COVID-19 - Outpatient Evaluation and Management of Acute Illness in Adults - UpToDate

9/8/2021 COVID-19: Outpatient evaluation and management of acute illness in adults - UpToDate
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COVID-19: Outpatient evaluation and management of

acute illness in adults
Authors: Pieter Cohen, MD, Jessamyn Blau, MD
Section Editor: Joann G Elmore, MD, MPH
Deputy Editors: Lisa Kunins, MD, Allyson Bloom, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2021. | This topic last updated: Aug 02, 2021.
INTRODUCTION
At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia
cases in China; the infection rapidly spread throughout the world, resulting in a global
pandemic. The virus has been designated severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) and the illness it causes is coronavirus disease 2019 (COVID-19). The spectrum
of COVID-19 in adults ranges from asymptomatic infection to mild respiratory tract
symptoms to severe pneumonia with acute respiratory distress syndrome (ARDS) and
multiorgan dysfunction. Our understanding of the spectrum of disease as well as optimal
management strategies continues to evolve.
This topic will address the management of adult patients with acute COVID-19 in the
outpatient setting (eg, <12 weeks after illness onset), including self-care advice, telehealth
and outpatient clinic management, emergency department (ED) referral, and post-hospital
discharge care. It is important to note that the data informing outpatient management
strategies continue to evolve, and the approach described here is based upon our clinical
experience and a rapidly developing evidence base; clinicians should take into the account
the individual patient's clinical and social circumstances as well as available local resources.
The diagnosis and epidemiology and virology of COVID-19, as well as infection control
measures, care for hospitalized patients, and system-specific COVID-19 complications are
discussed in detail elsewhere, as are considerations for special populations.
COVID-19 virology, epidemiology, diagnosis, infection control, and prevention:
● (See "COVID-19: Epidemiology, virology, and prevention".)
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● (See "COVID-19: Diagnosis".)

● (See "COVID-19: Clinical features".)
● (See "COVID-19: Infection control for persons with SARS-CoV-2 infection".)
● (See "COVID-19: Vaccines to prevent SARS-CoV-2 infection".)
COVID-19 hospital management:
● (See "COVID-19: Management in hospitalized adults".)

● (See "COVID-19: Management of the intubated adult".)
● (See "COVID-19: Anesthetic concerns, including airway management and infection
control".)
● (See "COVID-19: Extracorporeal membrane oxygenation (ECMO)".)
System-specific COVID-19 considerations, including manifestations, management, and

issues related to recovery:
● (See "COVID-19: Evaluation and management of adults following acute viral illness".)
● (See "COVID-19: Acute limb ischemia".)
● (See "COVID-19: Evaluation and management of cardiac disease in adults".)
● (See "COVID-19: Arrhythmias and conduction system disease".)
● (See "COVID-19: Cardiac manifestations in adults".)
● (See "COVID-19: Myocardial infarction and other coronary artery disease issues".)
● (See "COVID-19: Intensive care ventilation with anesthesia machines".)
● (See "COVID-19: Neurologic complications and management of neurologic conditions".)
● (See "COVID-19: Cutaneous manifestations and issues related to dermatologic care".)
● (See "COVID-19: Hypercoagulability".)
● (See "COVID-19: Convalescent plasma and hyperimmune globulin".)
(Related Pathway(s): COVID-19: Anticoagulation in adults with COVID-19.)
Issues related to COVID-19 in specific adult populations:
● (See "COVID-19: Pregnancy issues and antenatal care".)

● (See "COVID-19: Labor, birth, and postpartum issues and care".)
● (See "COVID-19: Cancer screening, diagnosis, post-treatment surveillance in uninfected
patients during the pandemic and issues related to COVID-19 vaccination in cancer
patients".)
● (See "COVID-19: Risks for infection, clinical presentation, testing, and approach to
infected patients with cancer".)
● (See "COVID-19: Psychiatric illness".)
● (See "COVID-19: Issues related to gastrointestinal disease in adults".)
● (See "COVID-19: Issues related to acute kidney injury, glomerular disease, and
hypertension".)

● (See "COVID-19: Issues related to end-stage kidney disease".)

● (See "COVID-19: Issues related to liver disease in adults".)
● (See "COVID-19: Issues related to diabetes mellitus in adults".)
● (See "COVID-19: Issues related to solid organ transplantation".)
● (See "COVID-19: Care of adult patients with systemic rheumatic disease".)
● (See "COVID-19: Management in nursing homes".)
Issues related to COVID-19 in the pediatric population:
● (See "COVID-19: Clinical manifestations and diagnosis in children".)

● (See "COVID-19: Management in children".)
● (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical
features, evaluation, and diagnosis".)
● (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management
and outcome".)
GENERAL PRINCIPLES
Continuum of care — When possible, we favor managing all patients with suspected or

confirmed COVID-19 within an outpatient continuum of care management program that
includes:
● Self-assessment tools. (See 'Patient self-assessment tools' below.)
● Initial telephone triage. (See 'Initial telephone triage' below.)
● Coordinated outreach and management approach based upon individual patient risk,
severity of symptoms, and time course of disease. (See 'Risk stratification' below and
'Determine if in-person evaluation warranted' below and 'Telehealth follow-up' below.)
● Clinician telehealth (telephone call or video platform-based) visits (initial evaluation and
follow-up visits) [1,2]. (See 'Telehealth follow-up' below.)
● COVID-19 testing. (See 'Suspicion for COVID-19 and role of testing' below.)
● A separate outpatient respiratory clinic or dedicated space within an ambulatory clinic

appropriated for the care of patients with COVID-19 and other respiratory problems.
Strategies to reduce the risk of exposure to severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) by staff and other patients should be employed [3]. (See
"COVID-19: Infection control for persons with SARS-CoV-2 infection", section on
'Infection control in the health care setting'.)

In addition, the outpatient clinic should have a close, coordinated relationship with the
local emergency department (ED) and function in partnership within the continuum of
care program. (See 'Rationale for outpatient management and remote care' below.)
● A close working relationship with local public health officials and community leaders.
In such a system, patients could enter the ambulatory COVID-19 care program by contacting
their primary health care provider or following discharge from the ED or an inpatient
hospital stay.
In addition, during the course of illness and recovery, patients would be able to transition to
different sites of care for follow-up as dictated by clinical need (eg, from home self-care
management, to outpatient clinic or ED evaluation, to telehealth follow-up, and back to self-
care management).
In resource-limited rural settings, such as Native American reservations in the United States,
as well as underserved urban populations, an extension of this continuum of care may
include health care provider home visits to evaluate patients and at-risk family members
[4,5]. In-person home evaluations may facilitate more effective medical management of the
patient, assessment of potentially infected household contacts, and provide an opportunity
to promote infection control measures. Clinicians performing home visits should wear
appropriate personal protective equipment (PPE). (See "COVID-19: Infection control for
persons with SARS-CoV-2 infection", section on 'Type of PPE'.)
Rationale for outpatient management and remote care — Outpatient management is

appropriate for most patients with COVID-19; in approximately 80 percent of patients, illness
is mild and does not warrant medical intervention or hospitalization [6,7]. In addition,
remote (telehealth) management is preferred for the majority of patients for the following
reasons:
● Remote management can prevent unnecessary in-person medical visits, including visits
to urgent care facilities and EDs. It thus avoids additional, unnecessary strain on an
already overburdened and overwhelmed health care system (including utilization of
limited resources, especially PPE).
● In-person health care provider visits require the patient to leave their home, traveling
via public, private, or emergency transport and potentially exposing others to SARS-CoV-
2. In addition, upon arrival at a health care facility, patients may expose other patients
and health care workers to the virus.
Creating a comprehensive, coordinated outpatient care program that incorporates these

components may allow more patients to receive supportive care at home and, if necessary,
in the ambulatory clinic setting, further reducing ED and hospital resource utilization.
Telehealth has been used for patient management during previous disease outbreaks,
including SARS, Middle East respiratory syndrome (MERS), and influenza A H1N1 [8]. Remote
evaluation and management of patients with COVID-19 continues to be evaluated, and there
is accumulating evidence demonstrating the appropriateness and efficacy of this approach
[9-13]. (See "COVID-19: Risks for infection, clinical presentation, testing, and approach to
infected patients with cancer", section on 'Issues related to COVID-19 management'.)
Telehealth evaluation for COVID-19 during the pandemic can be performed by telephone
call, video-based telemedicine platform, or commercial video chat platform; the format
chosen should be compliant with applicable patient privacy regulations [14].
Flexibility in approach to care — High-quality data supporting the superiority of any single

outpatient management strategy are lacking, and treatment protocols are being developed
and modified as understanding of the disease evolves.
Our approach is based upon our clinical experience of treating patients with COVID-19 and
places additional emphasis on avoiding infection transmission, preserving limited resources,
and reducing the burden on overwhelmed health care systems. (See "COVID-19:
Epidemiology, virology, and prevention", section on 'Prevention' and "COVID-19: Diagnosis",
section on 'COVID-19 testing not readily available' and "COVID-19: Infection control for
persons with SARS-CoV-2 infection", section on 'When PPE is limited'.)
The intensity (frequency and duration) of outpatient follow-up will vary according to a
patient's risk for developing severe disease ( table 1), will vary by institution, region, and
resource availability, and will likely change with the burden of disease in a given location.
Some institutions have been able to establish dedicated outpatient respiratory clinics
devoted to managing COVID-19 patients, with available in-person and remote management
options; in many other locations, these patients are being managed by primary care
clinicians, often in consultation with a team of specially trained clinicians. Some health care
systems have created “hospital-at-home” care with “virtual observation units” for COVID-19
patients [15,16].
Additionally, institutions may need to revise protocols, even over a several-week period, in
response to surges in the number of patients with suspected infection they are managing
[17].
INITIAL EVALUATION
Most patients who have concerns about COVID-19, even those with mild symptoms, will
likely initiate contact with the health care system. For those patients, self-assessment tools,
or remote (telehealth) evaluation are the preferred initial management approaches [18-20].

Patient self-assessment tools — Patient education materials, including self-assessment

tools, can help patients determine if medical evaluation is necessary, and proactive
dissemination of these materials may increase awareness and encourage their use. Various
online self-assessment tools published by medical institutions [21] and governmental health
agencies can guide patients through questions and suggest when to seek medical care; by
following the guidance, many patients with mild illness may be able to recover at home on
their own without needing to come in direct contact with a health care provider. Before
recommending a specific assessment tool, however, clinicians should vet the options
carefully, as they may exceed the abilities of patients with limited health literacy or can
become quickly out-of-date based upon rapidly changing guidelines.
In one study, use of a self-assessment tool embedded into the electronic health record
allowed 40 percent of symptomatic patients to be appropriately triaged to self-care [20]. This
study, however, was conducted in the setting of relatively low community prevalence of
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and might not be
representative of settings with widespread community transmission.
Initial telephone triage — In addition to self-assessment tools, an initial triage call by clinic
staff can often determine which patients are appropriate for self-care at home, which
patients warrant a timely clinician telehealth visit (televisit), and which patients warrant an
outpatient clinic visit or urgent emergency department (ED) evaluation [22,23]. (See 'Risk
stratification' below.) (Related Pathway(s): COVID-19: Initial telephone triage of adult
outpatients.)
Any patient with symptoms suggestive of respiratory compromise or hypoxia (eg, significant
dyspnea at rest or mental confusion) should be referred for urgent in-person evaluation; the
appropriate site of care depends upon the severity of symptoms and is discussed elsewhere.
(See 'In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher
acuity level' below.)
Suspicion for COVID-19 and role of testing — During a pandemic, patients who live in
regions with widespread community transmission and have compatible symptoms are
generally managed presumptively as having COVID-19, even if they have not been tested or
have an initial negative test result.
Patients with COVID-19 typically first experience a viral-type illness with symptoms ranging
from a mild upper respiratory tract infection (eg, pharyngitis, rhinorrhea) to a lower
respiratory tract infection (eg, cough, fever), influenza-like symptoms (eg, fever, chills,
headache, myalgias), or gastroenteritis (eg, nausea, vomiting, diarrhea) ( table 2) [24,25].
Loss of smell and taste may also occur [26-28], with olfactory loss typically reported early in
the course of illness [29,30]. Dyspnea, if it develops, tends to occur in most patients between
four to eight days after the onset of symptoms, although it can occur after 10 days [24]. In
patients with less typical symptoms such as isolated rhinorrhea or headache, the likelihood
of illness due to COVID-19 should take into account the local prevalence of disease. However,
during a pandemic, COVID-19 cannot be ruled out based upon clinical history. Further, even
in locations with a high prevalence of COVID-19, the possibility of other etiologies of
symptoms should be considered. (See 'Managing other potential causes of symptoms' below
and "COVID-19: Clinical features", section on 'Initial presentation'.)
We favor the widespread use of testing, which is important for epidemiologic purposes.
However, the availability of testing for SARS-CoV-2 varies widely across regions. If resources
(eg, testing capacity and adequate personal protective equipment [PPE] supplies) are limited,
SARS-CoV-2 testing in outpatients with mild disease may not be readily available; in the
United States, the Infectious Diseases Society of America have proposed priorities for testing
( table 3). Specific criteria for testing vary by location and institution and will change over
time. (See "COVID-19: Diagnosis", section on 'COVID-19 testing not readily available'.)
In patients who are able to undergo testing, the diagnosis of COVID-19 is usually made by
direct detection of SARS-CoV-2 RNA by nucleic acid amplification tests (NAATs), most
commonly reverse-transcription polymerase chain reaction (RT-PCR), in upper respiratory
tract specimens. However, given the potential for false-negative results, in part because of
sampling variability and viral load variation, a single negative test does not exclude infection
in all patients [31,32]. If initial testing is negative but the suspicion for COVID-19 remains (eg,
suggestive symptoms without evident alternative cause) and confirming the presence of
infection is important for management or infection control, we advise repeating the test.
(See "COVID-19: Diagnosis", section on 'Negative NAAT result'.)
Tests that detect SARS-CoV-2 antigen can be performed rapidly and at the point of care and
thus may be more accessible with a faster time to results than some NAATs. However, data
on antigen test performance for SARS-CoV-2 are limited, and they are typically less sensitive
than NAATs ( table 4). Clinicians should be aware of the possibility of false-negative results
with antigen tests; a negative antigen test does not rule out SARS-CoV-2 infection. (See
"COVID-19: Diagnosis", section on 'Antigen testing as an alternative to NAAT'.)
Antibody detection has no or very limited utility for diagnosis in the acute outpatient setting;
we do not use serology to exclude or diagnose acute COVID-19 infection. (See "COVID-19:
Diagnosis", section on 'Serology to identify prior/late infection'.)
Laboratory testing for SARS-CoV-2 is reviewed in detail elsewhere. (See "COVID-19:

