days have passed since symptoms first appeared, and
At least 24 hours have passed since last fever without the use of fever-reducing medications, and
Symptoms (eg, cough, shortness of breath) have improved.
The test-based strategy as described below for moderately to severely immunocompromised HCP can be used to inform the duration of work restriction.

The specific criteria that influence which healthcare providers will continue to shed replicable virus for an extended period remain unclear. When deciding on the appropriate duration for individual healthcare providers, it is essential to take into account factors such as disease severity and the presence of immunocompromising conditions.

Healthcare providers with moderate to severe immunocompromised status might continue to produce replicable virus for more than 20 days after the onset of symptoms or, for individuals who were asymptomatic during their infection, beyond the date of their initial positive viral test.

It is advisable to employ a test-based approach (outlined below) and seek guidance from an infectious disease specialist or another expert, as well as an occupational health specialist, to decide when these healthcare providers can safely return to work.

Test-based strategy

HCP who are symptomatic could return to work after the following criteria are met:

Resolution of fever without the use of fever-reducing medications, and
Improvement in symptoms (eg, cough, shortness of breath), and
Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.

HCP who are not symptomatic could return to work after the following criteria are met:

Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.

Return to work criteria for HCP who were exposed to individuals with confirmed SARS-CoV-2 infection:

Exposures that could necessitate testing or work restrictions can occur at work or in the community. Higher-risk exposures typically involve healthcare providers' eyes, nose, or mouth coming into contact with potentially contaminated material, especially during aerosol-generating procedures.

Lesser-risk exposures, such as physical contact with patients without appropriate protective gear or hand hygiene, may also pose some transmission risk. Various factors related to these exposures should be individually assessed, such as ventilation quality and the use of personal protective equipment. Based on this evaluation, the level of risk and necessary interventions, including work restrictions, can be adjusted accordingly.

In this guidance, higher-risk exposures are defined as scenarios where healthcare providers had prolonged close contact with a patient, visitor, or healthcare provider with confirmed SARS-CoV-2 infection, and:

The healthcare provider was not wearing a respirator (or if wearing a facemask, the infected person was not wearing a cloth mask or facemask)
The healthcare provider was not wearing eye protection if the infected person was not wearing a cloth mask or facemask
The healthcare provider was not wearing all recommended personal protective equipment (such as gown, gloves, eye protection, respirator) while in the room during an aerosol-generating procedure.

After a higher-risk exposure, HCP should:

Undergo a sequence of three viral tests for SARS-CoV-2 infection.
- Testing should be initiated promptly (but not sooner than 24 hours after exposure), followed by subsequent tests 48 hours after the first negative result and, if negative, another test 48 hours after the second negative result. This typically occurs on day 1 (with the exposure day considered day 0), day 3, and day 5.
- Testing is generally not recommended for asymptomatic individuals who have recovered from SARS-CoV-2 infection within the last 30 days due to challenges in result interpretation. For those who have recovered within 31-90 days, testing may be considered, with an antigen test instead of NAAT recommended. This approach accounts for the potential of individuals to remain NAAT positive without being infectious during this timeframe.
Adhere to all prescribed infection prevention and control measures, including wearing properly fitted source control, monitoring for fever or COVID-19 symptom onset, and refraining from reporting to work when symptomatic or upon testing positive for SARS-CoV-2 infection.
Healthcare providers experiencing fever or symptoms consistent with COVID-19 should promptly isolate themselves and contact their designated point of contact (eg, occupational health program) to arrange for medical evaluation and testing.

Most asymptomatic healthcare providers do not require work restrictions following a higher-risk exposure, regardless of their vaccination status. Situations where work restrictions might be contemplated include:

The healthcare provider cannot undergo testing or wear recommended source control for the 10 days following their exposure
The healthcare provider is moderately to severely immunocompromised
The healthcare provider provides care for or works on a unit with patients who are moderately to severely immunocompromised
The healthcare provider works on a unit where there is continual SARS-CoV-2 transmission that is not managed with initial measures

If work restriction is advised, healthcare providers (HCP) may resume work after one of the following timeframes:

HCP can return to work on day 7 following the exposure (considered day 0) if they remain asymptomatic and all viral tests, as detailed for asymptomatic HCP after a higher-risk exposure, yield negative results.
If viral testing is not conducted, HCP can return to work on day 10 following the exposure (day 0) in the absence of symptoms.

Additionally, healthcare providers are advised to:

Adhere to all prescribed infection prevention and control measures, such as wearing properly fitting source control, monitoring themselves for fever or COVID-19 symptoms, and refraining from reporting to work if unwell or upon testing positive for SARS-CoV-2 infection.
Healthcare providers experiencing fever or symptoms consistent with COVID-19 should promptly reach out to their designated point of contact (e.g., occupational health program) to coordinate medical assessment and testing.

HCP with travel or community exposures should consult their occupational health program for guidance on need for work restrictions. In general, HCP who have had prolonged close contact with someone with SARS-CoV-2 in the community (e.g., household contacts) should be managed as described for higher-risk occupational exposures above.

Please see the full guideline for complete information.

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.^[285]

Hospitals should monitor the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/index.html) 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 https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html .

