SARS-CoV-2: Difference between revisions

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*Coronavirus related to [[SARS-CoV]]
  
*Coronavirus related to [[SARS-CoV]]
 
*Virion consists of:
  
*Virion consists of:
−
**Spike glycoprotein (S)
 +
**Spike glycoprotein (S), which appears to be an important virulence factor
  +
***Vaccines may target either the full protein or only its distal receptor binding domain
 
**Membrane protein (M)
  
**Membrane protein (M)
 
**Nucleocapsid protein (N)
  
**Nucleocapsid protein (N)
Line 12: Line 13:
 
===Epidemiology===
  
===Epidemiology===
   
  +
*Transmitted mostly by respiratory droplets, with some amount transmission via aerosols and little to no transmission via contact
 
*First cases detected Dec 2019 related to likely exposure in wet market in Wuhan, Hubei, China, and declared a pandemic in 2020
  
*First cases detected Dec 2019 related to likely exposure in wet market in Wuhan, Hubei, China, and declared a pandemic in 2020
 
*Secondary household attack rate of 12-17%
  
*Secondary household attack rate of 12-17%
  +
*Possibility of animal reservoirs, including cats (possibly), dogs (unlikely), deer (probably)
  +
**Difficult to prove transmission to humans
  +
**Unlikely to contribute to household transmission, since human-to-human transmission is far more likely
   
 
===Risk Factors for Mortality===
  
===Risk Factors for Mortality===
Line 25: Line 30:
 
==Clinical Manifestations==
  
==Clinical Manifestations==
   
−
*Incubation period [[Usual incubation period::4 to 5 days]] (range [[Incubation period::2 to 11 days]]), possibly as long as 14 days in some cases
 +
*Incubation period [[Usual incubation period::4 to 5 days]] (range [[Incubation period range::2 to 11 days]]), possibly as long as 14 days in some cases
−
*Main presenting symptoms were fever and cough, followed by myalgia, fatigue, headache, dyspnea
 +
*Main presenting symptoms were [[fever]] and [[cough]], followed by [[myalgia]], [[fatigue]], [[headache]], [[dyspnea]]
−
*Other symptoms include dyspnea, rhinorrhea, vomiting, diarrhea, anosmia/hyposmia
 +
*Other symptoms include [[dyspnea]], [[rhinorrhea]], [[vomiting]], [[diarrhea]], [[anosmia]]/[[hyposmia]]
−
*Lymphopenia is common, as is hypoalbuminemia, elevated D-dimer, CRP, LDH, AST/ALT
 +
*[[Lymphopenia]] is common, as is hypoalbuminemia, elevated D-dimer, CRP, LDH, AST/ALT
 
*Viral load detectable before symptom onset and peaks around the time of symptom onset
  
*Viral load detectable before symptom onset and peaks around the time of symptom onset
  +
  +
===Pregnancy===
  +
  +
*Please refer to [https://doi.org/10.1136/bmj.m3320 a living systematic review on the topic]
  +
*Slightly less reported fever and myalgias
  +
*Slightly more ICU admissions and mechanical ventilation
  +
**Risk factors included age, obesity, hypertension, and diabetes
  +
*With regards to the fetus, there were more preterm deliveries (6%) and more needed NICU admission (25%)
  +
  +
===Severity===
  +
  +
*Mild: no oxygen
  +
*Moderate: low-flow supplemental oxygen
  +
*Severe: high-flow supplemental oxygen or non-invasive mechanical ventilation
  +
*Critical: invasive mechanical ventilation
  +
  +
===Bacterial Coinfection===
  +
  +
*True coinfection with bacterial pneumonia is rare, detected in about 5% of patients at presentation, and complicates about 8% of cases as a secondary infection[[CiteRef::lansbury2020co]]
  +
**See https://www.tarrn.org/covid for a living systematic review
  +
*Most commonly [[Mycoplasma pneumonia]], [[Pseudomonas aeruginosa]], and [[Haemophilus influenzae]]
  +
*Also possibly need to consider [[COVID-19-associated pulmonary aspergillosis|Aspergillus fumigatus]] and even [[Pneumocystis jirovecii]]
   
 
===Complications===
  
===Complications===
Line 37: Line 64:
 