Diagnosis".)
Risk stratification — Our patient-centered continuum of care management approach is

based on stratification by risk for developing severe disease and close monitoring for
respiratory decompensation. Patients without severe initial symptoms, who are deemed

stable enough to not require immediate in-person evaluation, are risk stratified to determine
the intensity (frequency and duration) of follow-up.
Assess risk for severe disease — Older age and certain chronic medical conditions have
been associated with more severe illness and higher mortality from COVID-19 ( table 1).
Specifically, in addition to increasing age, established and probable risk factors for severe
disease in adults include [33,34]:
● Cancer
● Cerebrovascular disease
● Chronic kidney disease
● Chronic obstructive pulmonary disease (COPD) and other lung disease (including
interstitial lung disease, pulmonary fibrosis, pulmonary hypertension)
● Diabetes mellitus, type 1 and type 2
● Down syndrome
● Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
● HIV
● Neurologic conditions, including dementia
● Overweight and obesity (BMI ≥25 kg/m2)
● Pregnancy
● Sickle cell disease
● Smoking, current and former
● Solid organ or blood stem cell transplantation
● Substance use disorders
● Use of corticosteroids or other immunosuppressive medications
In addition, possible risk factors for severe disease include:
● Cystic fibrosis
● Thalassemia

Additional possible risk factors for severe disease include hypertension, asthma, immune
deficiencies, and liver disease, although there are fewer high-quality data to support an
association with these conditions.
These categories are based upon CDC guidance, using evidence from a variety of studies,
including meta-analyses, systematic reviews, individual observational cohort studies, and
case series, in which many of these underlying conditions were associated with severe
disease and death [7,35-43]. Of note, the risk of severe COVID-19 in patients with cancer may
depend upon several variables, including the type of malignancy (see "COVID-19: Risks for
infection, clinical presentation, testing, and approach to infected patients with cancer",
section on 'Is illness more severe in patients with malignancy?'). It is also important to note
that although patients who are older or who have poorly controlled chronic medical
conditions have a higher risk for hospitalization and death, infection with SARS-CoV-2 may
cause catastrophic illness in any patient, even among those without any risk factors. Risk
factors for severe COVID-19 are discussed in detail elsewhere. (See "COVID-19: Clinical
features", section on 'Risk factors for severe illness'.)
Additionally, in the United States, African American and Hispanic American patients have
represented a disproportionately high percentage of hospitalizations and deaths
[7,36,37,39,44,45]. The reasons for this finding are unclear but are most likely related to
inequalities in the social determinants of health (eg, access to health care, economic stability,
living environment, community experience, education) [46,47].
COVID-19 has also disproportionately affected residents of nursing homes and long-term
care facilities due to the high proportion of frail older adults and those with underlying
chronic conditions [48]. These factors increase both the prevalence and severity of infection,
resulting in high mortality rates among this population [49]. (See "COVID-19: Management in
nursing homes", section on 'Scope of the problem'.)
In addition, although the vast majority of children with COVID-19 have mild disease [50,51],
infants and children with underlying medical conditions warrant close monitoring; severe
disease is most likely to occur in children with underlying medical conditions [52].
Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition that
has been reported in children and adolescents in association with current or recent COVID-
19 infection or exposure [53-57]. Rare cases of a similar syndrome have been reported in
adults (multisystem inflammatory syndrome in adults [MIS-A]) [58]. The evaluation and
management of children with COVID-19 exposure and infection, MIS-C, and MIS-A are
reviewed in detail elsewhere. (See "COVID-19: Clinical manifestations and diagnosis in
children" and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical
features, evaluation, and diagnosis" and "COVID-19: Multisystem inflammatory syndrome in
children (MIS-C) management and outcome" and "COVID-19: Care of adult patients with

systemic rheumatic disease", section on 'Rheumatic disease features that can mimic or be
mimicked by COVID-19' and "COVID-19: Cardiac manifestations in adults", section on
'Multisystem inflammatory syndrome in adults (MIS-A)'.)
Assess symptom duration and severity
Time course and development of dyspnea — For any patient with suspected or

confirmed COVID-19, we establish the illness timeline: the first day symptoms began, the
presence of dyspnea, and the day of dyspnea onset. While mild dyspnea is common,
worsening dyspnea, particularly dyspnea at rest, and more severe chest
discomfort/tightness, are concerning symptoms and suggest the development or
progression of pulmonary involvement. The trajectory of dyspnea over the days following its
onset is particularly important, as significant worsening and acute respiratory distress
syndrome (ARDS) can manifest soon after the onset of dyspnea; in studies among patients
who develop ARDS, progression to ARDS occurred a median of 2.5 days after onset of
dyspnea [59-63]. In patients with any risk factors for severe disease ( table 1), outreach
efforts should be focused particularly on the days following the onset of dyspnea to assess
for any worsening of respiratory status.
It is unclear what percentage of patients with COVID-19 develop dyspnea, as available

reports are likely not representative of all patients with SARS-CoV-2 infection. However, of
patients with symptomatic infection, dyspnea likely develops in only a subgroup of patients.
As examples, dyspnea developed in 19 percent of approximately 1000 COVID-19 patients
admitted to a hospital in Wuhan, China [64]. However, in a CDC study of laboratory-
confirmed COVID-19 patients in the United States, 43 percent of symptomatic adults and 13
percent of symptomatic children developed dyspnea [52]. Among patients who develop
dyspnea, it typically begins at least several days after the onset of illness. In one study of 41
hospitalized patients in China, dyspnea developed, on average, eight days after the onset of
symptoms [65]. (See "COVID-19: Clinical features", section on 'Clinical manifestations'.)
Dyspnea assessment — Remote assessment of dyspnea should focus on the patient's

subjective symptoms, as well as an objective assessment of breathing, including
deterioration in respiratory function [66]. We begin by asking if patients have developed any
difficulty with their breathing, other than that associated with coughing. If yes, we ask the
patient to describe the difficulty in their own words and assess the ease and comfort of their
speech (eg, if they can speak comfortably in complete sentences).
In addition, we ask questions that provide a more objective assessment of changes in

respiratory status, including [66]:
● “What activities that you could previously do without difficulty are now causing you to be
out of breath?”
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● "Has this gotten worse over the last one, two, or three days?"
● “Are you breathing harder or faster than usual when sitting still?”
● “Can you no longer do your usual household activities due to shortness of breath?”
● “Does walking cause you to feel dizzy?”
We use this assessment to categorize dyspnea by severity:
● Mild dyspnea – Dyspnea that does not interfere with daily activities (eg, mild shortness
of breath with activities such as climbing one to two flights of stairs or walking briskly).
● Moderate dyspnea – Dyspnea that creates limitations to activities of daily living (eg,
shortness of breath that limits the ability to walk up one flight of stairs without needing
to rest, or interferes with meal preparation and light housekeeping tasks).
● Severe dyspnea – Dyspnea that causes shortness of breath at rest, renders the patient
unable to speak in complete sentences, and interferes with basic activities such as
toileting and dressing.
If available, telemedicine consultation with video capability may allow an even better
evaluation of respiratory status, by allowing the clinician to observe the patient's respiratory
pattern, including the use of accessory muscles of respiration [18].
Dyspnea may not correlate with the presence or degree of hypoxia in all patients [67], but
dyspnea, along with risk factors for developing severe disease ( table 1), can be used to
guide clinicians in determining whether a patient requires in-person evaluation. (See 'Assess
risk for severe disease' above and 'Determine if in-person evaluation warranted' below.)
Oxygenation assessment — If a patient with COVID-19 already has access to a pulse

oximeter at home, and can adequately measure and report the results to the clinician, we
consider the oxygen saturation as an additional piece of information to assess their clinical
status. Patients are advised to use their pulse oximeter on warm fingers, as readings
obtained on cold digits may not be as accurate [68,69]. In the outpatient setting, we instruct
patients to check their oximetry twice daily and inform us if the value drops below 95
percent.
● For any patient with an oxygen saturation of ≤94 percent on room air, in-person
evaluation is warranted. (See 'In-person evaluation for moderate/severe dyspnea,
hypoxia, and concern for higher acuity level' below.)
● For patients who have an oxygen saturation of ≥95 percent on room air, the decision on
in-person evaluation depends on other clinical features such as severity of dyspnea, risk

for severe disease, and assessment of overall acuity. (See 'Determine if in-person
evaluation warranted' below.)
However, oximetry should only be considered within the context of the patient's overall
clinical presentation; a normal oxygen saturation level cannot be used to exclude clinically
significant respiratory involvement in a patient with concerning symptoms such as
progressive or severe dyspnea or high overall acuity level (see 'Assessment of overall acuity
level' below). In addition, although normal oximetry can be reassuring, results may be not
always be accurate, particularly in patients with darker skin pigmentation [69,70] (see "Pulse
oximetry", section on 'Falsely normal or high reading'), and there is no guarantee that
respiratory status will not deteriorate as illness progresses.
We do not advise that all patients diagnosed with COVID-19 purchase a pulse oximeter.
Further, we do not consider oxygen saturation readings obtained through an application
("app") on a mobile telephone accurate enough to depend upon for clinical use [71].
As with dyspnea, the availability of telemedicine with video capability may allow the indirect
assessment of hypoxia by the observation of cyanosis, if present [18].
Assessment of overall acuity level — In addition to evaluation of respiratory status,

we assess the patient's overall acuity level by asking questions regarding orthostasis,
dizziness, falls, hypotension (if home blood pressure measurement is available), mental
status change (eg, lethargy, confusion, change in behavior, difficulty in rousing), observed
cyanosis, and urine output. While mild orthostasis symptoms may be addressed with
instruction to increase fluids, mental status changes, falls, cyanosis, hypotension, anuria,
and chest pain suggestive of acute coronary syndrome are concerning and warrant in-
person evaluation. (See 'In-person evaluation for moderate/severe dyspnea, hypoxia, and
concern for higher acuity level' below.)
Assess home setting and social factors — We assess the ability of patients to monitor
their symptoms and to understand the importance of seeking medical guidance should
symptoms progress. Patients who lack the ability to self-monitor and self-report may need
more intensive staff outreach in order to be adequately managed at home.
In addition, in accordance with interim CDC guidelines on home management, we assess if

the patient's residential setting is appropriate for home management and recovery [72];
patients managed at home should be capable of adhering to appropriate infection control
and isolation precautions for the duration of illness and recovery (including using a separate
bedroom if not living alone). Other important home resources include an available caregiver,
adequate access to food, and assistance with activities of daily living if necessary. Whether
the patient has any household members who have risk factors for severe disease is another

consideration ( table 1). (See "COVID-19: Infection control for persons with SARS-CoV-2
infection", section on 'Infection control in the home setting'.)
DETERMINE IF IN-PERSON EVALUATION WARRANTED
Based upon the above assessment, in particular the risk for developing severe disease,
dyspnea and oxygenation, and overall acuity level, we determine the urgency and
appropriate setting (in-person evaluation versus scheduled telehealth follow-up or self-care)
for further management.
For those patients who warrant in-person evaluation, we decide if outpatient clinic or
emergency department (ED) evaluation is appropriate. (Related Pathway(s): COVID-19: Initial
telephone triage of adult outpatients.)
While we use the following general criteria to determine the most appropriate clinical setting
for in-person evaluation, these criteria are not fixed and will vary by institution, region, and
over time with changing resource availability and treatment options.
In-person evaluation for moderate/severe dyspnea, hypoxia, and concern for higher
acuity level — All patients with moderate or severe dyspnea, an initial oxygen saturation
≤94 percent on room air (if oximetry information available), or any symptoms suggestive of
higher acuity level warrant in-person evaluation, either in the ED or in an outpatient clinic,
depending upon the severity of findings.
Criteria for ED evaluation and likely hospital admission — We typically refer patients
with one or more of the following features to the ED for further management and likely
hospital admission:
● Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete
sentences) (see 'Dyspnea assessment' above)
● Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea (see
'Oxygenation assessment' above)
● Concerning alterations in mentation (eg, confusion, change in behavior, difficulty in

rousing) or other signs and symptoms of hypoperfusion or hypoxia (eg, falls,
hypotension, cyanosis, anuria, chest pain suggestive of acute coronary syndrome) (see
'Assessment of overall acuity level' above)
Patients meeting the above criteria will typically be admitted to the hospital for inpatient
evaluation and management. In the United States, the National Institutes of Health (NIH)
COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the

following: an oxygen saturation of <94 percent on room air, respiratory rate of >30
breaths/minute, PaO2/FiO2 <300 mmHg, or lung infiltrates >50 percent [73]. While most
patients with this presentation will require inpatient care, there are no fixed criteria for
inpatient hospital admission with COVID-19; criteria vary by country, region, and availability
of COVID-19 specific therapy (see "COVID-19: Management in hospitalized adults", section on
'COVID-19-specific therapy'). Further, in areas of high infection prevalence, the criteria may
also vary with the availability of hospital resources; a lower threshold for hospitalization may
be feasible in settings where the burden of disease does not exceed resource availability. In
addition to clinical considerations, there are social factors that might support earlier
hospitalization. Models to predict the likelihood of critical illness in hospitalized COVID-19
patients are being developed, although none have been validated for the evaluation and
management of outpatients [74].
As our inpatient hospital resources are outpaced by patient volume in the setting of a surge
of COVID-19 cases, we have established an outpatient system to closely follow-up and
monitor such patients who do not get admitted. However, this approach may not be
appropriate in settings with more limited outpatient resources. (See 'Patients appropriate for
evaluation in clinic' below.)
Patients appropriate for evaluation in clinic — Patients with one or more of the

following features are typically appropriate for evaluation in an outpatient clinic (ideally a
dedicated respiratory/COVID-19 clinic if available), provided they do not meet any of the
above criteria for evaluation in the ED:
● Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94

percent (see 'Dyspnea assessment' above)
● Mild dyspnea in a patient with risk factors for severe disease ( table 1) (see 'Assess risk
for severe disease' above and 'Dyspnea assessment' above)
● Moderate dyspnea in any patient
● Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but
not severe enough to require ED referral (see 'Assessment of overall acuity level' above)
Clinic evaluation — For patients evaluated in an outpatient clinic (if feasible, a

respiratory/COVID-19 clinic), we assess the patient's respiratory and circulatory status, and
we evaluate for other potentially treatable causes of symptoms [24]. (See 'Managing other
potential causes of symptoms' below.)
Based upon a careful clinical history and physical exam, including vital signs as well as
measurements of oxygen saturation at rest and with ambulation, we then determine if the
patient is appropriate for self-care, home management with telehealth follow-up, outpatient
monoclonal antibody or therapy (if available through a clinical trial) (see 'Monoclonal
antibodies' below), or transfer to the ED for further evaluation or possible inpatient hospital
admission.
In our practice, we have found laboratory testing and chest imaging to be of limited utility in
the evaluation of most patients with COVID-19 in the outpatient clinic; the patient's clinical
presentation is a more important consideration in our management decision. (See "COVID-
19: Clinical features", section on 'Laboratory findings' and "COVID-19: Clinical features",
section on 'Imaging findings'.)
● Patients who require supplemental oxygen are transferred to the ED for hospital
admission and treatment with COVID-19. Management of hospitalized adults with
COVID-19 is discussed elsewhere. (See "COVID-19: Management in hospitalized adults",
section on 'Defining disease severity' and "COVID-19: Management in hospitalized
adults", section on 'Approach'.)
● Some patients without a supplemental oxygen requirement may also need further ED
evaluation and possible hospital admission (eg, those with confusion, weakness,
progressive dyspnea). (See 'Criteria for ED evaluation and likely hospital admission'
above.)
● Other patients with less severe disease may be referred for inpatient admission or
treated in the outpatient clinic; the decision to manage such patients in an ambulatory
setting (eg, the ability to administer intravenous fluids and medications and to arrange
for outpatient follow-up) or admit as inpatients will vary between institutions, by region,
by hospital resource availability and capacity, and over time, and thus influence this
determination. We also consider the patient's home setting and social factors in
determining the appropriateness of continued outpatient (clinic and telehealth)
management.
The use of home oximetry monitoring is being evaluated for patients seen in the
ambulatory or ED setting and discharged home [75]. However, there is no high-quality
evidence that patient outcomes are improved using this approach.
Home management without in-person evaluation for others — The majority of patients

without moderate or severe dyspnea, hypoxia (if oximetry information available), or
symptoms suggestive of higher overall acuity level can remain at home for management
without in-person evaluation, provided they can reliably report worsened symptoms and
self-isolate for the anticipated duration of illness.
Whether such patients warrant telehealth follow-up depends upon their risk for severe
disease and the extent of dyspnea ( table 1) (see 'Assess risk for severe disease' above and

