What is known about COVID treatment options for mild to moderately ill patients who are being monitored in an outpatient setting?

Summary

The following is a short summary of the best available evidence from trusted sources rated as providing high quality information on treatment options for mild to moderately ill COVID-19 patients who are being monitored in an ambulatory or outpatient setting. One evidence synthesis, three international guidelines, four national guidelines, one professional organization guidance, one review and one single study were used in this REAL Note. For additional information about each of the sources, see the Table below.

The World Health Organization (WHO) , the United Kingdom National Health Service (NHS) and the Royal Australian College of General Practitioners all recommend treating mild COVID-19 similar to the flu where patients should rest, drink plenty of fluids, and ensure adequate nutritional needs are met [4,7,9]. Acetaminophen can be taken to manage a fever, and if the patient is already on ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs), they may continue these medication(s) [7,9]. The NHS suggests in its guidance on How to treat coronavirus symptoms at home  for patients who are feeling breathless to: 1) lie on their side or sit upright rather than on their back and have a teaspoon of honey to manage a cough; 2) keep the room cool; and 3) practise breathing exercises (breath slowly in through your nose and out through your mouth), relax shoulders and lean forward slightly and support yourself with your hands on knees or on a stable object [7]. In its  guidance on Clinical management of COVID-19 , the WHO advises against the use of antibiotics or prophylaxis to treat mild COVID-19 given the potential increase in antibiotic resistance rates, unless a bacterial infection, including pneumonia, is suspected, in which case, antibiotics should be used [4]. The WHO recommends in its Home care for patients with suspected or confirmed COVID-19 and management of their contacts guidance that those with chronic disease (e.g., asthma, diabetes, etc.) should reserve a 6-month supply of necessary medications including inhaled medication, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), if required [3]. However, the Royal Australian College of General Practitioners recommend that nebulizers should be avoided to prevent aerosol spread of the virus [9]. In the United States, the National Institute of Health (NIH) and the Mild of Moderate COVID-19 clinical practice guidance note that anti-SARS-CoV-2 monoclonal antibodies or antivirals may potentially be used to treat mild to moderate illness, but there is no consolidated guideline on these medications and there is insufficient data to recommend or not recommend any specific antiviral or antibody therapy [8,10]. In November 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization for antibody therapy, i.e., bamlanivimab, and casirivimab plus imdevimab to be given to outpatients 12 years old and older who have mild/moderate COVID-19 and at risk for disease progression [8].  
 
The Centers for Disease Control and Prevention (CDC) notes that patients who are at greater risk for severe illness (i.e., older adults, patients with underlying medical conditions) should be monitored closely, especially in the second week after symptom onset where there is a possible risk of severe illness progression [5]. The Government of Canada notes that the following signs and symptoms require urgent clinical re-evaluation include difficult, fast or shallow breathing (for infants: grunting and an inability to breastfeed), blue lips or face, chest pain or pressure, inability to drink or keep down liquids, and extreme weakness [6]. 
 
The WHO notes that telemedicine or community outreach teams should be utilized to assist in monitoring cases remotely [4]. The evidence synthesis on Provider-Led Virtual Care in Ambulatory Care noted that virtual care in ambulatory settings can be effective in: 1) increasing access and equity in care; 2) reducing travel times; 3) increasing quality of care; 4) reducing burden on the health care system; 4) increasing the number of patient consultations; and 5) increasing access to timely supports [1].The WHO, CDC and the Government of Canada stress the importance of monitoring disease progression (e.g., home pulse oximetry devices help identify if outpatients require medical evaluation in a safe and non-invasive manner) [3,5,6]. A study done in New York City, Ambulatory Management of Moderate to High Risk COVID-19 Patients: The Coronavirus Related Outpatient Work Navigators (CROWN) Protocol, demonstrated the feasibility of a home-care based ambulatory protocol to evaluate, monitor, and treat moderate to high risk COVID-19 patients, which resulted in no unexpected hospital admissions or deaths [11]. The protocol includes patient evaluations via telehealth with a pulmonologist and home-care support including a registered nurse (RN) visit, pulse oximetry, lab-work, intravenous fluids and medication if needed, and the collection of patient data, comorbidities and symptoms [11]. 
 