**[[AKI]] (40%)
  
**[[AKI]] (40%)
 
**[[Thrombosis]] (10%)
  
**[[Thrombosis]] (10%)
  +
  +
== Investigations ==
  +
  +
* Chest x-ray typically showed diffuse, bilateral mixed interstitial and airspace disease
  +
* CT chest imaging may show:[[CiteRef::simpson2020ra]]
  +
** Typical appearance:, classic for COVID-19
  +
*** Peripheral, bilateral ground-glass opacity with out without consolidation or visible intralobular lines (crazy paving)
  +
*** Multifocal rounded GGO with or without consolidation or crazy paving
  +
*** Reverse halo sign or other findings of organizing pneumonia (later finding)
  +
** Indeterminate appearance:
  +
*** Multifocal, diffuse, perihilar, or unilateral GGO with or without consolidation lacking a specific distribution and are non-rounded or non-peripheral
  +
*** Few very small GGO with a non-rounded and non-peripheral distribution
  +
** Atypical appearance, which suggests unlikely to be COVID-19:
  +
*** Isolated lobar or segmental consolidation without GGO
  +
*** Discrete small nodules (centrilobular, tree-in-bud)
  +
*** Lung cavitation
  +
*** Smooth interlobular septal thickening with pleural effusion
   
 
==Diagnosis==
  
==Diagnosis==
   
  +
*Rapid antigen testing from NP swab
  +
**Sensitivity depends on circulating variant
 
*PCR from NP swab
  
*PCR from NP swab
  +
**Highest sensitivity within 5 days of symptom onset, with decreasing sensitivity as the disease enters the immune-mediated phase
 
**May be positive long after no longer infectious
  
**May be positive long after no longer infectious
  +
*Diagnostic accuracy of PCR by sample site (below) has a lot of heterogeneity among the studies
  +
  +
{| class="wikitable"
  +
!
  +
!Sensitivity
  +
!Specificity
  +
|-
  +
! colspan="3" |Upper Respiratory Samples
  +
|-
  +
|Oral
  +
|56
  +
|99
  +
|-
  +
|Nasal
  +
|76
  +
|100
  +
|-
  +
|NP
  +
|97
  +
|100
  +
|-
  +
|Nasal
  +
|95
  +
|100
  +
|-
  +
|Saliva
  +
|85
  +
|100
  +
|-
  +
|Mid-turbinate
  +
|100
  +
|100
  +
|-
  +
! colspan="3" |Upper Versus Lower Tract
  +
|-
  +
|Upper respiratory tract
  +
|57
  +
|100
  +
|-
  +
|Lower respiratory tract
  +
|81
  +
|100
  +
|-
  +
! colspan="3" |Single Versus Repeat Testing
  +
|-
  +
|Single test
  +
|71
  +
|100
  +
|-
  +
|Repeat testing
  +
|100
  +
|100
  +
|}
  +
  +
*Serology (IgM and IgG)
  +
**Total antibodies have poor sensitivity (51%) in first week, and increases to about 90% by week 3
   
 
==Management==
  
==Management==
   
  +
=== Mild Disease (No Supplemental Oxygen) ===
−
*For patients no requiring supplemental oxygen, the focus is on supportive care
  
−
*For patients requiring supplemental oxygen:
 +
*For patients not requiring supplemental oxygen, the focus is on supportive care
  +
*Patients who are high risk for progression to severe disease may benefit from prophylaxis with either 3 days of [[remdesivir]] or 5 days of [[Paxlovid]]
−
**[[Dexamethasone]] 6 mg PO/IV daily for 10 days, which has a mortality benefit
  
  +
*Risk factors include age, vaccination status, and the following:
−
**[[Remdesivir]] 200 mg PO once on day one followed by 100 mg PO daily for 5-10 days, which has not been shown to have a mortality benefit
  
  +
**[[Obesity]], with BMI ≥30
−
*Avoid [[hydroxychloroquine]]/[[chloroquine]], [[lopinavir-ritonavir]]
  
  +
**[[Diabetes]]
−
*Other investigational therapeutics include [[tocilizumab]]
  