'Dyspnea assessment' above):
● Patients without risk factors for severe disease and without dyspnea are discharged to
self-care at home; they do not need in-person evaluation or scheduled follow-up
telehealth visits. They receive instructions to contact their clinician with any worsening
symptoms.
● Patients without risk factors for severe disease who have mild dyspnea do not need in-
person evaluation but are scheduled for telehealth follow-up visits.
● Patients who have any risk factors for severe disease but without dyspnea are scheduled
for telehealth follow-up visits. Referral for monoclonal antibody therapy, if available
through a clinical trial provided they meet criteria, is also an option for some of these
patients. (See 'Monoclonal antibodies' below.)
The components of home management and counseling for patients with suspected or
confirmed COVID-19 are discussed elsewhere. (See 'Management and counseling for all
outpatients' below.)
The frequency and content of follow-up telehealth evaluation is discussed elsewhere. (See
'Telehealth follow-up' below.)
Supervised residential care to facilitate isolation — Patients who would be appropriate

for home care (with or without telehealth follow-up) but are unable to be adequately
managed in their usual residential setting are candidates for temporary shelter in
supervised residential care facilities, if available [76].
In particular, patients who may be unable to adequately self-isolate (eg, patients living in
multigenerational households, patients living with individuals who have any risk factors for
severe disease ( table 1), patients experiencing homelessness) should be provided
resources such as dedicated housing units, where available [77-80]. Disruption of families
should be minimized as much as possible. Every attempt should be made to avoid
hospitalization simply for the purpose of facilitating self-isolation, as this option is typically
not realistically available in regions with widespread disease.
Unfortunately, dedicated residential care facilities for COVID-19 patients are not widely
available in many countries and regions, and community-based solutions to self-isolation
should be explored.
MANAGEMENT AND COUNSELING FOR ALL OUTPATIENTS

When clinically appropriate, it is generally preferable to manage patients with suspected or

confirmed COVID-19 remotely via telehealth visits. (See 'Rationale for outpatient
management and remote care' above and "Telemedicine for adults", section on
'Telemedicine during COVID-19 pandemic'.)
Interim recommendations on the outpatient management of patients with COVID-19 are

provided by the World Health Organization, the Centers for Disease Control and Prevention
(CDC) in the United States, National Institute for Health and Care Excellence (NICE) in the
United Kingdom, and several academic medical centers [81-85]. (See "COVID-19:
Management in hospitalized adults", section on 'Institutional protocols'.)
Infection control — With all patients, we reinforce the importance of infection control and
self-isolation and provide instructions on the anticipated duration of isolation. These are
reviewed in detail elsewhere. (See "COVID-19: Infection control for persons with SARS-CoV-2
infection", section on 'Infection control in the home setting'.)
COVID-19 specific therapy — Among the treatments evaluated in outpatients with

nonsevere COVID-19, monoclonal antibody therapy has shown a benefit for patients with
certain risk factors for severe disease. However, these agents require parenteral
administration, and they must be given early in the course of illness; these factors make
administration operationally complicated in many outpatient settings. (See 'Monoclonal
antibodies' below.)
Other therapies are being evaluated in outpatients with non-severe disease, although high-
quality data on the efficacy of these therapies are limited. (See 'Limited role for other
outpatient therapies' below.)
Monoclonal antibodies
● Monoclonal antibody therapy – Monoclonal antibodies that target severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to be evaluated in
outpatients with mild to moderate disease, and trial results suggest a benefit from these
agents [86-88]. In the United States, the following monoclonal antibody therapies are
available through emergency use authorization (EUAs) for select outpatients at risk for
severe disease ( table 5):
• Casirivimab-imdevimab (600-600 mg, administered as a single IV dose [preferred],

although may be given subcutaneously if IV not feasible or would delay treatment)
• Sotrovimab (500 mg, administered as a single IV dose)
Bamlanivimab-etesevimab (700-1400 mg, administered as a single intravenous [IV]

dose) had been made available through an EUA, but distribution was suspended in the

United States in June 2021 due to variants of concern with likely resistance to this agent.
For patients with early, symptomatic COVID-19 who have risk factors for progression to
severe illness ( table 5), we suggest monoclonal antibody therapy. We suggest
casirivimab-imdevimab rather than sotrovimab; although both appear likely to retain
neutralizing activity against circulating SARS-CoV-2 variants that have mutations in the
spike protein (the binding target) ( table 6), complete trial results for sotrovimab are
not available for review. Monoclonal antibody treatment should be given as soon as
possible after diagnosis and within seven days of symptom onset. Although direct data
on timing of monoclonal antibody therapy are limited, indirect evidence from studies of
convalescent plasma suggest that benefit is maximized with early administration.
An important additional practical consideration is that the resources and supporting

infrastructure required for administration may divert resources from other COVID-19
care efforts and may favor use in resource-rich over resource-limited communities.
Thus, it is essential that equitable access to these treatments be ensured. We also
encourage treatment through clinical trials, if available, so that the efficacy of these
agents can continue to be evaluated.
Our approach is largely consistent with that of other expert groups including the
National Institutes of Health (NIH) treatment guidelines panel and the Infectious
Disease Society of America (IDSA), which recommend treatment with monoclonal
antibody therapy in high-risk groups as defined by the EUA criteria outlined below
[89,90], with consideration of the local prevalence of viral variants and the potential for
resistance.
The NIH and CDC suggest that treatment decisions (including use of monoclonal
antibody therapy) be made regardless of COVID-19 vaccination status [91,92]. However,
there are no direct data to inform the risks and benefits of monoclonal antibodies in
vaccinated patients; we individualize the decision, taking into account the potential for
severe disease despite vaccination based upon age, comorbidities, and extent of
symptoms.
SARS-CoV-2 variants, particularly those with mutations affecting the spike protein, are
likely to impact the clinical efficacy of available monoclonal antibody therapies [93-95].
Due to the increasing prevalence of SARS-CoV-2 variants in the United States that are
resistant to bamlanivimab-etesevimab, this agent is no longer being distributed [96,97].
Information on the in vitro neutralization of various recognized SARS-CoV-2 variants’
spike proteins by each monoclonal antibody therapy is available for review on the US
Food and Drug Administration (FDA) EUAs for casirivimab-imdevimab and sotrovimab;
clinicians should be aware of the prevalence of variants in their local area [98,99] and
the potential resistance of variants to these agents ( table 6). Additional clinical
studies in populations affected by SARS-CoV-2 variants are needed to determine the

efficacy of these therapies with the continued evolution of variants of concern. (See
"COVID-19: Epidemiology, virology, and prevention", section on 'Variants of concern'.)
The FDA EUAs for casirivimab-imdevimab and sotrovimab are for non-hospitalized
COVID-19 patients with mild to moderate illness (eg, not requiring supplemental oxygen
or, if on chronic supplemental oxygen, without an increased oxygen requirement) who
have certain risk factors for severe disease ( table 5) [100,101]. These risk factors for
adults (≥18 years) include any of the following:
• Older age (≥65 years)
• Body mass index (BMI) ≥25 kg/m²
• Pregnancy
• Chronic kidney disease
• Diabetes mellitus
• Immunosuppression (immunosuppressive disease or treatment)
• Cardiovascular disease (including congenital heart disease) or hypertension
• Chronic lung disease (eg, chronic obstructive pulmonary disease [COPD], asthma
[moderate to severe], interstitial lung disease, cystic fibrosis, pulmonary
hypertension)
• Sickle cell disease
• Neurodevelopmental disorders (eg, cerebral palsy) or other medically complex

conditions (eg, genetic or metabolic syndromes and severe congenital anomalies)
• Dependence on a medical-related technology (eg, tracheostomy, gastrostomy, or

positive pressure ventilation [unrelated to COVID-19])
In addition, other conditions may place an individual at high risk for progression to
severe COVID-19, and the use of monoclonal antibody therapy is not strictly limited to
those with the risk factors listed above.
• Casirivimab-imdevimab – In preliminary results of a phase 3 randomized controlled

trial including 4057 non-hospitalized adults with mild to moderate COVID-19 and
one or more risk factors for severe disease, combination casirivimab-imdevimab, at
two different doses (1200 and 2400 mg total doses) administered intravenously
within seven days of symptom onset was compared with placebo [87]. At 29 days,

there was a reduction in the combined outcome of hospitalization and death among
those treated with both doses of casirivimab-imdevimab compared with placebo
(1200 mg total dose, 1 versus 3.2 percent [70 percent relative risk (RR) reduction,
95% CI 32-87]; 2400 mg dose, 1.3 versus 4.6 percent [71 percent RR reduction, 95%
CI 52-83]). There were five deaths in the placebo group and two deaths among
those receiving casirivimab-imdevimab. Treatment with IV casirivimab-imdevimab
was associated with rare infusion-related reaction events of moderate severity,
including fever, chills, urticaria, pruritus, abdominal pain, and flushing. A single
episode of anaphylaxis was also reported [87,102]. Subcutaneous administration
was associated with greater local injection site reactions compared with placebo (12
versus 4 percent) [103].
The EUA for casirivimab-imdevimab is for the combined 1200 mg dose,

administered IV (preferred) or subcutaneous if IV administration is not feasible or
would delay treatment [103]. There are no outcomes data regarding subcutaneous
administration; dosing is based upon safety and pharmacokinetic data in healthy
subjects.
• Sotrovimab – In unpublished results of a randomized clinical trial including 583 non-

hospitalized adults with early, mild to moderate COVID-19 and one or more risk
factors for severe disease or age ≥55 years, sotrovimab (500 mg) administered
within five days of illness onset was compared with placebo [88]. At 29 days, there
was a reduction in the combined rates of hospitalization and death compared with
placebo (1 versus 7.2 percent; 85 percent RR reduction, 97% CI 44-96). The single
study death occurred in the placebo group. Complete trial results are unavailable
for review.
• Bamlanivimab-etesevimab – In randomized trials, bamlanivimab-etesevimab

reduced the risk of hospitalization and death in outpatients with mild to moderate
COVID-19 and risk factors for progression to severe disease [100,104,105].
However, distribution of bamlanivimab-etesevimab was suspended in the United

States in June 2021 due to the increasing prevalence of variants of concern with
likely resistance to this agent, and it is no longer available for use [96].
In Europe, the European Medicines Agency (EMA) has provisionally approved the use of
the monoclonal antibody regdanvimab for outpatients with COVID-19 who have certain
risk factors for severe disease and who do not require supplemental oxygen [106,107].
In an unpublished report of a randomized clinical trial including 327 adult outpatients
with early, mild to moderate COVID-19, treatment with regdanvimab (40 mg/kg) within
three days of symptom onset reduced the risk of hospitalization, oxygen requirement,
and death compared with placebo (4 versus 8.7 percent). Among patients with risk
factors for progression to severe disease, the benefit was greater (4.3 versus 12.7
percent). Regdanvimab is administer as a single intravenous dose of 40 mg/kg, with a
maximum dose of 8000 mg.
Limited role for other outpatient therapies — Other COVID-19 treatments are under
investigation but should not be prescribed in the ambulatory setting outside of a clinical trial
[108]. Evidence continues to evolve, but high-quality data supporting the efficacy of these
treatments are limited [109]. In addition, there are concerns for potential toxicities with
some of these agents when administered in an unmonitored setting [110,111]. (See "COVID-
19: Management in hospitalized adults", section on 'Specific treatments under evaluation'.)
● High-titer convalescent plasma – Convalescent plasma has not demonstrated efficacy

for most outpatients with mild illness [112]. However, limited high-quality data suggest
that high-titer convalescent plasma given early to certain high-risk adult outpatients
with mild illness appears to have efficacy in reducing the risk of progression to severe
disease [113]. Given the short window of opportunity for administration (within 72 hours
of symptom onset) and additional operational challenges with outpatient intravenous
administration, this therapy may have a practical role in the management of eligible
older adults with mild COVID-19 in a skilled nursing setting (eg, a skilled nursing,
inpatient acute or sub-acute rehabilitation facility, or correctional facility medical unit) if
monoclonal antibody therapy is not available. High-titer convalescent plasma therapy
remains investigational and should be administered through a clinical trial if available.
The preparation, administration, and adverse effects of convalescent plasma are
discussed in detail elsewhere. (See "COVID-19: Convalescent plasma and hyperimmune
globulin".)
• A randomized controlled trial including 160 older adults (age ≥75 years or ≥65 years
with one or more specific comorbidities [hypertension, chronic obstructive lung
disease, diabetes mellitus on pharmacotherapy, cardiovascular disease, chronic
renal failure, obesity]), a positive SARS-CoV-2 polymerase chain reaction (PCR) test,
and mild COVID-19 symptoms, compared early treatment with high-titer
convalescent plasma with placebo [113]. High-titer convalescent plasma therapy
administered within 72 hours of symptom onset reduced the risk of developing
severe respiratory disease compared with placebo (16 versus 31 percent; RR 0.52,
95% CI 0.29-0.94). Further, among those receiving convalescent plasma, there was a
dose response, with higher-titer anti-SARS-CoV-2 immunoglobulin G (IgG) plasma
associated with reduced risk of disease progression compared with lower-titer
plasma.
Trials evaluating convalescent plasma given later during illness to outpatients with mild
disease have not shown similar benefit. As an example, the Clinical Trial of COVID-19

