Description of condition
COVID‑19 is the syndrome caused by a novel coronavirus, SARS-CoV‑2, which was originally detected late 2019 in Wuhan, Hubei Province, China. SARS-CoV‑2 is primarily transmitted between people through respiratory particles, direct human contact, and contact with contaminated surfaces. A person can be infected when respiratory particles are inhaled, or come into contact with the eyes, nose or mouth.
COVID‑19 is predominantly a respiratory illness with a range of symptoms of varying severity. Common symptoms include fever, a new continuous cough, loss or change in sense of smell or taste, loss of appetite, nausea or vomiting, diarrhoea, shortness of breath, fatigue, muscle aches, headache, sore throat, and nasal congestion or rhinorrhoea. Atypical symptoms such as delirium and reduced mobility may present in elderly and immunocompromised individuals, often without a fever. COVID‑19 infection varies in severity from asymptomatic or mild upper respiratory tract infection in some individuals, to severe pneumonia and critical disease in others. Patients with COVID‑19 may deteriorate rapidly, and life-threatening complications include thromboembolic events, cardiac disease, acute kidney injury, sepsis, septic shock, and acute respiratory and multi-organ failure. Individuals who are older, male, from deprived areas, or from black, Asian and minority ethnic groups are at higher risk of severe disease and death. The risk also increases in pregnancy and in those with obesity, certain underlying co-morbidities, frailty, impaired immunity, or a reduced ability to cough and clear secretions.
After acute infection with COVID‑19, individuals may experience prolonged symptoms that persist for more than 4 weeks (known as 'long COVID'). For guidance on the management of 'long COVID', see NICE, SIGN and the Royal College of General Practitioners (RCGP) COVID‑19 rapid guideline: Managing the long-term effects of COVID‑19 (available at: https://www.nice.org.uk/guidance/ng188).
COVID‑19 vaccination significantly reduces the risk of infection, hospitalisation, and death. However, fully vaccinated individuals can still become infected with SARS-CoV‑2 and transmit the infection to other individuals. For information on vaccination against COVID‑19, see COVID-19 vaccines.
Management
COVID‑19 is a notifiable disease in the UK. For further information, see Notifiable diseases in Antibacterials, principles of therapy.
For guidance on infection prevention and control, and sampling and diagnostics, see the UKHSA collection: Coronavirus (COVID‑19): guidance (available at: https://www.gov.uk/government/collections/coronavirus-covid-19-list-of-guidance).
For guidance on the management of COVID‑19, see NICE rapid guideline: Managing COVID‑19 (see Useful resources).
Drug treatment
Individuals with COVID‑19 have an increased risk of venous thromboembolism (VTE). For guidance on the prophylaxis and management of VTE, see NICE rapid guideline: Managing COVID‑19 (see Useful resources) and SIGN rapid guideline: Prevention and management of venous thromboembolism in patients with COVID‑19 (available at: https://www.sign.ac.uk/our-guidelines/prevention-and-management-of-venous-thromboembolism-in-covid-19/).
Dexamethasone should be offered to patients with COVID‑19 who need supplemental oxygen, or who have a level of hypoxia that requires supplemental oxygen but are unable to have or tolerate it. If dexamethasone is unsuitable or unavailable, either hydrocortisone or prednisolone can be used.
Other treatment options for patients hospitalised due to COVID‑19, or for symptomatic patients who are at high risk of progression to severe disease, include antivirals (such as remdesivir, molnupiravir, or nirmatrelvir with ritonavir); SARS-CoV‑2 neutralising monoclonal antibodies (such as sotrovimab); interleukin‑6 inhibitors (such as tocilizumab); or a Janus kinase inhibitor (such as baricitinib [unlicensed use]). For further guidance on drug treatments for COVID‑19, see NICE rapid guideline: Managing COVID‑19 (see Useful resources).
Antibacterials are not recommended for preventing or treating pneumonia if it is likely to be caused by SARS-CoV‑2, another virus, or a fungal infection. Empirical antibacterials should be started if a secondary bacterial infection is suspected in patients with COVID‑19. For guidance on the management of suspected or confirmed bacterial pneumonia, see Respiratory system infections, antibacterial therapy.
Antifungals should only be offered for treatment of COVID-19-associated pulmonary aspergillosis (CAPA) if diagnosis is confirmed, or CAPA is suspected and a multidisciplinary team or local protocols support starting treatment.
For guidance on the management of COVID‑19 infection in pregnancy, including therapies that should be offered to pregnant or postpartum females with COVID‑19, see Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Paediatrics and Child Health, PHE and Public Health Scotland guidance: Coronavirus (COVID-19) infection in pregnancy (available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/). Exposure to COVID-19 antivirals in pregnant females should be reported to the UK COVID-19 antivirals in pregnancy registry. For further information, see https://www.medicinesinpregnancy.org/COVID-19-Antivirals-Pregnancy-Registry/.
For information on the fetal and neonatal risks of exposure to COVID‑19 treatments, see UK Teratology Information Service (UKTIS): Medications used to treat COVID‑19 in pregnancy (available at: https://www.medicinesinpregnancy.org/bumps/monographs/MEDICATIONS-USED-TO-TREAT-COVID-19-IN-PREGNANCY/).
For breastfeeding advice on drugs that may be used for COVID‑19, see UK Drugs in Lactation Advisory Service (UKDILAS) guidance on the Specialist Pharmacy Service website (available at: https://www.sps.nhs.uk/articles/breastfeeding-with-covid-19-infection/).
Management of COVID‑19 symptoms
Patients with a cough should be encouraged to avoid lying on their backs, if possible, because this may make coughing less effective. Cough should be initially managed using simple non-drug measures (such as honey). For cough that is distressing in a patient with COVID‑19, consider short-term use of a cough suppressant (such as codeine phosphate or morphine).
Patients with fever should be advised to drink fluids regularly to avoid dehydration, and to take antipyretics (such as paracetamol or ibuprofen) as appropriate (whilst both fever and other symptoms that antipyretics would help treat are present).
Reversible causes of breathlessness (such as pulmonary oedema, pulmonary embolism, chronic obstructive pulmonary disorder, and asthma) should be identified and treated accordingly. When other significant medical pathology has been excluded or further investigation is inappropriate, non-drug management (such as relaxation and breathing techniques, and changing body positioning) may help to manage breathlessness as part of supportive care. If hypoxia is the likely cause of breathlessness, consider a trial of oxygen therapy if appropriate.
Reversible causes of anxiety should be addressed by discussing the patient's concerns. Consider a trial of a benzodiazepine (such as lorazepam) to manage anxiety or agitation.
Reversible causes of delirium should be assessed—see NICE guideline: Delirium: prevention, diagnosis and management (available at: https://www.nice.org.uk/guidance/cg103).
For further guidance on the management of COVID‑19 symptoms, and for information on end of life care, see NICE rapid guideline: Managing COVID‑19 (see Useful resources).
Useful resources
COVID‑19 rapid guideline: managing COVID‑19. National Institute for Health and Care Excellence. NICE guideline 191. March 2023.
https://www.nice.org.uk/guidance/ng191
- Baricitinib
- Dexamethasone
- Hydrocortisone
- Molnupiravir
- Nirmatrelvir with ritonavir
- Prednisolone
- Remdesivir
- Sotrovimab
- Tocilizumab
Related treatment summaries
- Acute coronary syndromes
- Antibacterials, principles of therapy
- COVID-19 vaccines
- Respiratory system infections, antibacterial therapy
- Venous thromboembolism