  +
**Heart disease, [[hypertension]], or [[heart failure]]
  +
**Chronic respiratory disease, including [[cystic fibrosis]]
  +
**[[Cerebral palsy]]
  +
**Intellectual disability
  +
**[[Sickle cell disease]]
  +
**[[Chronic kidney disease]] with eGFR ≤60 mL/min
  +
**Liver disease with [[Child-Pugh classification|Child-Pugh]] class B or C
  +
{| class="wikitable"
  +
|+Risk for progression to severe disease
  +
! rowspan="2" |Age (years)
  +
! colspan="3" |Vaccinations
  +
|-
  +
!0 doses
  +
!1 or 2 doses
  +
!3+ doses
  +
|-
  +
|<20
  +
|higher risk if ≥3 risk factors
  +
|standard risk
  +
|standard risk
  +
|-
  +
|20 to 39
  +
|higher risk if ≥3 risk factors
  +
|higher risk if ≥3 risk factors
  +
|standard risk
  +
|-
  +
|40 to 69
  +
|higher risk if ≥1 risk factors
  +
|higher risk if ≥3 risk factors
  +
|standard risk
  +
|-
  +
|≥70
  +
|higher risk
  +
|higher risk if ≥1 risk factors
  +
|higher risk if ≥3 risk factors
  +
|-
  +
|Immunocompromised (regardless of age)
  +
| colspan="3" |higher risk
  +
|-
  +
|pregnancy (regardless of age)
  +
|higher risk
  +
|standard risk
  +
|standard risk
  +
|}
  +
  +
* [[Remdesivir]] 200 mg IV once followed by 100 mg IV daily for 2 more days may be used within 7 days of symptom onset who have at least one risk factor for disease progression (age ≥60 years, obesity, or other medical conditions)[[CiteRef::gottlieb2021ea]]
  +
*[[Paxlovid]] for 5 days may be considered for patients at high risk of progressing to severe disease, within 5 days of symptom onset
  +
**[[Nirmatrelvir-ritonavir]] 300 mg / 100 mg (3 tablets total) twice daily for 5 days
  +
**Needs dose adjustment in renal dysfunction
  +
**Management of drug-drug interactions is available at [https://www.med.umich.edu/asp/pdf/outpatient_guidelines/Paxlovid-DDI.pdf University of Michigan] or [https://www.covid19-druginteractions.org/ University of Liverpool]
  +
**[https://doi.org/10.47326/ocsat.2022.03.58.3.0 Ontario guidelines are available]
  +
*Consider of monoclonal antibodies, depending on the variant
  +
*Can consider [[fluvoxamine]] or inhaled [[budesonide]]
  +
**Evidence for significant benefit is weak
  +
**[[Fluvoxamine]] 100 mg p.o. twice daily for 15 days, started within 7 days of symptom onset
  +
**[[Budesonide]] 800 mcg inhaled twice daily for 14 days
  +
  +
=== Moderate Disease (Low-Flow Supplemental Oxygen) ===
  +
*For patients requiring supplemental oxygen or with oxygen saturation less than 94%:
  +
*[[Dexamethasone]] 6 mg PO/IV daily for 10 days, which has a mortality benefit
  +
*[[Remdesivir]] 200 mg IV once on day one followed by 100 mg PO daily for 5-10 days, which has not been shown to have a mortality benefit
  +
*[[Tocilizumab]] indicated if progressing despite [[dexamethasone]], still requiring oxygen and CRP ≥75 mg/L, per RECOVERY trial
  +
**ARR for 28-day mortality of about 4% in unvaccinated patients
  +
**If tocilizumab is unavailable, then [[baricitinib]] 4 mg p.o. daily for 14 days or until hospital discharge
  +
*Consider monoclonal antibodies, depending on the variant
  +
*Consider therapeutic anticoagulation with [[LMWH]] for 14 days (stopped at discharge or on transfer to ICU)
  +
**May decrease progression to invasive mechanical ventilation
  +
  +
=== Severe or Critical Disease (High-Flow or Mechanical Ventilation) ===
  +
  +
* Patients requiring ventilatory support, including high-flow nasal oxygen, non-invasive ventilation, invasive mechanical ventilation, or ECMO
  +
* [[Dexamethasone]] 6 mg p.o./IV daily for 10 days
  +
** Can consider 12 mg dosing in patients unable to receive IL-6 inhibitors
  +