Convalescent Plasma of Outpatients (C3PO), evaluating convalescent plasma given

within seven days of symptom onset to adults age ≥18 years with mild illness and one or
more risk factors for severe disease, was halted early for lack of clinical benefit [112].
● Systemic glucocorticoids – In non-hospitalized patients, we do not treat COVID-19 with

dexamethasone, prednisone, or other corticosteroids [114]. Extrapolating from the
results of studies of hospitalized patients, there is no evidence that corticosteroids
benefit patients without a supplemental oxygen requirement, and further, they may be
associated with poorer clinical outcomes [115]. However, in resource-limited settings
with limited hospital capacity, it may be reasonable to treat select COVID-19 outpatients
who have a new or increased supplemental oxygen requirement with dexamethasone if
close clinical follow-up can be assured [116]. In addition, patients with COVID-19 and a
concomitant acute exacerbation of asthma or COPD should receive appropriate
treatment with systemic glucocorticoids as indicated by usual guidelines. This is
reviewed in detail elsewhere. (See "COVID-19: Management in hospitalized adults" and
"COVID-19: Management in hospitalized adults", section on 'Dexamethasone and other
glucocorticoids' and "An overview of asthma management", section on 'Advice related to
COVID-19 pandemic' and "Stable COPD: Overview of management", section on 'Advice
related to COVID-19'.)
● Colchicine – Although there are some data demonstrating a benefit from the use of
colchicine in early, mild to moderate COVID-19, the benefit is modest without a
reduction in mortality, and adverse effects are common. In a randomized trial including
over 4100 adult outpatients (≥age 40) with early, mild to moderate, testing-confirmed
COVID-19, treatment with oral colchicine (0.5 mg twice daily for three days, followed by
0.5 mg daily for a total of 30 days), reduced the risk of hospitalization compared with
placebo (4.5 versus 5.9 percent of patients; odds ratio [OR] 0.75, 95% CI 0.57-0.99) [117].
However, there was no reduction in mortality. Gastrointestinal side effects (eg, diarrhea)
were more common, and pulmonary embolism occurred more frequently in the
colchicine compared with the placebo group (24 versus 15 percent; and 0.5 versus 0.1
percent, respectively).
● Ivermectin – Ivermectin is being evaluated as a potential therapy for early treatment in

outpatients with nonsevere disease. However, there is a lack of high-quality data to
support its efficacy in these patients [118-120].
● Inhaled corticosteroids – Inhaled corticosteroids may be of some benefit in the

treatment of mild, early, COVID-19. In the non-placebo controlled steroids in COVID-19
(STOIC) trial, 139 adult outpatients in the United Kingdom with mild, early COVID-19
were treated with inhaled budesonide 800 mcg twice daily (an average of seven days) or
assigned to usual care [121]. Among those treated with inhaled budesonide, fewer

patients required urgent medical evaluation or hospitalization (1.4 versus 14.4 percent)
at 28 days. However, additional randomized controlled trials are necessary to determine
the efficacy of inhaled corticosteroids for early, mild, COVID-19.
● Fluvoxamine – Limited data suggest that fluvoxamine may reduce progression to

severe disease in early, mild COVID-19, although high-quality evidence is lacking. As
examples, in a small randomized controlled trial including 152 outpatients with
nonsevere COVID-19, treatment with fluvoxamine (100 mg orally twice daily for two
days, then three times daily for a total of 15 days of treatment) reduced clinical
(respiratory) deterioration compared with placebo (0 versus 8.3 percent; ARR 8.7, 95% CI
1.8-16.4) [109]. The trial, however, was limited by methodologic problems, including
limited study duration and loss to follow-up. In a prospective cohort study including 113
adults with asymptomatic or mild COVID-19, treatment with fluvoxamine (50 mg twice
daily for 14 days) was associated with a reduced incidence of hospitalization compared
with observation alone (0 versus 12.5 percent) [122]. In addition, persistent symptoms
were less likely among those treated with fluvoxamine at 14 days (0 versus 60 percent),
although this observation is limited by the short duration of follow-up.
● Hydroxychloroquine and azithromycin – Hydroxychloroquine and azithromycin have

received attention as agents with possible antiviral activity, but trials have not suggested
a clinical benefit for patients with COVID-19, including those managed in the outpatient
setting [123-128]. Although some observational and unpublished anecdotal reports
have suggested a clinical benefit of hydroxychloroquine, those are subject to a number
of potential confounders [129], and randomized trials offer higher-quality evidence that
hydroxychloroquine has no proven role for COVID-19. As an example, in an open-label
trial including 293 patients with mild COVID-19 who did not warrant hospitalization,
hydroxychloroquine administered within five days of symptom onset did not reduce viral
levels at day 3 or 7 compared with no treatment [123]. In addition, there was no
statistically significant reduction in hospitalization rates or time to symptom resolution.
The rate of adverse effects, primarily gastrointestinal symptoms, were greater with
hydroxychloroquine.
● Others – Other treatments are being evaluated in outpatients with mild to moderate
illness, including vitamin and mineral supplementation as well as antiviral agents and
anticoagulants.
• Limited observational data suggest a possible association between certain vitamin

and mineral deficiencies and more severe disease [130-133]. However, there are no
high-quality data that supplementation with vitamin C, vitamin D, or zinc reduces
the severity of COVID-19 in non-hospitalized patients [134]. Issues related to vitamin

D and COVID-19 are reviewed in detail elsewhere. (See "Vitamin D and extraskeletal
health", section on 'COVID-19'.)
• There is no evidence that treatment with lopinavir-ritonavir improves outcomes in

outpatients with mild disease [126]. In addition, although treatment with
peginterferon lambda may induce more rapid reduction in SARS-CoV-2 viral load in
patients with early, mild disease, its impact on clinically important outcomes is
unclear [135].
• In a randomized trial including 243 adults with mild to moderate COVID-19 but risk
factors for progression to severe disease, treatment with sulodexide (a
glycosaminoglycan with anticoagulant and antiinflammatory properties) within
three days of symptom onset reduced hospitalizations and the need for
supplemental oxygen compared with placebo (RR 0.60, 95% CI 0.37-0.96 and RR
0.71, 95% CI 0.50-1.00, respectively), but not mortality or thromboembolic events
[136]. Further trials are required to determine if there is a clinical role for this agent
in treating outpatients with COVID-19.
Other COVID-19 specific therapies, such as remdesivir and baricitinib, are being used
and evaluated in hospitalized patients; these therapies are discussed in detail elsewhere.
(See "COVID-19: Management in hospitalized adults", section on 'COVID-19-specific
therapy'.)
Clinicians are encouraged to refer patients for participation in available clinical trials of
investigational COVID-19 therapies. A catalog of clinical trials can be found at covid-trials.org;
the list of trials can be filtered by location, type of study, patient setting (ie, outpatient versus
inpatient), and many other criteria.
For patients with documented COVID-19, treatment with antibiotics is not indicated. Data are
limited, but bacterial superinfection does not appear to be a prominent feature of COVID-19.
Treatment for bacterial pneumonia may be reasonable if the diagnosis is uncertain, or in
patients with documented COVID-19 in whom there is clinical suspicion (eg, new fever after
defervescence with new consolidation on chest imaging). (See "COVID-19: Management in
hospitalized adults" and "COVID-19: Management in hospitalized adults", section on 'Empiric
treatment for bacterial pneumonia in select patients'.)
Outpatients with COVID-19 who are already receiving anticoagulant or antiplatelet therapy
for underlying conditions should continue these medications. However, we do not initiate
anticoagulation or antiplatelet therapy unless the patient has specific indications for
treatment or is participating in a clinical trial [137]. Consultation with an appropriate
specialist (eg, hematology, pulmonology) may be helpful in circumstances where

anticoagulation is being considered. (See "COVID-19: Hypercoagulability", section on

'Patients not admitted to the hospital'.)
Symptom management and recovery expectation — Symptomatic treatment includes

antipyretics and analgesics for fever, myalgias, and headaches. We generally prefer
acetaminophen; however, we inform patients that nonsteroidal antiinflammatory drug
(NSAID) use is acceptable if symptoms do not respond to acetaminophen. (See "COVID-19:
Management in hospitalized adults", section on 'NSAID use'.)
Some patients with cough or dyspnea may experience symptomatic improvement with self-
proning (resting in the prone rather than the supine position) [138]. In addition, we provide
education on breathing exercises ( table 7); these exercises are used to help patients with
lung disease manage dyspnea, although they have not been evaluated in patients with
COVID-19.
However, patients are cautioned that progressive respiratory symptoms, particularly

worsening dyspnea, should prompt contact with their clinician for further evaluation. (See
'Reevaluation for worsening dyspnea' below.)
All other care is generally supportive, similar to that advised for other acute viral illnesses:
● We advise that patients stay well hydrated, particularly those patients with sustained or
higher fevers, in whom insensible fluid losses may be significant.
● Cough that is persistent, interferes with sleep, or causes discomfort can be managed
with an over-the-counter cough medication (eg, dextromethorphan) or prescription
benzonatate, 100 to 200 mg orally three times daily as needed.
● We advise rest as needed during the acute illness; for patients without hypoxia, frequent
repositioning and ambulation is encouraged. In addition, we encourage all patients to
advance activity as soon as tolerated during recovery.
In addition, we educate patients about the wide variability in time to symptom resolution
and complete recovery from COVID-19. Although early data from China suggested that
patients with mild disease recover in two weeks and those with more severe disease recover
in three to six weeks [139], accumulating data suggest that the course of recovery is more
variable, often longer, and may depend upon premorbid risk factors (eg, age, health status)
in addition to illness severity [140]. (See "COVID-19: Clinical features", section on 'Recovery
and long-term sequelae'.)
As an example, in a survey of 292 outpatients recovering from COVID-19, an average of 35

percent had not returned to baseline health by 14 to 21 days; younger patients were less
likely to have residual symptoms compared with older patients (26 percent of those age 18

to 34 versus 47 percent of those >50 years) [141]. In addition, the number of medical
comorbidities was associated with prolonged illness among all age groups; young and
healthy patients with mild disease typically recovered sooner, while patients with multiple
comorbidities had a more prolonged recovery. Fatigue, dyspnea, and headache were the
symptoms most commonly reported to persist.
Managing other potential causes of symptoms — Since symptoms of COVID-19 can

overlap with those of many common conditions, it is important to consider other possible
etiologies of symptoms including other respiratory infections (eg, influenza, streptococcal
pharyngitis, community-acquired pneumonia [CAP]), congestive heart failure, asthma or
COPD exacerbations, and even anxiety ( table 2) [24].
For conditions that can be treated remotely, such as possible streptococcal pharyngitis, mild
asthma exacerbations, or mild exacerbations of chronic congestive heart failure (CHF), we
will often treat without an in-person evaluation but with scheduled daily follow-up telehealth
visits. Management of specific medical conditions is discussed in the relevant UpToDate topic
reviews.
The prevalence of other diseases should also be considered. As an example, in regions

where COVID-19 is prevalent and seasonal influenza activity remains high, patients who have
symptoms consistent with both conditions should be treated empirically for influenza.
We also consider the prevalence of COVID-19 in the community in our determination

whether to evaluate the patient in-person; clinical judgement, however, remains the most
important consideration in this decision. As an example, in regions where COVID-19
prevalence is high, efforts should be made to avoid or minimize in-person evaluations if
possible; remote evaluation and management of mild dyspnea, if clinically appropriate, is
preferred. (See 'Reevaluation for worsening dyspnea' below and 'Consider additional causes
of worsening dyspnea' below.)
Medication management — In general, the patient’s usual home medication regimen is not
adjusted, although some changes may be needed.
We advise patients who use nebulized medications to avoid their use in the presence of
others and to use a metered dose inhaler preparation instead, when possible, to avoid
potential aerosolization of SARS-CoV-2. (See "COVID-19: Management in hospitalized adults",
section on 'Avoiding nebulized medications' and "COVID-19: Respiratory care of the
nonintubated critically ill adult (high flow oxygen, noninvasive ventilation, and intubation)",
section on 'Nebulized medications'.)
If patients already use a continuous positive airway pressure (CPAP) or bilevel positive airway
pressure (BPAP) device for management of obstructive sleep apnea, they may continue to

use their machine; as with nebulizers, they are advised to use the device only when isolated
from others.
For patients taking an immunomodulating medication, we consult with the prescribing

clinician about the relative risks and benefits of temporarily discontinuing it, which depend
upon its indication and the severity of the underlying condition. (See "COVID-19: Issues
related to solid organ transplantation", section on 'Adjusting immunosuppression' and
"COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Medication
management with documented or presumptive COVID-19' and "COVID-19: Issues related to
gastrointestinal disease in adults", section on 'Adjusting IBD medications' and "COVID-19:
Risks for infection, clinical presentation, testing, and approach to infected patients with
cancer", section on 'Initial approach'.)
Outpatients with COVID-19 who are already receiving anticoagulant or antiplatelet therapy
for underlying conditions should continue these medications. (See "COVID-19:
Hypercoagulability", section on 'Patients not admitted to the hospital'.)
Management of medications is reviewed in more detail elsewhere. (See "COVID-19:

Management in hospitalized adults", section on 'Managing chronic medications' and "COVID-
19: Management in hospitalized adults", section on 'NSAID use' and "COVID-19:
Management in hospitalized adults", section on 'Avoiding nebulized medications' and
"COVID-19: Management in hospitalized adults", section on 'Immunomodulatory agents' and
"COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension",
section on 'Renin angiotensin system inhibitors' and "Dipeptidyl peptidase 4 (DPP-4)
inhibitors for the treatment of type 2 diabetes mellitus", section on 'Immune function' and
"COVID-19: Issues related to diabetes mellitus in adults".)
Counseling on warning symptoms — We counsel all patients on the warning symptoms

that should prompt reevaluation by telehealth visit and in-person, including ED evaluations.
These include new onset of dyspnea, worsening dyspnea, dizziness, and mental status
changes such as confusion. Patients are educated about the time course of symptoms and
the possible development of respiratory decline that may occur, on average, one week after
the onset of illness. In addition, we assess the availability of support at home, ensure that
they know who to call should they need assistance, and reinforce when and how to access
emergency medical services.
Patients with obstructive lung disease (eg, COPD or asthma) are specifically advised to
closely monitor their respiratory status, and are cautioned not to presume that any
worsening shortness of breath is due to an exacerbation of their underlying lung disease.
Addressing goals of care — Given the potential severity of COVID-19, all patients should
have updated health care proxy and advance directive information in their electronic health

record.
For patients with significant underlying medical comorbidities and poor health status,
COVID-19 may cause catastrophic illness including respiratory failure due to acute
respiratory distress syndrome (ARDS). Among such patients, those who develop life-
threatening complications are likely to have a poor outcome despite the use of aggressive
measures such as mechanical ventilation. For patients who are at highest risk of
complications and who have the lowest likelihood of survival, the appropriateness of
hospitalization and ventilator assistance should be discussed in advance of significant
deterioration in clinical condition. For these patients, it may be appropriate to address home
palliative care strategies in anticipation of need. Many institutions have palliative care and
hospice programs to provide skilled nursing and social work support for patients and
families. (See "COVID-19: Management of the intubated adult", section on 'Surge capacity
and resource allocation' and "COVID-19: Management of the intubated adult", section on
'End of life issues' and "Advance care planning and advance directives", section on 'COVID-19
resources'.)
COVID-19 vaccination after recovery from acute illness — COVID-19 vaccination after

recovery from acute infection, including those who received antibody-based therapy
(monoclonal antibodies or convalescent plasma) is reviewed in detail elsewhere. (See
"COVID-19: Vaccines to prevent SARS-CoV-2 infection", section on 'History of SARS-CoV-2
infection'.)
TELEHEALTH FOLLOW-UP
Frequency of follow-up — For patients with COVID-19 determined to be appropriate for

home management with telehealth follow-up, the frequency of telehealth visits is
determined by their risk for severe disease, severity of respiratory symptoms, and our
comfort level with their ability to self-report worsening symptoms. (See 'Home management
without in-person evaluation for others' above.)
● For most patients, telehealth visits are scheduled on days 4, 7, and 10 (following the
onset of clinical illness).
● However, for patients in whom we have the highest level of concern, we generally
schedule the first follow-up telehealth visit within 24 hours. These include:
• Patients aged ≥65 years who have one or more risk factors for severe disease (
table 1) (see 'Assess risk for severe disease' above)
• Any patient with moderate dyspnea at the time of initial evaluation (see 'Dyspnea
assessment' above)
• Patients who would be possible candidates for inpatient admission but are being
managed at home due to limited hospital resources and capacity (see 'Clinic
evaluation' above)
• Patients who we feel may not reliably report a deterioration in symptoms
For these patients, the frequency of subsequent telehealth visits can be reduced to
every other day if the patient remains clinically stable.
Repeat assessment of dyspnea and hypoxia — At each telehealth visit, we evaluate a

