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Overview

This guideline covers the management of COVID-19 for children, young people, and adults. It brings together NICE’s existing recommendations on managing COVID-19 so that healthcare staff and those planning and delivering services can find and use them more easily. The guideline also includes new recommendations on therapeutics.

This guideline updates and replaces the following NICE COVID-19 rapid guidelines on:

  • critical care in adults (NG159)
  • managing symptoms (including at the end of life) in the community (NG163)
  • managing suspected or confirmed pneumonia in adults in the community (NG165)
  • acute myocardial injury (NG171)
  • antibiotics for pneumonia in adults in hospital (NG173)
  • acute kidney injury in hospital (NG175)
  • reducing the risk of venous thromboembolism in over 16s with COVID-19 (NG186).

While this guideline covers management in all care settings, this Guidelines summary only includes recommendations relevant to primary care settings, and therefore does not include recommendations on in-hospital assessment and management of COVID-19, or palliative care. For recommendations in these areas, refer to the full guideline.

This summary has been abridged for print. View the full summary online at guidelines.co.uk/455939.article

Communication and shared decision making

Assessment in the community 

Identifying severe COVID-19

  • Use the following signs and symptoms to help identify people with COVID-19 with the most severe illness:
    • severe shortness of breath at rest or difficulty breathing
    • reduced oxygen saturation levels measured by pulse oximetry (see the recommendation on pulse oximetry levels that indicate serious illness, below)
    • coughing up blood
    • blue lips or face
    • feeling cold and clammy with pale or mottled skin
    • collapse or fainting (syncope)
    • new confusion
    • becoming difficult to rouse
    • reduced urine output.
  • When pulse oximetry is available in primary and community care settings, to assess the severity of illness and detect early deterioration, use:
    • NHS England’s guide to pulse oximetry in people aged 18 years and over with COVID-19
    • oxygen saturation levels below 91% in room air at rest in children and young people (17 years and under) with COVID-19.
  • Be aware that different pulse oximeters have different specifications, and that some can under- or overestimate readings especially if the saturation level is borderline. Overestimation has been reported in people with dark skin.

For people with severe respiratory symptoms associated with COVID-19 (for example, suspected pneumonia) being managed in the community, see the recommendation on venous thromboembolism in hospital-led acute care in the community, in the Preventing and managing acute complications section of this summary.

Care planning

  • Discuss with people with COVID-19, and their families and carers, the benefits and risks of hospital admission or other acute care delivery services (for example, virtual wards or hospital at home teams).
  • Explain that people with COVID-19 may deteriorate rapidly. Discuss future care preferences at the first assessment to give people who do not have existing advance care plans an opportunity to express their preferences.

For recommendations on assessing patients for COVID-19 that have been admitted to hospital, refer to the full guideline.

Management in the community

Care planning

  • Put treatment escalation plans in place in the community after sensitively discussing treatment expectations and care goals with people with COVID-19, and their families and carers.
  • People with COVID-19 may deteriorate rapidly. If it is agreed that the next step is a move to secondary care, ensure that they and their families understand how to access this with the urgency needed. If the next step is other community-based support (whether virtual wards, hospital at home services or palliative care), ensure that they and their families understand how to access these services, both in and out of hours.

Managing cough 

  • Encourage people with cough to avoid lying on their backs, if possible, because this may make coughing less effective.
  • Be aware that older people or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions are more likely to develop severe pneumonia. This could lead to respiratory failure and death.
  • Use simple measures first, including advising people over 1 year with cough to take honey.
  • The dose is 1 teaspoon of honey.
  • Consider short-term use of codeine linctus, codeine phosphate tablets or morphine sulfate oral solution in people 18 years and over to suppress coughing if it is distressing. Seek specialist advice for people under 18 years.

See the full guideline for practical information on dosages for treatment to manage cough in people aged 18 years and over.