* [[Tocilizumab]] for patients on [[dexamethasone]]
  +
* Do ''not'' treat with therapeutic anticoagulation, [[remdesivir]], monoclonal antibodies, or [[Paxlovid]]
  +
  +
=== Strongyloidiasis ===
  +
  +
* Patients should be screened per CATMAT guidelines and treated if appropriate
  +
* For steroid exposure, 10 days of dexamethasone +/- tocilizumab is considered substantial risk
  +
* See also [https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2021-47/issue-7-8-july-august-2021/covid-19-treating-strongyloides-ivermectin-patients.html Ivermectin treatment for ''Strongyloides'' infection in patients with COVID-19] from the CCDR
  +
  +
=== Anti-SARS-CoV-2 Monoclonal Antibodies ===
  +
  +
* Effectiveness varies by strain/lineage
  +
* Refer to https://www.covid19treatmentguidelines.nih.gov/tables/variants-and-susceptibility-to-mabs/ for up-to-date table of effectiveness
  +
  +
=== Immunocompromised Patients With Persistent Infection ===
  +
  +
* A few case studies
  +
** [https://doi.org/10.1093/cid/ciac847 10.1093/cid/ciac847]: 60M CLL, got [[Paxlovid]] x5 days; recurred, got [[remdesivir]] x10 days; recurred, got betelovimab; was on concurrent high-dose steroids essentially throughout for organizing pneumonia; finally [[remdesivir]] and [[Paxlovid]] combination to 20 days, with negative NP swab and clinical resolution
  +
** [https://doi.org/10.1093/ofid/ofac382 10.1093/ofid/ofac382]: 44 yo with [[GPA]] and [[hypogammaglobulinemia]] with 5 months of symptomatic infection treated with IVIG, convalescent plasma, and finally [[remdesivir]] to negative NP swab PCR, which took 30 days
  +
** [https://doi.org/10.1093%2Finfdis%2Fjiaa446 10.1093/infdi/jiaa446]: 50M with CLL post-treatment had relapse twice after 10-day courses of [[remdesivir]], finally resolved after infusion of convalescent plasma
  +
** [https://doi.org/10.1136/bcr-2021-244768 10.1136/bcr-2021-244768]: child with [[Primary immunodeficiency|PID]] eventually resolved with multiple courses of [[IVIG]]
  +
** [https://doi.org/10.1093/infdis/jiaa666 10.1093/infdis/jiaa666]: lymphoma with 3 admissions over 4 months, treated with two courses of [[remdesivir]] and convlescent plasma
  +
** [https://doi.org/10.1016/j.ijid.2020.12.050 10.1016/j.ijid.2020.12.050]: follicular lymphoma post treatment with 2 months of COVID, got [[remdesivir]] twice (second time 10 days) as part of trials, as well as IVIG
  +
  +
==Prevention==
  +
  +
===Infection Prevention and Control===
  +
  +
====Healthcare Workers====
  +
  +
*Awaiting results
  +
**If symptomatic, HCWs should be off work
  +
**If asymptomatic, HCWs may return to work while awaiting results, depending on the reason for testing and the staffing needs
  +
*Positive but asymptomatic: in exceptional circumstances, may return to work early
  +
  +
====Clearance====
  +
  +
*Non-test based (preferred)
  +
**Asymptomatic: isolate for 10 days from swab
  +
**Mild to moderate symptoms in immunocompetent person: 10 days from onset of symptoms, as long as afebrile (without antipyretics) and clinically improving
  +
**Severe (i.e. ICU-level care) or immunocompromised: 20 days from onset of symptoms, as long as afebrile (without antipyretics) and clinically improving
  +
***Immunocompromise includes [[chemotherapy]], untreated [[HIV]] with CD4 <200, [[primary immunodeficiency]], [[prednisone]] 20 mg/day for 14 days, and other immunosuppressing medication
  +
*Test based (alternative): 2 negative swabs at least 24 hours apart (if still positive, repeat in 3 to 4 days), as long as afebrile and clinically improving
   