patient's respiratory status, focusing on assessing for new or worsening dyspnea and
hypoxia, as these are the most likely indications requiring in-person clinical reevaluation and
potential hospitalization. In addition, we assess overall acuity level, ensuring that the patient
remains clinically stable enough for remote management. (See 'Dyspnea assessment' above
and 'Assessment of overall acuity level' above.)
Reevaluation for worsening dyspnea — All patients who develop worsening or more

severe dyspnea require further evaluation and management. We use the same criteria for
determining whether a patient needs to be evaluated in-person as in our initial evaluation.
(See 'Determine if in-person evaluation warranted' above.)
For patients who do not meet criteria for in-person evaluation, and who have potentially
treatable causes of dyspnea by clinical history (eg, anxiety, mild exacerbation of congestive
heart failure, mild asthma or chronic obstructive pulmonary disease [COPD] exacerbations),
we typically treat these conditions remotely. However, these patients are closely followed
with daily telehealth visits for at least the next several days or until they are improving. The
frequency and duration of subsequent follow-up is determined by their clinical course.
Dyspnea severe enough to interfere with activities of daily living or cause difficulty with
speaking requires an in-person evaluation. Further, new dyspnea in a patient with any risk
factors for severe disease should prompt an in-person evaluation ( table 1). (See 'Assess
risk for severe disease' above.)
The in-person evaluation should occur in the most appropriate clinical setting, depending
upon the severity of dyspnea, and may vary by health care system. (See 'In-person
evaluation for moderate/severe dyspnea, hypoxia, and concern for higher acuity level'
above.)
Consider additional causes of worsening dyspnea — In addition, even though some

patients with worsening symptoms may be managed remotely, we perform an in-person
evaluation if they have complaints suggestive of serious conditions or complications that are
not amenable to telehealth management, such as severe community-acquired pneumonia
(CAP; eg, new productive cough, pleuritic chest discomfort), asthma or COPD exacerbation
(eg, cough, increasing wheezing), pulmonary embolism (eg, worsening dyspnea, pleuritic
chest pain, hemoptysis), heart failure (increasing dyspnea, edema, orthopnea) or acute
pericarditis (eg, chest pain). This evaluation can take place in a respiratory (COVID-19) clinic
or appropriate clinical care setting. Discussion of the evaluation and management of these
conditions can be found in the relevant UpToDate topics.
In particular, patients with suspected COVID-19 and dyspnea who have underlying
obstructive lung disease (including COPD and asthma) present unique management
challenges. For such patients, dyspnea may be simply due to an exacerbation of obstruction,
and it is not possible to differentiate clinically between an isolated exacerbation of
underlying pulmonary disease and an exacerbation related to COVID-19. In such cases, a
presumptive asthma or COPD exacerbation should be treated with a short course of oral
corticosteroids and increased use of short-acting beta agonists. Patients on home oxygen at
baseline should be evaluated for increased oxygen requirements. (See "An overview of
asthma management", section on 'Advice related to COVID-19 pandemic' and "COPD
exacerbations: Management".)
OUTPATIENT MANAGEMENT FOLLOWING INPATIENT OR ED DISCHARGE
After discharge from the inpatient hospital setting or the emergency department (ED),
clinician follow-up is warranted, either in outpatient clinic or via telehealth visit [142]. At each
encounter after hospital or ED discharge, we reinforce the importance of infection control
and provide counseling on the warning symptoms which should prompt reevaluation. (See
'Infection control' above and 'Counseling on warning symptoms' above.)
In some cases, patients are discharged home or to supervised residential care from the
inpatient hospital setting on low flow oxygen therapy, with oximetry monitoring by
telehealth (preferred if available) or visiting nurse. The practice of sending patients home on
supplemental oxygen is widely variable, however, and if done warrants careful patient
selection and close monitoring [143].
Some patients discharged from the hospital, including those with documented venous
thromboembolism (VTE) as well as those who are at high risk for VTE, will be discharged on
anticoagulation. This is discussed in detail elsewhere. (See "COVID-19: Hypercoagulability",
section on 'Patients discharged from the hospital'.) (Related Pathway(s): COVID-19:
Anticoagulation in adults with COVID-19.)
Post-intensive care syndrome (PICS), a constellation of symptoms that includes a decline in

physical, cognitive, and psychiatric function, may occur among some COVID-19 patients who
have recovered from critical illness. In addition, some patients with more severe pulmonary
involvement may have persistent pulmonary and respiratory symptoms, although there are

no data regarding the long-term pulmonary sequelae of COVID-19. (See "Post-intensive care
syndrome (PICS)" and "COVID-19: Epidemiology, clinical features, and prognosis of the
critically ill adult", section on 'Long term sequelae'.)
Patients discharged home
● Most patients discharged from the inpatient setting require a follow-up clinician visit
within one to two days following discharge; depending on their unique clinical and social
situation, telehealth visit [144] or in-person outpatient visit may be appropriate.
● For those patients evaluated and discharged from the ED and who are felt to need
follow-up care, telehealth visits may also be appropriate. The timing of such visits,
however, would vary depending upon patient acuity and indication.
Patients discharged to supervised residential care for recovery — As part of the

continuum of care of patients with COVID-19, temporary housing in supervised residential
care facilities may also be appropriate for managing patients discharged from the inpatient
hospital setting, as well as those evaluated and discharged from the ED. (See 'Supervised
residential care to facilitate isolation' above.)
Depending upon the type of facility, the patient's medical acuity, and available resources,
telehealth follow-up may be appropriate; the intensity of telehealth follow-up will vary
depending upon the indication for housing (eg, solely the need for isolation versus isolation
with more acute medical need).
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: COVID-19 – Index of
guideline topics".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient
education: COVID-19 and pregnancy (The Basics)" and "Patient education: COVID-19 and
children (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Our understanding of the spectrum of coronavirus disease 2019 (COVID-19) as well as

optimal management strategies continues to evolve. There are limited data informing
outpatient management strategies, and the approach described here is based upon our
clinical experience and a rapidly evolving evidence base; clinicians should take into
account the individual patient's clinical and social circumstances as well as the available
resources. (See 'Introduction' above.)
● Outpatient management is appropriate for most patients with suspected or confirmed

COVID-19. When possible, we favor a coordinated care management program that
includes initial risk stratification, clinician telehealth visits (telephone call or video
platform-based), a dedicated outpatient respiratory clinic, and a close relationship with a
local emergency department (ED). (See 'General principles' above.)
● Patients who live in regions with widespread community transmission of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) and have compatible symptoms are
generally managed presumptively as having COVID-19, even if they have not been
tested or have an initial negative test result ( table 2). (See 'Suspicion for COVID-19
and role of testing' above.)
On initial evaluation, we assess risk factors for severe disease ( table 1), dyspnea
severity and duration (and oxygenation status of those with dyspnea, if that information
is available), overall level of acuity, and the patient’s home setting to determine who
warrants an in-person evaluation at an outpatient clinic or in the ED. The additional
criteria we use to make this determination are not fixed and will vary by institution,
region, and over time as resource availability and treatment options evolve. (See 'Risk
stratification' above.) (Related Pathway(s): COVID-19: Initial telephone triage of adult
outpatients.)
We typically refer patients with one or more of the following features to the ED for
further management and likely hospital admission (see 'Criteria for ED evaluation and
likely hospital admission' above):

• Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in
complete sentences)
• Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea
• Concerning alterations in mentation (eg, confusion, change in behavior, difficulty in

rousing) or other signs and symptoms of hypoperfusion or hypoxia (eg, falls,
hypotension, cyanosis, anuria, chest pain suggestive of acute coronary syndrome)
We refer patients for evaluation in an outpatient clinic if they have one or more of the
following features without any of the preceding features (see 'Patients appropriate for
evaluation in clinic' above):
• Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94

percent
• Mild dyspnea in a patient with any risk factors for severe disease ( table 1)
• Moderate dyspnea in any patient
• Symptoms concerning enough to warrant in-person evaluation (eg, mild

orthostasis) but not severe enough to require ED referral
● The decision to refer patients for hospital admission or manage at home depends upon
several factors, including their requirement for supplemental oxygen, an assessment of
their overall acuity level, and hospital resources and capacity. (See 'Clinic evaluation'
above.)
● Other patients can generally remain at home for management without in-person
evaluation if they can reliably report worsened symptoms and can self-isolate for the
anticipated duration of illness. Some outpatients may be candidates for COVID-19
specific therapy, if available. Whether patients managed at home warrant telehealth
follow-up depends upon their risk for severe disease and the extent of dyspnea. (See
'Home management without in-person evaluation for others' above.)
● When managing outpatients with COVID-19 (see 'Management and counseling for all
outpatients' above):
• We reinforce the importance of infection control and self-isolation. Instructions for

home isolation (including the duration) are discussed in detail elsewhere. (See
"COVID-19: Infection control for persons with SARS-CoV-2 infection", section on
'Infection control in the home setting'.)

• For some symptomatic, non-hospitalized COVID-19 patients with mild to moderate

illness and specific risk factors for severe disease, data suggest that early treatment
with monoclonal antibody therapy may reduce the risk of progression to severe
disease. However, these agents require parenteral administration and must be
given as early as possible after a positive SARS-CoV-2 test and illness onset, which
make administration operationally complicated in many outpatient settings. (See
'Monoclonal antibodies' above.)
- In the United States, treatment with anti-SARS-CoV-2 monoclonal antibody

therapies are available through emergency use authorizations (EUAs). For
patients with early, symptomatic COVID-19 and risk factors for progression to
severe illness ( table 5), we suggest treatment with monoclonal antibody
therapy (Grade 2B). For eligible patients, we suggest treatment with
casirivimab-imdevimab rather than sotrovimab (Grade 2C). Although both
agents appear likely to retain neutralizing activity against circulating SARS-CoV-
2 variants that have mutations in the spike protein (the binding target) (
table 6), complete trial results for sotrovimab are not available for review.
Monoclonal antibody therapy should be given as early as possible after
diagnosis and within seven days of symptom onset rather than later in the
course of illness; it is likely that earlier administration is associated with the
greatest benefit. In the United States, bamlanivimab-etesevimab is no longer
being distributed due to the increasing prevalence of variants of concern with
likely resistance.
We also encourage treatment through clinical trials, if available, so that the

efficacy of these agents can continue to be evaluated.
A catalog of clinical trials can be found at covid-trials.org; the list of trials can be
filtered by setting (eg, outpatient versus inpatient).
Other therapies are being evaluated for the treatment of COVID-19, but none have a
proven role for nonsevere disease. None of these other treatments should be
prescribed in the ambulatory setting outside of a clinical trial; data are limited, and
there are concerns for potential toxicity in an unmonitored setting.
In non-hospitalized patients, we do not treat COVID-19 with dexamethasone,

prednisone, or other corticosteroids. However, in resource-limited settings with
limited hospital capacity, it may be reasonable to treat select COVID-19 outpatients
who have a new or increased supplemental oxygen requirement with
dexamethasone if close clinical follow-up can be assured. In addition, patients with a
concomitant acute exacerbation of asthma or chronic obstructive pulmonary

disease (COPD) should receive appropriate treatment with systemic glucocorticoids

as indicated.
For patients with documented COVID-19, treatment with antibiotics is not indicated.
Data are limited, but bacterial superinfection does not appear to be a prominent
feature of COVID-19. Further, we do not routinely initiate anticoagulation or
antiplatelet therapy. (See 'Limited role for other outpatient therapies' above.)
• Symptoms of COVID-19 can overlap with those of many common conditions, so it is

important to consider other possible etiologies of symptoms including other
respiratory infections, congestive heart failure, asthma or COPD exacerbations, and
even anxiety. For conditions that can be treated remotely, we will often treat without
an in-person evaluation but with scheduled daily follow-up telehealth visits. (See
'Managing other potential causes of symptoms' above.)
• In general, the patient’s usual home medication regimen is not adjusted. However,
we advise patients who use nebulized medications to avoid their use in the
presence of others. (See 'Medication management' above.)
• We counsel all patients on the warning symptoms that should prompt reevaluation
by telehealth visit and in-person, including ED evaluations. (See 'Counseling on
warning symptoms' above.)
• All patients should have updated health care proxy and advance directive
information in their electronic health record. (See 'Addressing goals of care' above.)
● On follow-up (eg, by telehealth visit), we evaluate a patient's respiratory status, focusing

on assessing for new or worsening dyspnea. We use the same criteria for determining
whether a patient needs to be evaluated in-person as in our initial evaluation. (See
'Reevaluation for worsening dyspnea' above and 'Consider additional causes of
worsening dyspnea' above.)
● Most patients discharged from the inpatient setting warrant clinician follow-up within
one to two days following discharge; whether a telehealth or in-person outpatient visit is
most appropriate depends on their unique clinical and social situation. Temporary
housing in supervised residential care facilities, when available, may also be appropriate
for some patients discharged from the inpatient hospital setting. (See 'Outpatient
management following inpatient or ED discharge' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES

1. Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020;
382:1679.
2. Lam PW, Sehgal P, Andany N, et al. A virtual care program for outpatients diagnosed
with COVID-19: a feasibility study. CMAJ Open 2020; 8:E407.
3. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html (Access
ed on April 20, 2020).
4. Close RM, Stone MJ. Contact Tracing for Native Americans in Rural Arizona. N Engl J Med
2020; 383:e15.
5. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0116 (Accessed on August 14, 2020).
6. World Health Organization. Report of the WHO-China joint mission on coronavirus disea
se 2019 (COVID-19), 2020. Available at: https://www.who.int/publications-detail/report-o
f-the-who-china-joint-mission-on-coronavirus-disease-2019-(covid-19) (Accessed on April
09, 2020).
7. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case
Surveillance - United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep
2020; 69:759.
8. Ohannessian R. Telemedicine: Potential applications in epidemic situations. Eur Res
Telemed 2015; 4:95.
9. Pritchett JC, Borah BJ, Desai AP, et al. Association of a Remote Patient Monitoring (RPM)
Program With Reduced Hospitalizations in Cancer Patients With COVID-19. JCO Oncol
Pract 2021; :OP2100307.
10. Annis T, Pleasants S, Hultman G, et al. Rapid implementation of a COVID-19 remote

patient monitoring program. J Am Med Inform Assoc 2020; 27:1326.
11. Medina M, Babiuch C, Card M, et al. Home monitoring for COVID-19. Cleve Clin J Med
2020.
12. Xu H, Huang S, Qiu C, et al. Monitoring and Management of Home-Quarantined Patients
With COVID-19 Using a WeChat-Based Telemedicine System: Retrospective Cohort
Study. J Med Internet Res 2020; 22:e19514.
13. Agarwal P, Mukerji G, Laur C, et al. Adoption, feasibility and safety of a family medicine-
led remote monitoring program for patients with COVID-19: a descriptive study. CMAJ
Open 2021; 9:E324.
14. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/n
otification-enforcement-discretion-telehealth/index.html (Accessed on April 27, 2020).
15. Sitammagari K, Murphy S, Kowalkowski M, et al. Insights From Rapid Deployment of a
"Virtual Hospital" as Standard Care During the COVID-19 Pandemic. Ann Intern Med
2021; 174:192.

