Guideline for therapeutic management of Hospitalized ADULT patients with confirmed COVID-19

Criteria & Principles

Guidance is intended to provide a framework for therapeutic management of adult patients with confirmed COVID-19. Given the rapid evolution of the pandemic, this is subject to change as new data emerge. Detailed guidance by severity is provided in the attachments.

DUHS supply of COVID-19 therapeutics may be limited. Daily updates are available on this dashboard.

Table 1. Summary of Therapeutic Management of Hospitalized Adults by Severity of Disease (see detailed guideline in attachment section).  Restriction requirements are in Table 2.

All above guidance should take into consideration contraindications of individual patient.  Utilize this link to review drug interactions: http://www.covid19-druginteractions.org/

*Baricitinib in combination with tocilizumab should be avoided

OS=NIH Ordinal Score

When to Consult ID

• ID consultation is recommended for cases in which diagnostic and/or therapeutic management is complex.
• Beginning 1.18.22, transplant ID consultation is also recommended for cases in which diagnostics and/or therapeutic management is complex and is required for inpatients with severe or critical laboratory-confirmed COVID-19 in: Solid organ transplant, Hematopoietic cell transplant, Active hematologic malignancy.
• General ID consultation is required for use of restricted agents, unless there is a protocol exception (new exceptions as stated below 1.18.22)

~ID consultation requirement for use depends on individual, hospital-level approval processes. Review and verification of required documentation by an ID pharmacist may replace full ID consultation at Duke Regional and Duke Raleigh Hospitals.

*Use is expected to be rare

Table 3. Summary of agents for COVID-19 disease

*Please utilize this link to review drug interactions: http://www.covid19-druginteractions.org/

EUA=emergency use authorized by FDA which requires 1) specific clinical use criteria be met, 2) counseling and risk/benefit discussion with the patient/caregiver and provision of the FDA Fact Sheet, and 3) safety event reporting to the FDA.

General Notes

Infection prevention, diagnostic testing, and specimen collection guidance are available on the DUHS COVID-19 page.  See separate guidance for pediatric patients <18 years of age.

• For inpatient clinical trial enrollment, reference the Research Protocol Summary page for inclusion/exclusion and contact the Principle Investigator if patient/caregiver is interested.
• Discussions with patients regarding investigational or off-label treatment should include clear discussion of unknown benefits and known potential harms.
• Approach to treatment should be similar to other respiratory viral illnesses which can have severe manifestations and/or secondary infectious complications.
• Antibiotics for secondary bacterial infections should include agents outlined in Hospital-acquired/Ventilator-acquired Pneumonia or Community Acquired Pneumonia guidance. The principles of antibiotic de-escalation still apply.

References: In attachment (section to the right)

 

General Notes

1. Up-to-date cost information, click here 
2. IV antimicrobials outpatient (OPAT) dosing, click here
3. Obesity dosing weight recommendations here
4. Helpful drug-drug interaction check website here 
5. When dosing guidance is provided it is important to note the following:

Fixed (ie non weight-based) doses in adults are historically based on a 70 kg patient. Specific disease states or individual patients may warrant dosages that differ from the above recommendations. Since product-specific criteria for dose adjustment based on creatinine clearance exist, consult product information regarding specific recommendations for dosage adjustment based on estimated creatinine clearance.