 
==Further Reading==
  
==Further Reading==
   
  +
=== Review Articles ===
 
*Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. ''JAMA''. doi: [https://doi.org/10.1001/jama.2020.12839 10.1001/jama.2020.12839]
  
*Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. ''JAMA''. doi: [https://doi.org/10.1001/jama.2020.12839 10.1001/jama.2020.12839]
  +
−
*[https://www.antimicrobialstewardship.com/covid-19 UHN-MSH Ontario Clinical Practice Guidelines]
  
  +
=== Canadian Guidelines ===
−
*[https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html PHAC Interim guidelines for the clinical management of patients with moderate to severe COVID-19]
  
  +
*AMMI Canada Practice Point: Treatments for adults with COVID-19 in 2021–2022. ''JAMMI''. 2022;7(3):163-169. doi: [https://doi.org/10.3138/jammi-2022-08-08 10.3138/jammi-2022-08-08]
  +
*[https://doi.org/10.47326/ocsat.cpg.2022.11.0 Ontario Science Table Clinical Practice Guideline Summary: Recommended Drugs and Biologics in Adult Patients with COVID-19]
  +
*[http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/treatments BC COVID-19 Therapeutics Committee (CTC) and COVID-19 Therapeutics Review and Advisory Working Group (CTRAWG) Clinical Practice Guidance]
   
 
[[Category:Coronaviridae]]
  
[[Category:Coronaviridae]]

Latest revision as of 15:22, 17 November 2022

Background

Microbiology

  • Coronavirus related to SARS-CoV
  • Virion consists of:
    • Spike glycoprotein (S), which appears to be an important virulence factor
      • Vaccines may target either the full protein or only its distal receptor binding domain
    • Membrane protein (M)
    • Nucleocapsid protein (N)
    • Hemagglutinin esterase (He)
    • Envelope protein (E)

Epidemiology

  • Transmitted mostly by respiratory droplets, with some amount transmission via aerosols and little to no transmission via contact
  • First cases detected Dec 2019 related to likely exposure in wet market in Wuhan, Hubei, China, and declared a pandemic in 2020
  • Secondary household attack rate of 12-17%
  • Possibility of animal reservoirs, including cats (possibly), dogs (unlikely), deer (probably)
    • Difficult to prove transmission to humans
    • Unlikely to contribute to household transmission, since human-to-human transmission is far more likely

Risk Factors for Mortality

Clinical Manifestations

Pregnancy

  • Please refer to a living systematic review on the topic
  • Slightly less reported fever and myalgias
  • Slightly more ICU admissions and mechanical ventilation
    • Risk factors included age, obesity, hypertension, and diabetes
  • With regards to the fetus, there were more preterm deliveries (6%) and more needed NICU admission (25%)

Severity

  • Mild: no oxygen
  • Moderate: low-flow supplemental oxygen
  • Severe: high-flow supplemental oxygen or non-invasive mechanical ventilation
  • Critical: invasive mechanical ventilation

Bacterial Coinfection

Complications

Investigations

  • Chest x-ray typically showed diffuse, bilateral mixed interstitial and airspace disease
  • CT chest imaging may show:2
    • Typical appearance:, classic for COVID-19
      • Peripheral, bilateral ground-glass opacity with out without consolidation or visible intralobular lines (crazy paving)
      • Multifocal rounded GGO with or without consolidation or crazy paving
      • Reverse halo sign or other findings of organizing pneumonia (later finding)
    • Indeterminate appearance:
      • Multifocal, diffuse, perihilar, or unilateral GGO with or without consolidation lacking a specific distribution and are non-rounded or non-peripheral
      • Few very small GGO with a non-rounded and non-peripheral distribution
    • Atypical appearance, which suggests unlikely to be COVID-19:
      • Isolated lobar or segmental consolidation without GGO
      • Discrete small nodules (centrilobular, tree-in-bud)
      • Lung cavitation
      • Smooth interlobular septal thickening with pleural effusion

Diagnosis

  • Rapid antigen testing from NP swab
    • Sensitivity depends on circulating variant
  • PCR from NP swab
    • Highest sensitivity within 5 days of symptom onset, with decreasing sensitivity as the disease enters the immune-mediated phase
    • May be positive long after no longer infectious
  • Diagnostic accuracy of PCR by sample site (below) has a lot of heterogeneity among the studies
Sensitivity Specificity
Upper Respiratory Samples
Oral 56 99
Nasal 76 100
NP 97 100
Nasal 95 100
Saliva 85 100
Mid-turbinate 100 100
Upper Versus Lower Tract
Upper respiratory tract 57 100
Lower respiratory tract 81 100
Single Versus Repeat Testing
Single test 71 100
Repeat testing 100 100
  • Serology (IgM and IgG)
    • Total antibodies have poor sensitivity (51%) in first week, and increases to about 90% by week 3