Managing fever

  • Advise people with COVID-19 and fever to drink fluids regularly to avoid dehydration. Support their families and carers to help when appropriate. Communicate that fluid intake needs can be higher than usual because of fever.
  • Advise people to take paracetamol or ibuprofen if they have fever and other symptoms that antipyretics would help treat. Tell them to continue only while both the symptoms of fever and the other symptoms are present.
  • People can take paracetamol or ibuprofen when self-medicating for symptoms of COVID-19, such as fever (see the Central Alerting System: novel coronavirus - anti-inflammatory medication for further details of ibuprofen including dosage).
  • For people 18 years and over, the paracetamol dosage is 1 g orally every 4 to 6 hours (maximum 4 g per day). See the BNF and Medicines and Healthcare products Regulatory Agency advice for appropriate use and dosage in specific adult populations.
  • For children and young people over 1 month and under 18 years, see the dosing information on the pack or the BNF for children.
  • Rectal paracetamol, if available, can be used as an alternative. For rectal dosage information, see the BNF and BNF for children. 

See the full guideline for practical information on dosages for treatment to manage fever in adults, children, and young people.

Managing breathlessness

  • Identify and treat reversible causes of breathlessness, for example, pulmonary oedema, pulmonary embolism, chronic obstructive pulmonary disorder and asthma.
  • For further information on identifying and managing pulmonary embolism, see the NICE guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing.
  • When significant medical pathology has been excluded or further investigation is inappropriate, the following may help to manage breathlessness as part of supportive care:
    • keeping the room cool
    • encouraging relaxation and breathing techniques, and changing body positioning
    • encouraging people who are self-isolating alone to improve air circulation by opening a window or door.
  • If hypoxia is the likely cause of breathlessness:
    • consider a trial of oxygen therapy
    • discuss with the person, their family or carer possible transfer to and evaluation in secondary care.

Managing anxiety, delirium and agitation

  • Assess reversible causes of delirium. See the NICE guideline on delirium: prevention, diagnosis and management.
  • Address reversible causes of anxiety by:
    • exploring the person’s concerns and anxieties
    • explaining to people providing care how they can help.
  • Consider trying a benzodiazepine to manage anxiety or agitation. See the practical info table in the full guideline for treatments for managing anxiety, delirium and agitation in people 18 years and over. Seek specialist advice for people under 18 years.

See the full guideline for practical information for dosages for treatment to manage anxiety, delirium, and agitation in people aged 18 years and over.

Managing medicines

Therapeutics for COVID-19

For recommendations on the hospital use of casirivimab and imdevimab for COVID-19, refer to the full guideline.

Corticosteroids

  • Offer dexamethasone, or either hydrocortisone or prednisolone when dexamethasone cannot be used or is unavailable, to people with COVID-19 who:

    • need supplemental oxygen to meet their prescribed oxygen saturation levels or

    • have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it.

  • Continue corticosteroids for up to 10 days unless there is a clear indication to stop early, which includes discharge from hospital or a hospital-supervised virtual COVID ward.

  • Being on a hospital-supervised virtual COVID ward is not classed as being discharged from hospital.

  • Do not routinely use corticosteroids to treat COVID-19 in people who do not need supplemental oxygen, unless there is another medical indication to do so.

For recommendations on cortocosteroid dosage in adults (including suitable alternatives), pregnancy, and children with a greater than 44-week corrected gestational age, refer to the full guideline. 

Remdesivir

Tocilizumab

  • Offer tocilizumab to adults in hospital with COVID-19 if all the following apply:

    • they are having or have completed a course of corticosteroids such as dexamethasone, unless they cannot have corticosteroids

    • they have not had another interleukin-6 inhibitor during this admission

    • there is no evidence of a bacterial or viral infection (other than SARS-CoV-2) that might be worsened by tocilizumab.

  • And they:

    • need supplemental oxygen and have a C-reactive protein level of 75 mg/litre or more, or

    • are within 48 hours of starting high-flow nasal oxygen, continuous positive airway pressure, non-invasive ventilation or invasive mechanical ventilation.