16. Chou SH, McWilliams A, Murphy S, et al. Factors Associated With Risk for Care Escalation
Among Patients With COVID-19 Receiving Home-Based Hospital Care. Ann Intern Med
2021.
17. Amrane S, Tissot-Dupont H, Doudier B, et al. Rapid viral diagnosis and ambulatory
management of suspected COVID-19 cases presenting at the infectious diseases referral
hospital in Marseille, France, - January 31st to March 1st, 2020: A respiratory virus
snapshot. Travel Med Infect Dis 2020; 36:101632.
18. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ
2020; 368:m998.
19. Turer RW, Jones I, Rosenbloom ST, et al. Electronic personal protective equipment: A
strategy to protect emergency department providers in the age of COVID-19. J Am Med
Inform Assoc 2020; 27:967.
20. Judson TJ, Odisho AY, Neinstein AB, et al. Rapid design and implementation of an
integrated patient self-triage and self-scheduling tool for COVID-19. J Am Med Inform
Assoc 2020; 27:860.
21. Mehring WM, Poksay A, Kriege J, et al. Initial Experience with a COVID-19 Web-Based
Patient Self-assessment Tool. J Gen Intern Med 2020; 35:2821.
22. https://www.cdc.gov/coronavirus/2019-ncov/hcp/phone-guide/index.html (Accessed on

July 02, 2020).
23. Crane SJ, Ganesh R, Post JA, Jacobson NA. Telemedicine Consultations and Follow-up of
Patients With COVID-19. Mayo Clin Proc 2020; 95:S33.
24. Cohen PA, Hall LE, John JN, Rapoport AB. The Early Natural History of SARS-CoV-2
Infection: Clinical Observations From an Urban, Ambulatory COVID-19 Clinic. Mayo Clin
Proc 2020; 95:1124.
25. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html (Accessed on April
28, 2020).
26. Menni C, Valdes AM, Freidin MB, et al. Real-time tracking of self-reported symptoms to
predict potential COVID-19. Nat Med 2020; 26:1037.
27. Agyeman AA, Chin KL, Landersdorfer CB, et al. Smell and Taste Dysfunction in Patients
With COVID-19: A Systematic Review and Meta-analysis. Mayo Clin Proc 2020; 95:1621.
28. Saniasiaya J, Islam MA, Abdullah B. Prevalence of Olfactory Dysfunction in Coronavirus

Disease 2019 (COVID-19): A Meta-analysis of 27,492 Patients. Laryngoscope 2021;
131:865.
29. Eliezer M, Hautefort C, Hamel AL, et al. Sudden and Complete Olfactory Loss of Function
as a Possible Symptom of COVID-19. JAMA Otolaryngol Head Neck Surg 2020; 146:674.

30. Tong JY, Wong A, Zhu D, et al. The Prevalence of Olfactory and Gustatory Dysfunction in
COVID-19 Patients: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg
2020; 163:3.
31. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical
Specimens. JAMA 2020; 323:1843.
32. Liu Y, Yan LM, Wan L, et al. Viral dynamics in mild and severe cases of COVID-19. Lancet
Infect Dis 2020; 20:656.
33. Evidence used to update the list of underlying medical conditions that increase a perso
n’s risk of severe illness from COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/hc
p/clinical-care/underlying-evidence-table.html (Accessed on April 02, 2021).
34. Underlying Medical Conditions Associated with High Risk for Severe COVID-19: Informat
ion for Healthcare Providers https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-ca
re/underlyingconditions.html (Accessed on April 02, 2021).
35. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): Grou
ps at higher risk for severe illness. Available at: https://www.cdc.gov/coronavirus/2019-n
cov/need-extra-precautions/groups-at-higher-risk.html (Accessed on April 09, 2020).
36. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients
hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14
states, March 1-30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69.
37. https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Trac
ker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n#/views/NYS%2dCOVID10%2
dTracker/NYSDOHCOVID%2d19Tracker%2dFatalities%3aembed%3dyes%2653Atoolbar%
3dno%2653Atabs%3dn (Accessed on April 10, 2020).
38. Lighter J, Phillips M, Hochman S, et al. Obesity in Patients Younger Than 60 Years Is a
Risk Factor for COVID-19 Hospital Admission. Clin Infect Dis 2020; 71:896.
39. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities,
and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City
Area. JAMA 2020; 323:2052.
40. Docherty AB, Harrison EM, Green CA, et al. Features of 20 133 UK patients in hospital
with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective
observational cohort study. BMJ 2020; 369:m1985.
41. Nakeshbandi M, Maini R, Daniel P, et al. The impact of obesity on COVID-19
complications: a retrospective cohort study. Int J Obes (Lond) 2020; 44:1832.
42. Rosenthal N, Cao Z, Gundrum J, et al. Risk Factors Associated With In-Hospital Mortality
in a US National Sample of Patients With COVID-19. JAMA Netw Open 2020; 3:e2029058.
43. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related
death using OpenSAFELY. Nature 2020; 584:430.
44. https://www.chicago.gov/content/dam/city/sites/covid/reports/2020-04-09/Chicago%20
COVID-19%20Update%20V2%204.9.2020.pdf (Accessed on April 10, 2020).
45. Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities In Outcomes Among COVID-19 Patients
In A Large Health Care System In California. Health Aff (Millwood) 2020; 39:1253.
46. Belanger MJ, Hill MA, Angelidi AM, et al. Covid-19 and Disparities in Nutrition and
Obesity. N Engl J Med 2020; 383:e69.
47. Smati H, Cohen PA, Nagda DV, et al. Risk Factors for Hospitalization Among Patients
with COVID-19 at a Community Ambulatory Clinic in Massachusetts During the Initial
Pandemic Surge. J Immigr Minor Health 2021.
48. Fisman DN, Bogoch I, Lapointe-Shaw L, et al. Risk Factors Associated With Mortality
Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care
Facilities in Ontario, Canada. JAMA Netw Open 2020; 3:e2015957.
49. https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg (Accessed on

October 20, 2020).
50. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. N Engl J Med 2020;

382:1663.
51. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China.
Pediatrics 2020; 145.
52. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children - United States,
February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:422.
53. Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children
during COVID-19 pandemic. Lancet 2020; 395:1607.
54. https://emergency.cdc.gov/han/2020/han00432.asp (Accessed on May 21, 2020).

55. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-risk-assessment-pa
ediatric-inflammatory-multisystem-syndrome-15-May-2020.pdf (Accessed on May 21, 20
20).
56. https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndr
ome-in-children-and-adolescents-with-covid-19 (Accessed on May 21, 2020).
57. Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at
the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet
2020; 395:1771.
58. Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory
Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United
States, March-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1450.
59. Yang X, Yu Y, Xu J, at al.. Clinical course and outcomes of critically ill patients with SARS-
CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational

study. Lancet 2020.

60. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019
Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020; 323:1061.
61. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-
CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational
study. Lancet Respir Med 2020; 8:475.
62. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients
with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054.
63. Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients
With COVID-19 in Washington State. JAMA 2020; 323:1612.
64. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China.
N Engl J Med 2020; 382:1708.
65. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel
coronavirus in Wuhan, China. Lancet 2020; 395:497.
66. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2020;
368:m1182.
67. Berezin L, Zhabokritsky A, Andany N, et al. Diagnostic accuracy of subjective dyspnoea
in detecting hypoxaemia among outpatients with COVID-19: a retrospective cohort
study. BMJ Open 2021; 11:e046282.
68. Khan M, Pretty C, Amies A, et al. Analysing the effects of cold, normal, and warm digits
on transmittance pulse oximetry. Biomedical Signal Processing and Control 2016; 26:34.
69. https://www.fda.gov/medical-devices/safety-communications/pulse-oximeter-accuracy-
and-limitations-fda-safety-communication (Accessed on February 24, 2021).
70. Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial Bias in Pulse Oximetry Measurement.
N Engl J Med 2020; 383:2477.
71. Modi A, Kiroukas R, Scott JB. Accuracy of smartphone pulse oximeters in patients visiting
an outpatient pulmonary function lab for a 6-minute walk test. Respir Care 2019; 64.
72. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html (Accessed o
n April 07, 2020).
73. https://www.covid19treatmentguidelines.nih.gov/ (Accessed on November 17, 2020).

74. Liang W, Liang H, Ou L, et al. Development and Validation of a Clinical Risk Score to
Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19. JAMA
Intern Med 2020; 180:1081.
75. Shah S, Majmudar K, Stein A, et al. Novel Use of Home Pulse Oximetry Monitoring in
COVID-19 Patients Discharged From the Emergency Department Identifies Need for
Hospitalization. Acad Emerg Med 2020; 27:681.

76. Park PG, Kim CH, Heo Y, et al. Out-of-Hospital Cohort Treatment of Coronavirus Disease
2019 Patients with Mild Symptoms in Korea: an Experience from a Single Community
Treatment Center. J Korean Med Sci 2020; 35:e140.
77. Kang E, Lee SY, Jung H, et al. Operating Protocols of a Community Treatment Center for
Isolation of Patients with Coronavirus Disease, South Korea. Emerg Infect Dis 2020;
26:2329.
78. Lee YH, Hong CM, Kim DH, et al. Clinical Course of Asymptomatic and Mildly
Symptomatic Patients with Coronavirus Disease Admitted to Community Treatment
Centers, South Korea. Emerg Infect Dis 2020; 26:2346.
79. Choi WS, Kim HS, Kim B, et al. Community Treatment Centers for Isolation of
Asymptomatic and Mildly Symptomatic Patients with Coronavirus Disease, South Korea.
Emerg Infect Dis 2020; 26:2338.
80. Chia ML, Him Chau DH, Lim KS, et al. Managing COVID-19 in a Novel, Rapidly Deployable
Community Isolation Quarantine Facility. Ann Intern Med 2021; 174:247.
81. World Health Organization. Home care for patients with suspected novel coronavirus (n
CoV) infection presenting with mild symptoms and management of contacts. Updated F
ebruary 4, 2020. https://www.who.int/publications-detail/home-care-for-patients-with-s
uspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-mana
gement-of-contacts (Accessed on February 14, 2020).
82. Centers for Disease Control and Prevention. Interim Guidance for Implementing Home
Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (2019-nCoV). U
pdated Janury 31, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hom
e-care.html (Accessed on February 04, 2020).
83. Centers for Disease Control and Prevention. Interim guidance for persons who may hav
e 2019 Novel Coronavirus (2019-nCoV) to prevent spread in homes and residential com
munities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.ht
ml#First_heading (Accessed on February 06, 2020).
84. National Institute for Health and Care Excellence (NICE) in collaboration with NHS
England and NHS Improvement. Managing COVID-19 symptoms (including at the end of
life) in the community: summary of NICE guidelines. BMJ 2020; 369:m1461.
85. University of California, San Francisco. UCSF Health COVID-19 ambulatory adult remote t
riage. Available at: https://infectioncontrol.ucsfmedicalcenter.org/sites/g/files/tkssra468
1/f/Algorithm%20for%20Ambulatory%20Remote%20Triage%20for%20Patients%20wit
h%20Respiratory%20Illness.pdf (Accessed on April 10, 2020).
86. Chen P, Nirula A, Heller B, et al. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in
Outpatients with Covid-19. N Engl J Med 2021; 384:229.

87. REGEN-COV Antibody Cocktail Clinical Outcomes Study in Covid-19 Outpatients https://w
ww.medrxiv.org/content/10.1101/2021.05.19.21257469v1.full.pdf (Accessed on May 23,
2021).
88. FACT SHEET FOR HEALTHCARE PROVIDERS
EMERGENCY USE AUTHORIZATION (EUA) OF
SOTROVIMAB https://www.fda.gov/media/149534/download (Accessed on May 28, 202
1).
89. COVID-19 Treatment Guidelines
Anti-SARS-CoV-2 Antibody Products https://www.covid1
9treatmentguidelines.nih.gov/anti-sars-cov-2-antibody-products/ (Accessed on May 26,
2021).
90. https://www.idsociety.org/covid-19-real-time-learning-network/therapeutics-and-interve
ntions/monoclonal-antibodies/ (Accessed on May 26, 2021).
91. https://www.covid19treatmentguidelines.nih.gov/anti-sars-cov-2-antibody-products/anti
-sars-cov-2-monoclonal-antibodies/ (Accessed on May 27, 2021).
92. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.htm
l?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-pr
oduct%2Fclinical-considerations.html (Accessed on May 27, 2021).
93. https://www.biorxiv.org/content/10.1101/2021.02.02.428884v1 (Accessed on February 2
4, 2021).
94. Starr TN, Greaney AJ, Addetia A, et al. Prospective mapping of viral mutations that
escape antibodies used to treat COVID-19. Science 2021; 371:850.
95. The COVID-19 Treatment Guidelines Panel’s Statement on the Emergency Use Authoriza
tion of Anti-SARS-CoV-2 Monoclonal Antibodies for the Treatment of COVID-19 https://w
ww.covid19treatmentguidelines.nih.gov/statement-on-anti-sars-cov-2-monoclonal-antib
odies-eua/?utm_campaign=+46919681&utm_content=&utm_medium=email&utm_sourc
e=govdelivery&utm_term= (Accessed on April 12, 2021).
96. Pause in distribution of bamlanivimab-etesevimab https://www.phe.gov/emergency/eve
nts/COVID19/investigation-MCM/Bamlanivimab-etesevimab/Pages/bamlanivimab-etese
vimab-distribution-pause.aspx.
97. CDC COVID data tracker https://covid.cdc.gov/covid-data-tracker/?CDC_AA_refVal=http
s%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fvariant-
proportions.html#variant-proportions (Accessed on June 28, 2021).
98. Variant Proportions in the U.S. https://www.cdc.gov/coronavirus/2019-ncov/cases-updat
es/variant-proportions.html (Accessed on March 25, 2021).
99. US COVID-19 Cases Caused by Variants https://www.cdc.gov/coronavirus/2019-ncov/tra
nsmission/variant-cases.html (Accessed on April 12, 2021).
100. FACT SHEET FOR HEALTH CARE PROVIDERS
BAMLANIVIMAB AND ETESEVIMAB https://www.fda.gov/media/145802/download (Acces
sed on May 20, 2021).

REGEN-COVTM (casirivimab with imdevimab) https://www.fda.gov/media/145611/downl
oad (Accessed on May 20, 2021).
102. Weinreich DM, Sivapalasingam S, Norton T, et al. REGN-COV2, a Neutralizing Antibody
Cocktail, in Outpatients with Covid-19. N Engl J Med 2021; 384:238.
REGEN-COVTM https://www.fda.gov/media/145611/download (Accessed on June 04, 202
1).
104. Dougan M, Nirula A, Azizad M, et al. Bamlanivimab plus Etesevimab in Mild or Moderate
Covid-19. N Engl J Med 2021.
105. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-f
da-authorizes-monoclonal-antibodies-treatment-covid-19-0?utm_medium=email&utm_s
ource=govdelivery (Accessed on February 10, 2021).
106. https://www.ema.europa.eu/en/news/ema-issues-advice-use-regdanvimab-treating-covi
d-19 (Accessed on April 01, 2021).
107. https://www.ema.europa.eu/en/documents/referral/celltrion-use-regdanvimab-treatme
nt-covid-19-article-53-procedure-conditions-use-conditions_en.pdf (Accessed on April 0
1, 2021).
108. US Food and Drug Administration. FDA cautions against use of hydroxychloroquine or c
hloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of he
art rhythm problems. Available at: https://www.fda.gov/drugs/drug-safety-and-availabili
ty/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospit
al-setting-or (Accessed on April 24, 2020).
109. Lenze EJ, Mattar C, Zorumski CF, et al. Fluvoxamine vs Placebo and Clinical Deterioration
in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA 2020;
324:2292.
110. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-f
da-reiterates-importance-close-patient-supervision-label-use (Accessed on April 27, 202
0).
111. https://www.covid19treatmentguidelines.nih.gov/antiviral-therapy/ (Accessed on Novem
ber 30, 2020).
112. https://www.nih.gov/news-events/news-releases/nih-halts-trial-covid-19-convalescent-pl
asma-emergency-department-patients-mild-symptoms (Accessed on March 03, 2021).
113. Libster R, Pérez Marc G, Wappner D, et al. Early High-Titer Plasma Therapy to Prevent
Severe Covid-19 in Older Adults. N Engl J Med 2021; 384:610.