Management

Mild Disease (No Supplemental Oxygen)

Risk for progression to severe disease
Age (years) Vaccinations
0 doses 1 or 2 doses 3+ doses
<20 higher risk if ≥3 risk factors standard risk standard risk
20 to 39 higher risk if ≥3 risk factors higher risk if ≥3 risk factors standard risk
40 to 69 higher risk if ≥1 risk factors higher risk if ≥3 risk factors standard risk
≥70 higher risk higher risk if ≥1 risk factors higher risk if ≥3 risk factors
Immunocompromised (regardless of age) higher risk
pregnancy (regardless of age) higher risk standard risk standard risk
  • Remdesivir 200 mg IV once followed by 100 mg IV daily for 2 more days may be used within 7 days of symptom onset who have at least one risk factor for disease progression (age ≥60 years, obesity, or other medical conditions)3
  • Paxlovid for 5 days may be considered for patients at high risk of progressing to severe disease, within 5 days of symptom onset
  • Consider of monoclonal antibodies, depending on the variant
  • Can consider fluvoxamine or inhaled budesonide
    • Evidence for significant benefit is weak
    • Fluvoxamine 100 mg p.o. twice daily for 15 days, started within 7 days of symptom onset
    • Budesonide 800 mcg inhaled twice daily for 14 days

Moderate Disease (Low-Flow Supplemental Oxygen)

  • For patients requiring supplemental oxygen or with oxygen saturation less than 94%:
  • Dexamethasone 6 mg PO/IV daily for 10 days, which has a mortality benefit
  • Remdesivir 200 mg IV once on day one followed by 100 mg PO daily for 5-10 days, which has not been shown to have a mortality benefit
  • Tocilizumab indicated if progressing despite dexamethasone, still requiring oxygen and CRP ≥75 mg/L, per RECOVERY trial
    • ARR for 28-day mortality of about 4% in unvaccinated patients
    • If tocilizumab is unavailable, then baricitinib 4 mg p.o. daily for 14 days or until hospital discharge
  • Consider monoclonal antibodies, depending on the variant
  • Consider therapeutic anticoagulation with LMWH for 14 days (stopped at discharge or on transfer to ICU)
    • May decrease progression to invasive mechanical ventilation

Severe or Critical Disease (High-Flow or Mechanical Ventilation)

  • Patients requiring ventilatory support, including high-flow nasal oxygen, non-invasive ventilation, invasive mechanical ventilation, or ECMO
  • Dexamethasone 6 mg p.o./IV daily for 10 days
    • Can consider 12 mg dosing in patients unable to receive IL-6 inhibitors
  • Tocilizumab for patients on dexamethasone
  • Do not treat with therapeutic anticoagulation, remdesivir, monoclonal antibodies, or Paxlovid

Strongyloidiasis

Anti-SARS-CoV-2 Monoclonal Antibodies

Immunocompromised Patients With Persistent Infection

Prevention

Infection Prevention and Control

Healthcare Workers

  • Awaiting results
    • If symptomatic, HCWs should be off work
    • If asymptomatic, HCWs may return to work while awaiting results, depending on the reason for testing and the staffing needs
  • Positive but asymptomatic: in exceptional circumstances, may return to work early

Clearance

  • Non-test based (preferred)
    • Asymptomatic: isolate for 10 days from swab
    • Mild to moderate symptoms in immunocompetent person: 10 days from onset of symptoms, as long as afebrile (without antipyretics) and clinically improving
    • Severe (i.e. ICU-level care) or immunocompromised: 20 days from onset of symptoms, as long as afebrile (without antipyretics) and clinically improving
  • Test based (alternative): 2 negative swabs at least 24 hours apart (if still positive, repeat in 3 to 4 days), as long as afebrile and clinically improving

Further Reading

Review Articles

  • Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. JAMA. doi: 10.1001/jama.2020.12839

Canadian Guidelines

References

  1. ^  Louise Lansbury, Benjamin Lim, Vadsala Baskaran, Wei Shen Lim. Co-infections in people with COVID-19: a systematic review and meta-analysis. Journal of Infection. 2020;81(2):266-275. doi:10.1016/j.jinf.2020.05.046.

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