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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK
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For the Chapter in the Schwinghammer Handbook, please go to Chapter 37, Coronavirus Disease (COVID-19).
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All information in this chapter is current as of November 15, 2023. The Public Health Emergency for COVID-19 ended on May 11, 2023. While this text should serve as a foundational reference, the National Institutes of Health (NIH) and Infectious Diseases Society of America (IDSA) COVID-19 Treatment Guidelines and the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination site should be referenced electronically for the most current treatment and prevention recommendations.
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KEY CONCEPTS
Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, was a global pandemic from March 2020 through May 2023. The disease was associated with significant morbidity and mortality particularly at the beginning of the pandemic and among patients 65 years of age and older, those with multiple chronic comorbidities, and/or patients of select racial and ethnic backgrounds.
The primary route of transmission of SARS-CoV-2 is direct person-to-person respiratory transmission via infected particles (ie, droplets, aerosols). Risk of transmission is greatest for individuals in close contact for a significant period of time, especially while indoors. Transmission can occur from symptomatic, presymptomatic, or asymptomatic individuals.
COVID-19 disease progression occurs in three phases of increasing severity: (i) early infection, (ii) pulmonary phase, and (iii) hyperinflammation. The majority of patients recover in the early infection phase and experience only mild illness; yet a small proportion may progress to the pulmonary and hyperinflammation phases.
Signs and symptoms typically emerge 3 to 5 days from onset of infection but may occur sooner or take up to 14 days to manifest. Common symptoms include rhinorrhea, headache, sore throat, sneezing, cough, and fever/chills. Current variants have a shorter incubation period and generate more upper respiratory tract symptoms compared to historical variants. Oxygenation status and patient location (hospitalized vs nonhospitalized) are defining characteristics that determine eligibility for specific pharmacotherapy.
Symptomatic COVID-19 is diagnosed by a positive nucleic acid amplification test (NAAT) or antigen test for SARS-CoV-2. Asymptomatic infection is a positive test in the absence of symptoms. Probable COVID-19 can be diagnosed by a compatible syndrome in either the absence of viral testing or a negative test. False negative tests are most common early in infection and with use of antigen tests.
Three vaccines are available in the United States: two using an mRNA technology platform (Pfizer, Moderna), and one using an adjuvanted recombinant spike protein platform (Novovax). Vaccination should be offered to patients in accordance with the latest CDC recommendations.
Monoclonal antibody products were previously available for pre-exposure prophylaxis and treatment of SARS-CoV-2. These agents are no longer available due to their inability to neutralize the most recent circulating variants.
Therapeutic management of mild-to-moderate COVID-19 in high-risk, nonhospitalized adult patients should include symptomatic management and either ritonavir-boosted nirmatrelvir or 3 days of remdesivir. If none of these therapies are available, molnupiravir ...