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 https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html.)
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 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html).

Hospitals should contact their local health department for questions and frequently review the CDC website dedicated to COVID-19 for health care professionals: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html.

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 https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html.

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 https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecommendations.html.

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 https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html.

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.

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 (eg, 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.

Medication

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Media Gallery

The heart is normal in size. There are diffuse, patchy opacities throughout both lungs, which may represent multifocal viral/bacterial pneumonia versus pulmonary edema. These opacities are particularly confluent along the periphery of the right lung. There is left midlung platelike atelectasis. Obscuration of the left costophrenic angle may represent consolidation versus a pleural effusion with atelectasis. There is no pneumothorax.
The heart is normal in size. There are bilateral hazy opacities, with lower lobe predominance. These findings are consistent with multifocal/viral pneumonia. No pleural effusion or pneumothorax are seen.
The heart is normal in size. Patchy opacities are seen throughout the lung fields. Patchy areas of consolidation at the right lung base partially silhouettes the right diaphragm. There is no effusion or pneumothorax. Degenerative changes of the thoracic spine are noted.
The same patient as above 10 days later.
The trachea is in midline. The cardiomediastinal silhouette is normal in size. There are diffuse hazy reticulonodular opacities in both lungs. Differential diagnoses include viral pneumonia, multifocal bacterial pneumonia or ARDS. There is no pleural effusion or pneumothorax.
Axial chest CT demonstrates patchy ground-glass opacities with peripheral distribution.
Coronal reconstruction chest CT of the same patient above, showing patchy ground-glass opacities.
Axial chest CT shows bilateral patchy consolidations (arrows), some with peripheral ground-glass opacity. Findings are in peripheral and subpleural distribution.

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Table 1. SARS-CoV-2 Monoclonal Antibodies – inactive EUAs

Table 1. SARS-CoV-2 Monoclonal Antibodies – inactive EUAs

Antibody	Description
Evusheld (tixagevimab/cilgavimab)	EUA for preexposure prophylaxis halted in January 2023 owing to Omicron XBB VOCs. Initial authorization was based on the phase 3 PROVENT in unvaccinated individuals with comorbidities and a retrospective cohort study of veterans who were immunosuppressed.^{[222, 223]}
Bebtelovimab	Data supporting the treatment EUA were primarily based on analyses from the phase 2 BLAZE-4 trial conducted before the emergence of the Omicron BQ.1 and BQ.1.1 VOCs. Most participants were infected with the Delta (49.8%) or Alpha (28.6%) VOCs.^[224]
Sotrovimab	EUA stopped owing to resistance to Omicron BA.2 subvariant. Initial IV and IM authorization based on COMET-ICE and COMET-TAIL studies.^{[225, 226]}
Casirivimab/imdevimab	EUA stopped in January 2022, as the Omicron variant is not susceptible. The EUA for treatment was supported by US trials and the UK RECOVERY trial.^{[227, 228, 229]}
Bamlanivimab/etesevimab	EUA revoked in April 2021 as the Delta VOC emerged. Initial EUA was supported by Phase 3 BLAZE-1 trial for treatment and the BLAZE-2 trial for postexposure prophylaxis.^{[230, 231]}

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Author

David J Cennimo, MD, FAAP, FACP, FIDSA, AAHIVS Associate Professor of Medicine and Pediatrics, Adult and Pediatric Infectious Diseases, Rutgers New Jersey Medical School

David J Cennimo, MD, FAAP, FACP, FIDSA, AAHIVS is a member of the following medical societies: American Academy of HIV Medicine, American Academy of Pediatrics, American College of Physicians, American Medical Association, HIV Medicine Association, Infectious Diseases Society of America, Medical Society of New Jersey, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Scott J Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP Antimicrobial Stewardship Program Coordinator, Infectious Diseases Pharmacy Residency Program Director, Department of Pharmaceutical and Nutrition Care, Division of Infectious Diseases, Nebraska Medicine; Clinical Associate Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center

Scott J Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP is a member of the following medical societies: American Association of Colleges of Pharmacy, American College of Clinical Pharmacy, American Pharmacists Association, American Society for Microbiology, American Society of Health-System Pharmacists, Infectious Diseases Society of America, Society of Infectious Diseases Pharmacists

Disclosure: Received research grant from: Merck & Co., Inc.

Keith M Olsen, PharmD, FCCP, FCCM Dean and Professor, College of Pharmacy, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Molly Marie Miller, PharmD Clinical Infectious Diseases Pharmacist Practitioner, Nebraska Medicine

Molly Marie Miller, PharmD is a member of the following medical societies: Society of Infectious Diseases Pharmacists

Disclosure: Nothing to disclose.

Coronavirus Disease 2019 (COVID-19) Guidelines

Guidelines Summary

Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing by the Infectious Diseases Society of America

Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023) by the Infectious Diseases Society of America (IDSA)

Infectious Diseases Society of America (IDSA) Management Guidelines

CDC Sample Collection and Testing Guidelines for COVID-19

Thromboembolism Prevention and Treatment

Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 by the CDC

Guidance for Hospitals on Containing Spread of COVID-19

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

COVID-19 Terminology and Definitions

References

Tables

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