114. https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/ (Accessed

on January 26, 2021).
115. RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in Hospitalized
Patients with Covid-19. N Engl J Med 2021; 384:693.
116. Therapeutic Management of Nonhospitalized Adults With COVID-19 https://www.covid1
9treatmentguidelines.nih.gov/management/clinical-management/nonhospitalized-adul
ts--therapeutic-management/ (Accessed on July 23, 2021).
117. Tardif JC, Bouabdallaoui N, L'Allier PL, et al. Colchicine for community-treated patients
with COVID-19 (COLCORONA): a phase 3, randomised, double-blinded, adaptive,
placebo-controlled, multicentre trial. Lancet Respir Med 2021.
118. Chaccour C, Hammann F, Ramón-García S, Rabinovich NR. Ivermectin and COVID-19:
Keeping Rigor in Times of Urgency. Am J Trop Med Hyg 2020; 102:1156.
119. https://www.covid19treatmentguidelines.nih.gov/statement-on-ivermectin/.
120. López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of
Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA 2021;
325:1426.
121. Ramakrishnan S, Nicolau DV, Langford B, Mahdi M. Inhaled budesonide in the treatment
of early COVID-19(STOIC): a phase 2, open-label, randomised controlled trial. Lancet
Respir Med 2021; 9.
122. Seftel D, Boulware DR. Prospective Cohort of Fluvoxamine for Early Treatment of
Coronavirus Disease 19. Open Forum Infect Dis 2021; 8:ofab050.
123. Mitjà O, Corbacho-Monné M, Ubals M, et al. Hydroxychloroquine for Early Treatment of
Adults with Mild Covid-19: A Randomized-Controlled Trial. Clin Infect Dis 2020.
124. Skipper CP, Pastick KA, Engen NW, et al. Hydroxychloroquine in Nonhospitalized Adults
With Early COVID-19 : A Randomized Trial. Ann Intern Med 2020; 173:623.
125. PRINCIPLE Trial Collaborative Group. Azithromycin for community treatment of
suspected COVID-19 in people at increased risk of an adverse clinical course in the UK
(PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021;
397:1063.
126. Reis G, Moreira Silva EADS, Medeiros Silva DC, et al. Effect of Early Treatment With
Hydroxychloroquine or Lopinavir and Ritonavir on Risk of Hospitalization Among
Patients With COVID-19: The TOGETHER Randomized Clinical Trial. JAMA Netw Open
2021; 4:e216468.
127. Schwartz I, Boesen ME, Cerchiaro G, et al. Assessing the efficacy and safety of
hydroxychloroquine as outpatient treatment of COVID-19: a randomized controlled trial.
CMAJ Open 2021; 9:E693.

128. Oldenburg CE, Pinsky BA, Brogdon J, Chen C. Effect of Oral Azithromycin vs Placebo on
COVID-19 Symptoms in Outpatients With SARS-CoV-2 Infection A Randomized Clinical
Trial. Jama Network Open 2021.
129. https://files.covid19treatmentguidelines.nih.gov/guidelines/covid19treatmentguideline
s.pdf (Accessed on August 11, 2020).
130. Jothimani D, Kailasam E, Danielraj S, et al. COVID-19: Poor outcomes in patients with zinc
deficiency. Int J Infect Dis 2020; 100:343.
131. Im JH, Je YS, Baek J, et al. Nutritional status of patients with COVID-19. Int J Infect Dis
2020; 100:390.
132. Yasui Y, Yasui H, Suzuki K, et al. Analysis of the predictive factors for a critical illness of
COVID-19 during treatment － relationship between serum zinc level and critical illness
of COVID-19. Int J Infect Dis 2020; 100:230.
133. Adams KK, Baker WL, Sobieraj DM. Myth Busters: Dietary Supplements and COVID-19.
Ann Pharmacother 2020; 54:820.
134. Thomas S, Patel D, Bittel B, et al. Effect of High-Dose Zinc and Ascorbic Acid
Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory
Patients With SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial. JAMA
Netw Open 2021; 4:e210369.
135. Feld JJ, Kandel C, Biondi MJ, et al. Peginterferon lambda for the treatment of outpatients
with COVID-19: a phase 2, placebo-controlled randomised trial. Lancet Respir Med 2021;
9:498.
136. Gonzalez-Ochoa AJ, Raffetto JD, Hernández AG, et al. Sulodexide in the Treatment of
Patients with Early Stages of COVID-19: A Randomized Controlled Trial. Thromb
Haemost 2021; 121:944.
137. https://www.covid19treatmentguidelines.nih.gov/antithrombotic-therapy/ (Accessed on
February 24, 2021).
138. Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in
the Emergency Department: A Single ED's Experience During the COVID-19 Pandemic.
Acad Emerg Med 2020; 27:375.
139. https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covi
d-19-final-report.pdf (Accessed on June 02, 2020).
140. Carfì A, Bernabei R, Landi F, Gemelli Against COVID-19 Post-Acute Care Study Group.
Persistent Symptoms in Patients After Acute COVID-19. JAMA 2020; 324:603.
141. https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm?s_cid=mm6930e1_w#sugg
estedcitation (Accessed on July 27, 2020).

142. SJ Crane, R Ganesh, JA Post, NA Jacobson. Telemedicine Consultations and Follow-up of

Patients With COVID-19. Mayo Clin Proc 2020; 95:S33.
143. Banerjee J, Canamar CP, Voyageur C, et al. Mortality and Readmission Rates Among
Patients With COVID-19 After Discharge From Acute Care Setting With Supplemental
Oxygen. JAMA Netw Open 2021; 4:e213990.
144. Gordon WJ, Henderson D, DeSharone A, et al. Remote Patient Monitoring Program for
Hospital Discharged COVID-19 Patients. Appl Clin Inform 2020; 11:792.
Topic 127759 Version 85.0

GRAPHICS
Comorbidities the CDC classifies as risk factors for severe COVID-19* [1,2]
1. Established and probable risk factors (comorbidities that have been associated with severe COVID-19 in at least 1 meta-
analysis or systematic review [starred conditions], or in observational studies)
Cancer*
Cerebrovascular disease*
Children with certain underlying conditions ¶
Chronic kidney disease*
COPD* and other lung disease (including interstitial lung disease, pulmonary fibrosis, pulmonary hypertension)
Diabetes mellitus, type 1* and type 2*
Down syndrome
Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)*
HIV
Neurologic conditions, including dementia
Obesity* (BMI ≥30 kg/m 2) and overweight (BMI 25 to 29 kg/m 2)
Pregnancy*
Smoking* (current and former)
Sickle cell disease
Solid organ or blood stem cell transplantation
Substance use disorders
Use of corticosteroids or other immunosuppressive medications
2. Possible risk factors (supported by mostly case series, case reports, or, if other study design, the sample size is small)
Cystic fibrosis
Thalassemia
3. Possible risk factors but evidence is mixed (comorbidities have been associated with severe COVID-19 in at least 1 meta-
analysis or systematic review, but other studies had reached different conclusions)
Asthma
Hypertension
Immune deficiencies
Liver disease
COVID-19: coronavirus disease 2019; CDC: Centers for Disease Control and Prevention; COPD: chronic obstructive pulmonary
disease; BMI: body mass index.
* These comorbidities are associated with severe COVID-19 in adults of all ages. Risk of severe disease also rises steadily with age,
with more than 80% of deaths occurring in adults older than age 65. People of color are also at increased risk of severe disease and
death, often at a younger age, due to systemic health and social inequities.
¶ Underlying medical conditions are also associated with severe illness in children, but evidence implicating specific conditions is
limited. Children with the following conditions might be at increased risk for severe illness: medical complexity; genetic, neurologic,
or metabolic conditions; congenital heart disease; obesity; diabetes; asthma or other chronic lung disease; sickle cell disease;
immunosuppression.
References:
1. Centers for Disease Control and Prevention. Underlying medical conditions associated with high risk for severe COVID-19:
Information for healthcare providers. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-
care/underlyingconditions.html (Accessed on April 5, 2021).
2. Centers for Disease Control and Prevention. Science brief: Evidence used to update the list of underlying medical conditions that
increase a person's risk of severe illness from COVID-19. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-
care/underlying-evidence-table.html (Accessed on April 5, 2021).
Graphic 127477 Version 8.0

Symptoms associated with coronavirus disease 2019 (COVID-19) [1]
Symptoms that may be seen in patients with COVID-19
Cough
Fever
Myalgias
Headache
Dyspnea (new or worsening over baseline)
Sore throat
Diarrhea
Nausea/vomiting
Anosmia or other smell abnormalities
Ageusia or other taste abnormalities
Rhinorrhea and/or nasal congestion
Chills/rigors
Fatigue
Confusion
Chest pain or pressure
Most patients with confirmed COVID-19 have fever and/or symptoms of acute respiratory illness. However, various other
symptoms have been associated with COVID-19; this list is not inclusive of all reported symptoms. These symptoms are also
not specific for COVID-19, and the predictive value of a single symptom in the diagnosis of COVID-19 is uncertain.
COVID-19: coronavirus disease 2019.
Reference:
1. Centers for Disease Control and Prevention. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus
Disease (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.

Suggested priorities for SARS-CoV-2 (COVID-19) testing
Priority IDSA guidance [1]
First/High priority Critically ill patients receiving ICU-level care with unexplained viral pneumonia or
respiratory failure (regardless of travel or exposure history)
Any individual (including health care workers) with fever or features of a lower respiratory
tract illness and close contact with patients with laboratory-confirmed COVID-19 within 14
days of symptom onset (including all residents of long-term care facilities with a
confirmed case)
Individuals with fever or features of a lower respiratory tract illness who are also
immunosuppressed (including patients with HIV), older, or have underlying chronic health
conditions
Individuals with fever or features of a lower respiratory tract illness who are critical to the
pandemic response, including health care workers, public health officials, and other
essential leaders
Second/Priority Non-ICU hospitalized patients and long-term care residents with unexplained fever and
features of a lower respiratory tract illness* ¶
Third Outpatients who meet criteria for influenza testing (eg, symptoms such as fever, cough,
and other suggestive respiratory symptoms plus comorbid conditions, such as diabetes
mellitus, chronic obstructive pulmonary disease, congestive heart failure, age >50 years,
immunocompromising conditions); testing of outpatient pregnant women and
symptomatic children with similar risk factors is also included in this priority level*
Fourth Community surveillance as directed by public health and/or infectious diseases

authorities
These testing priorities refer to testing with RT-PCR (or antigen testing, if available).
SARS-CoV-2: severe acute respiratory syndrome coronavirus 2;

COVID-19: coronavirus disease 2019;
IDSA: Infectious Diseases
Society of America;
ICU: intensive care unit;
RT-PCR: reverse transcription polymerase chain reaction.

* The number of confirmed COVID-19 cases in the community should be considered.

¶ As testing becomes more widely available, routine testing of hospitalized patients may be important for infection prevention and
management at discharge.
References:
1. Infectious Diseases Society of America. COVID-19 Prioritization of Diagnostic Testing. Available at:
http://www.idsociety.org/globalassets/idsa/public-health/covid-19-prioritization-of-dx-testing.pdf (Accessed on March 26, 2020).

Diagnostic tests for COVID-19 [1,2]
Test Primary Specimen Performance

Comments
category clinical use type characteristics
NAATs Diagnosis of Respiratory High analytic sensitivity and Time to perform the test
(including RT- current tract specificity in ideal settings. ranges from 15 minutes to 8
PCR) infection specimens* Clinical performance depends hours. Δ
on the type and quality of the Turnaround time is influenced
specimen and the duration of by the test used and
illness at the time of testing. laboratory workflow.
Reported false-negative rate Some assays allow home
ranges from <5 to 40%, collection of specimens that
depending on the test used. ¶ are mailed in.
Serology Diagnosis of Blood Sensitivity and specificity are Time to perform the test
(antibody prior infection highly variable. ranges from 15 minutes to 2
detection) (or infection of Detectable antibodies hours.
at least 3 to generally take several days to Turnaround time is influenced
4 weeks' weeks to develop; IgG usually by the test used and
duration) develops by 14 days after laboratory workflow.
onset of symptoms. It remains uncertain whether
Cross-reactivity with other a positive antibody test
coronaviruses has been indicates immunity against
reported. future infection.
Individual results should be
interpreted with caution in
settings of low
seroprevalence; serologic tests
that have high specificity still
have a low positive predictive
value.
Antigen tests Diagnosis of Nasopharyngeal Antigen tests are generally Time to perform the test is <1
current or nasal swabs less sensitive than nucleic acid hour.
infection tests.
Sensitivity is highest in
symptomatic individuals
within 5 to 7 days of symptom
onset.
COVID-19: coronavirus disease 2019; NAAT: nucleic acid amplification test; RT-PCR: real-time polymerase chain reaction; IgG:
immunoglobulin G; CDC: United States Centers for Disease Control and Prevention.
* Nasopharyngeal swabs, nasal swabs (from the mid-turbinate area or from both anterior nares), nasal or nasopharyngeal washes,
oropharyngeal swabs, and saliva are recommended by the CDC. The Infectious Diseases Society of America suggests a
nasopharyngeal swab, a mid-turbinate swab, an anterior nasal swab, saliva, or a combined anterior nasal/oropharyngeal swab
rather than an oropharyngeal swab. Nasal swabs can be self-collected by the patient on-site or at home. Mid-turbinate swabs and
saliva can be collected by the patient while supervised. Lower respiratory tract specimens can be collected in hospitalized patients
with suspected lower respiratory tract infection if an upper respiratory tract specimen tests negative.
¶ A single positive test generally confirms the diagnosis. If initial testing is negative and clinical suspicion remains, performing a
second test can enhance diagnostic yield.
Δ Low-complexity rapid tests can be performed at the point of care and provide results in less than 1 hour. Most moderate- to high-
complexity laboratory-based tests result in several hours. However, the time for a clinician or patient to receive a result depends on
how frequently the test is run and other processing factors.
References:
1. Cheng MP, Papenburg J, Desjardins M, et al. Diagnostic Testing for Severe Acute Respiratory Syndrome-Related Coronavirus 2: A
Narrative Review. Ann Intern Med 2020; 172:726.
2. Weissleder R, Lee H, Ko J, Pittet MJ. COVID-19 Diagnostics in Context. Sci Transl Med 2020; 12:eabc1931.

