COVID-19 Rapid Guideline: Managing COVID-19

Overview

This updated Guidelines summary 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.

Although 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.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Communication and Shared Decision Making

• Explain to people with COVID-19, their families, carers and close contacts that they should follow the UK Heath Security Agency's guidance for people with symptoms of a respiratory infection including COVID-19.
• Give people information in a way that they can use and understand, to help them take part in decisions about their care. Follow relevant national guidance on communication, providing information (including in different formats and languages) and shared decision making, for example, NICE's guideline on shared decision making and NICE's guideline on patient experience in adult NHS services.
• Communicate with people with COVID-19, and their families and carers, and support their mental wellbeing to help alleviate any anxiety and fear they may have. Signpost to charities and support groups (including NHS Volunteer Responders), to NHS every mind matters and to Royal College of Paediatrics and Child Health resources for parents and carers.
• For carers of people with COVID-19 (for example, carers of people with dementia and COVID-19), signpost to relevant support and resources, such as the Alzheimer's Society has information on staying safe from coronavirus and reducing the risk of infection.

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.

    For signs and symptoms to help identify paediatric inflammatory multisystem syndrome (PIMS) temporarily associated with COVID-19 (PIMS-TS), see the guidance on PIMS from the Royal College of Paediatrics and Child Health.

• 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 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 some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. For more information about this, see NHS England's guide on how to look after yourself at home if you have COVID-19 or symptoms of COVID-19.

  For more information on pulse oximetry at home, see NHS England's COVID Oximetry @home service.

• 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

• In the community, consider the risks and benefits of face-to-face and remote care for each person. Where the risks of face-to-face care outweigh the benefits, remote care can be optimised by:
  • offering telephone or video consultations
  • cutting non-essential face-to-face follow up
  • using electronic prescriptions rather than paper
  • using different methods to deliver medicines to people, for example, pharmacy deliveries, postal services and NHS volunteers, or introducing drive-through pick-up points for medicines.
• When possible, discuss the risks, benefits and possible likely outcomes of the treatment options with people with COVID‑19, and their families and carers. Use decision support tools (where available).
• 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
  • 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.
• For guidance on managing acute cough, see the NICE guideline on cough (acute): antimicrobial prescribing.

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.

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.
• Be aware that breathlessness with or without hypoxia often causes anxiety, which can then increase breathlessness further.

Managing Anxiety, Delirium and Agitation

• Assess reversible causes of delirium. See NICE's guideline on delirium: prevention, diagnosis and management in hospital and long-term care.
• Address reversible causes of anxiety by:
  • exploring the person's concerns and anxieties
  • explaining to people providing care how they can help.

Managing Medicines

• When supporting people with symptoms of COVID-19 who are having care in the community delivered by social care, follow the NICE guideline on managing medicines for adults receiving social care in the community. This includes processes for ordering and supplying medicines, and transporting, storing and disposing of medicines.
• When prescribing, handling, administering and disposing of medicines in care homes and hospices follow the NICE guideline on managing medicines in care homes. 

For recommendations on management in hospital, refer to the full guideline.

Therapeutics for COVID-19

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

Antivirals

Nirmatrelvir and Ritonavir

• Nirmatrelvir plus ritonavir is recommended as an option for treating COVID-19 in adults, only if they:
  • do not need supplemental oxygen for COVID-19 and
  • have any of the following:
    • an increased risk for progression to severe COVID-19
    • age 70 years and over
    • a body mass index (BMI) of 35 kg/m² or more
    • diabetes
    • heart failure.

Remdesivir

• Consider a 3-day course of remdesivir for children and young people aged 12 to 17 who weigh at least 40 kg and adults with COVID-19
  who:
  • do not need supplemental oxygen for COVID-19, and
  • are within 7 days of symptom onset, and
  • are thought to be at high risk of progression to severe COVID-19..

    When assessing the person, take into account likely response to any vaccinations against COVID-19 they have already had, any comorbidities or risk factors, and whether their condition is deteriorating. 

Molnupiravir

• Consider a 5-day course of molnupiravir for adults with COVID-19 who:
  • do not need supplemental oxygen for COVID-19, and
  • are within 5 days of symptom onset, and
  • are thought to be at high risk of progression to severe COVID-19.

    When assessing the person, take into account their likely response to any vaccinations already given, any comorbidities or risk factors, and whether their condition is deteriorating.

• Do not offer molnupiravir to children and young people aged under 18, or pregnant women.

Sotrovimab

• Sotrovimab is recommended as an option for treating COVID-19 in adults and young people aged 12 years and over and weighing at least 40 kg, only if:
  • they do not need supplemental oxygen for COVID-19 and
  • they have an increased risk for progression to severe COVID-19, as defined section 5 of NICE's technology appraisal guidance on casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab and
  • nirmatrelvir plus ritonavir is contraindicated or unsuitable. 

    Sotrovimab is only recommended if the company provides it according to the commercial arrangement.

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.

• Do not use corticosteroids to treat COVID-19 in people who do not need supplemental oxygen. (People who need corticosteroids for another medical reason should still have them.)

Antibiotics

• Do not use antibiotics for preventing or treating COVID-19 unless there is clinical suspicion of additional bacterial co-infection. See the section on suspected or confirmed co-infection. See also the recommendations 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 an ongoing clinical trial.

Vitamin D

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

  For existing UK guidance on taking vitamin D to maintain muscle and bone health, see NHS advice on vitamin D.

For recommendations on preventing and managing acute complications, refer to the full guideline.

Identifying and Managing Co-infections 

Managing Viral or Fungal Pneumonia

• 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. Antibiotics do not work on viruses, and inappropriate antibiotic use may reduce availability. Also, inappropriate use may lead to Clostridioides difficile infection and antimicrobial resistance, particularly with broad-spectrum antibiotics. 

For recommendations on identifying other causes of pneumonia, refer to the full guideline.

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 NICE's guideline on pneumonia (community-acquired): antimicrobial prescribing.

• 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, COVID-19-associated pulmonary aspergillosis, follow up and rehabilitation, and palliative care, refer to the full guideline.