COMMENTARY

Hundreds of COVID Patients: Here's What I've Learned

Charles P. Vega, MD

Disclosures

January 27, 2021

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

I'm Chuck Vega. Welcome, and thank you for joining me today. I will discuss the management of COVID-19 patients in outpatient settings. Inpatient settings have received most of the attention, and rightly so — the sickest patients may have access to more active, promising treatments. But the majority of those with COVID-19 will be managed as outpatients. To date in my practice in Santa Maria, California, I've treated hundreds of patients with COVID-19.

Isolate and Designate

The first step is to think about isolation. Isolation rules are fairly straightforward. The infected person should remain in isolation for 10 days from the onset of symptoms. They can break isolation when their symptoms are improving and they are afebrile for 24 hours.

I've learned a few things along the way. For one, thermometers aren't often used by patients at home, unfortunately. They may be experiencing some minor chills or sweats, but unfortunately, I can't really objectively determine whether patients have fever. Yet I'm holding them back from breaking isolation until they are fully free from symptoms, such as sweats and chills.

Patients really need to understand that symptoms don't have to be resolved within 10 days. Sometimes that happens, but the key is that they need to be improving. Such symptoms as fatigue, cough, and loss of smell and taste usually last longer than 10 days. But as long as they are improving, patients can break isolation after 10 days.

Another thing that I have found helpful in my practice is to designate someone to be the primary caregiver for patients at home with active COVID-19 infection. With the COVID-19 surges that we've experienced, the chances of finding someone to step in and help with necessary household tasks are higher. A person who has already been infected is not likely to become infected again.

Monoclonal Antibodies

Another thing that's very important to consider is the early use of monoclonal antibodies. These are relatively new agents that act against the spike protein that helps SARS-CoV-2 bind to cells. There is an emergency use authorization for two such agents. Monoclonal antibodies can only be used in patients 12 years of age and older who have a condition that places them at high risk for complications of COVID-19.

In the United States, we have to prescribe monoclonal antibodies within 10 days of symptom onset, but in fact we should give them as soon as possible. They will be most effective for patients during the first couple of days rather than waiting 7 or 8 days. I'm not sure that they're going to have as much relative value. Two agents, bamlanivimab and casirivimab plus imdevimab, are infused intravenously over an hour, and we watch the patients for an hour afterwards for potential complications, including anaphylaxis. You have to have a team ready. This is why the use of monoclonal antibodies has been limited; it's just the practicalities of coming in for an IV infusion when you're infected with COVID-19.

Although monoclonal antibodies can be effective therapy for patients with COVID-19 who are at high risk for complications, these agents are not being used in outpatient therapy. I think this is primarily due to logistics. I didn't think I would be using them anytime soon, but last week I prescribed an antibody to somebody with a high-risk condition. And thankfully, she's doing well.

In clinical trials, monoclonal antibodies have reduced hospital admissions and healthcare use overall in the weeks following the infusion. It's not a major impact but it's still an important one for patients at high risk for complications, and the overall side effect rate is similar to that for placebo.

So, we should be using monoclonal antibodies more often. Otherwise, outpatient care is just trying to control symptoms. I recommend acetaminophen or NSAIDs for both their antipyretic and analgesic properties. No evidence yet exists that these drugs can prolong the course of illness or make it worse. But I do recommend avoiding corticosteroids, either oral or inhaled, for patients who don't experience severe asthma exacerbations. The use of corticosteroids could make the illness worse.

Home vs Hospital

Routine antibiotics should be avoided in the absence of a strong suspicion for a secondary bacterial infection. It's hard to give patients a strong warning about pneumonia and what to look for. Among those being managed at home, dyspnea is the symptom that drives most patients to the emergency department (ED). It's great if the patient has a pulse oximeter at home. These devices were very difficult to find for many months but are becoming more available. But just like how many of my patients don't have thermometers, even fewer have pulse oximeters.

I've told patients previously that if you can't climb one flight of stairs without having difficulty breathing, then that's a sign that your dyspnea is getting worse and you might have to go to the ED. However, many patients don't have stairs, and in fact, they aren't very active at all. They are usually isolating in one small part of the house and not moving around much because they are sick. Dyspnea can really creep up, and by the time some patients report dyspnea, it's fairly severe and they are quickly intubated.

I also look for other signs, such as high, unrelenting fever and mental status changes. I advise patients to be aware of those signs and symptoms and go to the ED if these develop. I do like to check in with patients every few days, at least until they are in recovery mode and it's clear that their symptoms are improving. And, of course, I remind my patients that even though they have had COVID, they should still get the COVID vaccine. Typically, they should wait at least a few weeks after the acute illness.

For now, I hope that you found this very brief review of outpatient management, as it currently stands here in mid-January 2021, helpful.

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