Criteria for use of monoclonal antibodies to treat or prevent SARS-CoV-2*
Older age (≥65 years)
Obesity or being overweight (eg, adults with BMI >25 kg/m 2, or, if age 12 to 17, have BMI ≥85 th percentile for age and sex)
Pregnancy
Chronic kidney disease
Diabetes mellitus
Immunosuppression (immunosuppressive disease or treatment)
Cardiovascular disease (including congenital heart disease) or hypertension
Chronic lung diseases (eg, chronic obstructive pulmonary disease, asthma [moderate to severe], interstitial lung disease,
cystic fibrosis, pulmonary hypertension)
Sickle cell disease
Neurodevelopmental disorders (eg, cerebral palsy) or other medically complex conditions that confer medical complexity (eg,
genetic or metabolic syndromes and severe congenital anomalies)
Dependence on a medical-related technology (eg, tracheostomy, gastrostomy, or positive pressure ventilation [unrelated to
COVID-19])
SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; BMI: body mass index; COVID-19: coronavirus disease 2019.
* In the United States, emergency use authorization (EUA) has been authorized for casirivimab-imdevimab for treatment and
prevention and for sotrovimab for treatment of SARS-CoV-2 in select individuals at high risk of progression to severe COVID-19. The
conditions listed apply to adults and pediatric patients (age 12 to 17 years and weighing at least 40 kg). Other conditions may also
place individual patients at high risk for progression to severe COVID-19, and the use of these agents is not limited to the medical
conditions or factors listed above.
For treatment, monoclonal antibodies are only authorized for non-hospitalized patients with mild to moderate illness (eg, not
requiring supplemental oxygen or, if on chronic supplemental oxygen, without an increased oxygen requirement). These agents
must be administered as soon as possible, within 72 hours of a positive SARS-CoV-2 test and 7 days of symptom onset. Earlier
administration is likely associated with greater efficacy.
For prophylaxis, casiriviamb-imdevimab is authorized for individuals with close contact or at high risk of exposure in an institutional
setting who have not been fully vaccinated or who are expected to have inadequate response to vaccination.
Adapted from:
1. US Food and Drug Administration. Fact sheet for health care providers: Emergency use authorization (EUA) of REGEN-COV
(casirivimab with imdevimab). Available at: https://www.fda.gov/media/145611/download (Accessed on May 25, 2021).
2. US Food and Drug Administration. Fact sheet for health care providers: Emergency use authorization (EUA) of sotrovimab. Available
at https://www.fda.gov/media/149534/download (Accessed on June 7, 2021).

SARS-CoV-2 Variants of Concern
Spike protein
substitutions
Name
(receptor-
WHO Name
First
(Pango binding Known attributes
label [1] (Nextstrain*) detected
lineage*) domain
substitutions
in bold)
Alpha B.1.1.7 ¶ 20I/501Y.V1 Δ69/70 United ~50% increased transmission [2]

Δ144Y Kingdom Potential increased severity based
on hospitalizations and case fatality
(E484K ◊)
rates [3]
(S494P ◊)
Minimal impact on neutralization by
N501Y monoclonal antibody therapies §
A570D Bamlanivimab-etesevimab: No
change in susceptibility [4]
D614G
Casirivimab-imdevimab: No
P681H
Sotrovimab: No change in
susceptibility [6]
Minimal impact on neutralization by
convalescent and post-vaccination
sera [7-13]
Beta B.1.351 20H/501.V2 K417N South Africa ~50% increased transmission [14]
E484K Significant impact on neutralization
by some monoclonal antibody
N501Y
therapies §
D614G
Bamlanivimab-etesevimab:
Unlikely to be active (>45-fold
decrease in susceptibility) [4]
susceptibility [6]
Moderate reduction in neutralization
by convalescent and post-
vaccination sera
Gamma P.1 20J/501Y.V3 K417N/T Japan/Brazil Significant impact on neutralization

E484K by some monoclonal antibody
therapies §
N501Y
D614G Unlikely to be active (>511-fold
susceptibility [6]
Reduced neutralization by
convalescent and post-vaccination
sera [15]
Delta B.1.617.2 ¥ 20A T19R India Increased transmissibility compared

(G142D ) ◊ with B.1.1.7 (Alpha) [16]
Potential increased severity based
Δ156
on associated hospitalization
Δ157 rate [16,17]
R158G

L452R Potential minimal reduction in

T478K neutralization by monoclonal
antibody therapies ‡
D614G
Potential modest/moderate
P681R reduction in vaccine effectiveness
D950N against symptomatic COVID-19
without significant impact on vaccine
effectiveness against severe
disease [17-20]
Epsilon B.1.427 and 20C/S:452R L452R US- ~20% increased transmissibility [21]
B.1.429 † D614G California Significant impact on neutralization
by some monoclonal antibody
S13I (B.1.429
therapies §
only)
W152C (B.1.429
Unlikely to be active (7.4-fold
only)
susceptibility [6]
Moderate reduction in neutralization
by convalescent and post-
vaccination sera [21]
"Variants of Concern" have evidence of an increase in transmissibility, greater risk of severe disease, a significant reduction
in neutralization by antibodies generated during previous infection or vaccination, or reduced effectiveness of treatments
or vaccines. These variants share one specific mutation called D614G. This mutation was one of the first documented in the
United States in the initial stages of the pandemic, after having initially circulated in Europe. There is evidence that variants
with this mutation spread more quickly than viruses without this mutation. In the United States, the proportion of
circulating variants in each state can be found on the CDC website.
EUA: emergency use authorization; BEI resources: Biodefense and Emerging Infections Research resources; NIAID: National
Institute of Allergy and Infectious Diseases; CDC: United States Centers for Disease Control and Prevention.
* Pango lineage (or Pangolin) and Nextstrain are resources that compile reported SARS-CoV-2 genome sequences and assign them
to a most likely phylogenetic lineage. Each tool uses its own nomenclature.
¶ As of April 2021, the B.1.1.7 variant is the most common lineage circulating in the United States.
◊ Detected in some sequences but not all.
§ These estimates were established by manufacturers' assessments of neutralizing activity against pseudoviruses bearing the key
spike protein mutations found in each variant. Key mutations in B.1.526/20C, a Variant of Interest (distinct from a Variant of
Concern) that was first identified in New York and contains the E484K mutation, was also assessed for susceptibility to monoclonal
antibody therapy and showed a 17-fold reduction in susceptibility to bamlanivimab-etesevimab and no change in susceptibility to
casirivimab-imdevimab and sotrovimab. [4-6]
¥ This lineage has been designated a Variant of Concern by the World Health Organization and a Variant of Interest by the CDC in
the United States.
‡ B.1.617.2 does not contain mutations associated with reduced susceptibility to bamlanivimab-etesevimab, casirivimab-imdevimab,
or sotrovimab. [5,6,17]
† These lineages have been designated Variants of Concern by the CDC in the United States and Variants of Interest by the World
Health Organization.
References:
1. World Health Organization. Tracking SARS-CoV-2 variants. Available at: https://www.who.int/en/activities/tracking-SARS-CoV-2-
variants/.
2. Davies NG, Abbott S, Barnard RC, et al. Estimated transmissibility and impact of SARS-CoV-2 lineage B.1.1.7 in England. MedRXiv
2021.
3. Horby P, Huntley C, Davies N, et al. NERVTAG note on B.1.1.7 severity. New & Emerging Threats Advisory Group. Available at:
https://depts.washington.edu/pandemicalliance/2021/01/25/nervtag-note-on-b-1-1-7-severity/.
4. US Food and Drug Administration. Fact sheet for health care providers emergency use authorization (EUA) of bamlanivimab and
etesevimab. Available at: https://www.fda.gov/media/145802/download.
5. US Food and Drug Administration. Fact sheet for health care providers emergency use authorization (EUA) of REGEN-COV
(casirivimab with imdevimab). Available at: https://www.fda.gov/media/145611/download.
6. US Food and Drug Administration. Fact sheet for health care providers emergency use authorization (EUA) of sotrovimab. Available
at: https://www.fda.gov/media/149534/download.
7. Wang P, Nair MS, Liu L, et al. Antibody Resistance of SARS-CoV-2 Variants B.1.351 and B.1.1.7. BioXRiv 2021.

8. Shen X, Tang H, McDanal C, et al. SARS-CoV-2 variant B.1.1.7 is susceptible to neutralizing antibodies elicited by ancestral Spike
vaccines. BioRxiv 2021.
9. Edara VV, Floyd K, Lai L, et al. Infection and mRNA-1273 vaccine antibodies neutralize SARS-CoV-2 UK variant. MedRxiv 2021.
10. Collier DA, DeMarco A, Ferreira I, et al. SARS-CoV-2 B.1.1.7 sensitivity to mRNA vaccine-elicited, convalescent and monoclonal
antibodies. MedRxiv 2021.
11. Wu K, Werner AP, Moliva JI, et al. mRNA-1273 vaccine induces neutralizing antibodies against spike mutants from global SARS-CoV-2
variants. BioRxiv 2021.
12. Emary KRW, Golubchik T, Aley PK, et al. Efficacy of ChAdOx1 nCoV-19 (AZD1222) Vaccine Against SARS-CoV-2 VOC 202012/01
(B.1.1.7). The Lancet (preprint) 2021.
13. Novavax. Press release: Novavax COVID-19 Vaccine Demonstrates 89.3% Efficacy in UK Phase 3 Trial. Available at:
https://ir.novavax.com/news-releases/news-release-details/novavax-covid-19-vaccine-demonstrates-893-efficacy-uk-phase-3.
14. Pearson CAB, Russell TW, Davies NG, et al. Estimates of severity and transmissibility of novel South Africa SARS-CoV-2 variant
501Y.V2. Available at: https://cmmid.github.io/topics/covid19/reports/sa-novel-
variant/2021_01_11_Transmissibility_and_severity_of_501Y_V2_in_SA.pdf.
15. Wang P, Wang M, Yu J, et al. Increased Resistance of SARS-CoV-2 Variant P.1 to Antibody Neutralization. BioRxiv 2021.
16. Public Health England. SARS-CoV-2 variants of concern and variants under investigation in England. Technical briefing 14. June 3,
2021. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/991343/Variants_of_Concern_V
OC_Technical_Briefing_14.pdf.
17. Sheikh A, McMenamin J, Taylor B, et al. SARS-CoV-2 Delta VOC in Scotland: demographics, risk of hospital admission, and vaccine
effectiveness. Lancet 2021; 397:2461.
18. Lopez Bernal J, Andrews N, Gower C, et al. Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant. N Engl J Med
2021.
19. Public Health England. COVID-19 vaccine surveillance report: Week 29. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1005085/Vaccine_surveillance_r
eport_-_week_29.pdf
20. Nasreen S, He S, Chung H, et al. Effectiveness of COVID-19 vaccines against variants of concern, Canada. MedRxiv 2021.
21. Deng X, Garcia-Knight MA, Khalid MM, et al. Transmission, infectivity, and antibody neutralization of an emerging SARS-CoV-2
variant in California carrying a L452R spike protein mutation. MedRxiv 2021.
Adapted from: Centers for Disease Control and Prevention. SARS-CoV-2 Variant Classifications and Definitions. Available at:
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html#Concern (Accessed on March 31, 2021).

Breathing exercises that may help with dyspnea [1]
Pursed lip breathing exercises:
Sitting upright or slightly reclining, relax your neck and shoulder muscles.
With your mouth closed, inhale through the nose for 2 seconds, as if smelling a flower.
Exhale slowly (for 4 seconds if possible) through pursed lips, as if blowing out birthday candles.
Repeat inhalation and exhalation cycles for 2 minutes, several times a day and when needed.
Deep breathing exercises:
Recline in bed or on a sofa with a pillow under your head and knees. If reclining is not possible, this may be done while
sitting upright.
Place one hand on your belly, the other hand on your chest.
Slowly inhale through your nose; let your lungs fill with air, allowing your belly to rise. (The hand on the belly should
move more than the hand on the chest.)
Breathe out through your nose, and as you exhale, feel your belly lower.
Repeat the inhalation and exhalation cycles for 2 to 5 minutes several times a day and when needed.
Reference:
1. American Lung Association. Breathing exercises. Available at: https://www.lung.org/lung-health-diseases/wellness/breathing-
exercises (Accessed on August 3, 2020).

Contributor Disclosures
Pieter Cohen, MD Nothing to disclose Jessamyn Blau, MD Nothing to disclose Joann G Elmore, MD,
MPH Nothing to disclose Lisa Kunins, MD Nothing to disclose Allyson Bloom, MD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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9/8/2021 COVID-19: Outpatient evaluation and management of acute illness in adults - UpToDate

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COVID-19: Outpatient evaluation and management of

COVID-19 virology, epidemiology, diagnosis, infection control, and prevention:

● (See "COVID-19: Epidemiology, virology, and prevention".)

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● (See "COVID-19: Diagnosis".)

COVID-19 hospital management:

● (See "COVID-19: Management in hospitalized adults".)

System-specific COVID-19 considerations, including manifestations, management, and

Issues related to COVID-19 in specific adult populations:

● (See "COVID-19: Pregnancy issues and antenatal care".)

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● (See "COVID-19: Issues related to end-stage kidney disease".)

Issues related to COVID-19 in the pediatric population:

● (See "COVID-19: Clinical manifestations and diagnosis in children".)

Continuum of care — When possible, we favor managing all patients with suspected or

● Self-assessment tools. (See 'Patient self-assessment tools' below.)

● Initial telephone triage. (See 'Initial telephone triage' below.)

● A separate outpatient respiratory clinic or dedicated space within an ambulatory clinic

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Rationale for outpatient management and remote care — Outpatient management is

Creating a comprehensive, coordinated outpatient care program that incorporates these

Flexibility in approach to care — High-quality data supporting the superiority of any single

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Patient self-assessment tools — Patient education materials, including self-assessment

Laboratory testing for SARS-CoV-2 is reviewed in detail elsewhere. (See "COVID-19:

Risk stratification — Our patient-centered continuum of care management approach is

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● Chronic kidney disease

● Diabetes mellitus, type 1 and type 2

● Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)

● Neurologic conditions, including dementia

● Overweight and obesity (BMI ≥25 kg/m2)

● Sickle cell disease

● Smoking, current and former

● Solid organ or blood stem cell transplantation

● Substance use disorders

● Use of corticosteroids or other immunosuppressive medications

In addition, possible risk factors for severe disease include:

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Assess symptom duration and severity

Time course and development of dyspnea — For any patient with suspected or

It is unclear what percentage of patients with COVID-19 develop dyspnea, as available

Dyspnea assessment — Remote assessment of dyspnea should focus on the patient's

In addition, we ask questions that provide a more objective assessment of changes in

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● “Does walking cause you to feel dizzy?”

We use this assessment to categorize dyspnea by severity:

Oxygenation assessment — If a patient with COVID-19 already has access to a pulse

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Assessment of overall acuity level — In addition to evaluation of respiratory status,

In addition, in accordance with interim CDC guidelines on home management, we assess if

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DETERMINE IF IN-PERSON EVALUATION WARRANTED

● Concerning alterations in mentation (eg, confusion, change in behavior, difficulty in

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Patients appropriate for evaluation in clinic — Patients with one or more of the

● Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94

● Moderate dyspnea in any patient

Clinic evaluation — For patients evaluated in an outpatient clinic (if feasible, a

Home management without in-person evaluation for others — The majority of patients