  • In October 2021, the marketing authorisations for tocilizumab do not cover use in COVID-19. See NICE’s information on prescribing medicines for more about off-label and unlicensed use of medicines.

  • The recommended dosage for tocilizumab is a single dose of 8 mg/kg by intravenous infusion. The total dose should not exceed 800 mg.

  • For tocilizumab use in pregnancy, follow the Royal College of Obstetrics and Gynaecology guidance on coronavirus (COVID-19) infection and pregnancy.

For full details of adverse events and contraindications, see the summaries of product characteristics for tocilizumab.

See NHS England’s Interim Clinical Commissioning Policy on tocilizumab for hospitalised patients with COVID-19 pneumonia (adults) for further information.

Sarilumab

  • Consider sarilumab for COVID-19 in adults in hospital if tocilizumab is unavailable for this condition or cannot be used. Use the same eligibility criteria as those for tocilizumab. That is, if all the following apply:

    • they are having or have completed a course of corticosteroids such as dexamethasone, unless they cannot have corticosteroids

    • they have not had another interleukin-6 inhibitor during this admission

    • there is no evidence of a bacterial or viral infection (other than SARS-CoV-2) that might be worsened by sarilumab.

  • And they: 

    • need supplemental oxygen and have a C-reactive protein level of 75 mg/litre or more, or

    • are within 48 hours of starting high-flow nasal oxygen, continuous positive airway pressure, non-invasive ventilation or invasive mechanical ventilation.

  • In October 2021, the marketing authorisations for sarilumab do not cover use in COVID-19. See NICE’s information on prescribing medicines for more about off-label and unlicensed use of medicines.
  • The recommended dosage for sarilumab is a single dose of 400 mg by intravenous infusion.
  • For sarilumab use in pregnancy, follow the Royal College of Obstetrics and Gynaecology guidance on coronavirus (COVID-19) infection and pregnancy.
  • For full details of adverse events and contraindications, see the summaries of product characteristics.

See NHS England’s Interim Clinical Commissioning Policy on sarilumab for critically ill patients with COVID-19 pneumonia (adults) for further information.

Low molecular weight heparins

For recommendations on the therapeutic use of low molecular weight heparins, see the section on venous thromboembolism (VTE) prophylaxis in the full guideline.

Vitamin D supplementation

For recommendations on vitamin D, see the NICE COVID-19 rapid guideline on vitamin D.

Antibiotics

  • Antibiotics should not be used for preventing or treating COVID-19 unless there is clinical suspicion of additional bacterial co-infection. See the sub-section on suspected or confirmed co-infection in the section, Preventing and managing acute complications.
  • See also the recommendation on azithromycin and doxycycline.

Azithromycin

  • Do not use azithromycin to treat COVID-19.

Budesonide (inhaled)

  • Only use budesonide to treat COVID-19 as part of a clinical trial.
  • People already on budesonide for conditions other than COVID-19 should continue treatment if they test positive for COVID-19.

Colchicine

  • Do not use colchicine to treat COVID-19.

Doxycycline

  • Do not use doxycycline to treat COVID-19 in the community.

Ivermectin

  • Do not use ivermectin to treat COVID-19 except as part of a clinical trial.

Ongoing review of therapeutics for COVID-19

NICE is currently reviewing new and existing therapeutics for treating COVID-19 as part of a living guidelines approach. New and updated recommendations will be published for this guideline as they become available (see Update information | COVID-19 rapid guideline: managing COVID-19 | Guidance | NICE).

For recommendations on preventing and managing acute complications of COVID-19, refer to the full summary at guidelines.co.uk/455939.article

Preventing and managing acute complications

Acute kidney injury (AKI)

  • In people with COVID-19, AKI:
    • may be common, but prevalence is uncertain and depends on clinical setting (the Intensive Care National Audit and Research Centre’s report on COVID-19 in critical care provides information on people in critical care who need renal replacement therapy for AKI)
    • is associated with an increased risk of dying
    • can develop at any time (before, during or after hospital admission)
    • may be caused by volume depletion (hypovolaemia), haemodynamic changes, viral infection leading directly to kidney tubular injury, thrombotic vascular processes, glomerular pathology or rhabdomyolysis
    • may be associated with haematuria, proteinuria and abnormal serum electrolyte levels (both increased and decreased serum sodium and potassium).
  • In people with COVID-19:
    • maintaining optimal fluid status (euvolaemia) is difficult but critical to reducing the incidence of AKI
    • treatments for COVID-19 may increase the risk of AKI
    • treatments for pre-existing conditions may increase the risk of AKI
    • fever and increased respiratory rate increase insensible fluid loss.

Assessing and managing acute kidney injury (AKI)

For information on assessing and managing AKI, see the NICE guideline on acute kidney injury: prevention, detection and management.

Follow up

Acute myocardial injury

For recommendations on diagnosing acute myocardial injury, refer to the full guideline.

Managing myocardial injury

  • For all people with COVID-19 and suspected or confirmed acute myocardial injury:
    • monitor in a setting where cardiac or respiratory deterioration can be rapidly identified
    • do continuous ECG monitoring
    • monitor blood pressure, heart rate and fluid balance.
  • For people with a clear diagnosis of myocardial injury:
    • seek specialist cardiology advice on treatment, further tests and imaging
    • follow local treatment protocols.
  • For people with a high clinical suspicion of myocardial injury, but without a clear diagnosis:
    • repeat high sensitivity troponin (hs-cTnI or hs-cTnT) measurements and ECG monitoring daily, because dynamic change may help to monitor the course of the illness and establish a clear diagnosis
    • seek specialist cardiology advice on further investigations such as transthoracic echocardiography and their frequency.

Venous thromboembolism (VTE) prophylaxis

For in-hospital recommendations, refer to the full guideline.

In hospital-led acute care in the community

  • For people with COVID-19 managed in hospital-led acute care in the community settings:
    • assess the risks of VTE and bleeding
    • consider pharmacological prophylaxis if the risk of VTE outweighs the risk of bleeding.

People with COVID-19 and additional risk factors

Information and support

  • Give people with COVID-19, and their families or carers if appropriate, information about the benefits and risks of VTE prophylaxis.
  • Offer people the opportunity to take part in ongoing clinical trials on COVID-19.

Suspected or confirmed co-infection 

  • Do not offer an antibiotic for preventing or treating pneumonia if SARS-CoV-2, another virus, or a fungal infection is likely to be the cause. 

Antibiotic treatment in the community

  • Do not offer an antibiotic for preventing secondary bacterial pneumonia in people with COVID-19
  • If a person has suspected or confirmed secondary bacterial pneumonia, start antibiotic treatment as soon as possible. Take into account any different methods needed to deliver medicines during the COVID-19 pandemic (see the recommendation on minimising face-to-face contact in communication and shared decision making in the section Communication and shared decision making)
  • For antibiotic choices to treat community-acquired pneumonia caused by a secondary bacterial infection, see the recommendations on choice of antibiotic in the NICE antimicrobial prescribing guideline on community-acquired pneumonia
  • Advise people to seek medical help without delay if their symptoms do not improve as expected, or worsen rapidly or significantly, whether they are taking an antibiotic or not
  • On reassessment, reconsider whether the person has signs and symptoms of more severe illness (see the recommendation on signs and symptoms to help identify people with COVID-19 with the most severe illness in the section Communication and shared decision making) and whether to refer them to hospital, other acute community support services or palliative care services.

For recommendations on antibiotic treatment in hospital; discharge, follow up, and rehabilitation; identifying secondary bacterial pneumonia; and palliative care, refer to the full guideline.

© NICE 2021. COVID-19 rapid guideline: Managing COVID-19. Available from: www.nice.org.uk/guidance/191. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 23 March 2021.

Last updated: 01 December 2021.