When caring for a COVID-positive individual at home, the WHO advises: 1) housing patients in ventilated rooms with large quantiles of fresh and outdoor air; 2) disposing infectious waste from providing care in a strong bag or box; 3) disinfecting surfaces touched frequently daily using products containing 0.1% sodium hypochlorite; 4) cleaning hands with soap; 5) changing linens frequently; and 6) utilizing necessary personal protective equipment when conducting on-site visits [2,3]. Further, the WHO advises that basic mental health and psychosocial support for all COVID-19 patients should be provided (i.e., by asking patient about addressing their specific needs) [4]. 

Evidence

What‘s Trending on Social Media and Media

A Time article was published on April 9, 2020 that describes a team of Italian doctors treating COVID-19 patients in their homes at the height of the first wave in Italy. Hospitals were overwhelmed by the number of patients admitted and therefore some patients were being sent home if their illness was less severe. The Italian team treated hundreds of patients in their homes.  

Organizational Scan

St. Joseph’s Home Care, in partnership with St. Joseph’s Health System, Niagara Health and community partners in Ontario have created a COVID Care @ Home program that provides access to expanded home and community supports and services, reducing unnecessary Emergency Room visits and providing a contact point for questions, support and care. The program includes virtual care and remote monitoring, 24/7 on-call services, mobile COVID testing and access to specialists as needed.  

The University of Maryland Medical System in the US provides a helpful list of how to treat your COVID-19 symptoms from home. The resource includes various ways to treat a fever, a cough and shortness of breath. For more information, find the resource here.  

Review of Evidence

Resource	Type/Source of Evidence	Last Updated
Provider-Led Virtual Care in Ambulatory Care — Evidence Synthesis Network	Evidence Syntheses	Methods: Evidence Synthesis Briefing Note using high-quality, relevant, and timely synthesized research evidence   Benefits of virtual care in ambulatory settings include increased access and equity in care, reduced travel times, increased quality of care, reduced burden on the health care system, increased patient consultations and increased access to timely supports.   Last Updated: August 27, 2020
Home care for patients with suspected or confirmed COVID-19 and management of their contacts — WHO: World Health Organization	International Guidance	Treat waste from providing care as infectious waste and dispose of it in strong bags or boxes.  Clean and disinfect surfaces that are frequently touched daily (e.g., bedside tables, bedframes, and other bedroom furniture and toilet surfaces).  Use regular soap for cleaning and household containing 0.1% sodium hypochlorite for disinfecting.  Last Updated: August 12, 2020
Home care for patients with suspected or confirmed COVID-19 and management of their contacts — WHO: World Health Organization	International Guidance	Patients with chronic diseases should reserve 6-month supply of drugs in order to limit outdoor travel.   Home pulse oximetry can help identify if patients need additional medical evaluation in a safe, non-invasive way.  Patients should remain in a ventilated room with large quantities of fresh and outdoor air. Last Updated: August 11, 2020
Clinical management of COVID-19 — WHO: World Health Organization	International Guidance	Mild COVID-19: Provide symptomatic treatment such as antipyretics for fever and pain, adequate nutrition and appropriate rehydration.   Antibiotic therapy or prophylaxis are not recommended.  Moderate COVID-19: Monitor for disease progression.   Antibiotics are not recommended unless there is clinical suspicion of bacterial infection. Elderly people in long-term care facilities or children <5 years of age may be considered for empiric antibiotics for possible pneumonia.  Consider telemedicine or community outreach teams to assist monitoring.   Provide basic mental health and psychosocial support for all COVID-19 patients by asking about and addressing their needs.  Last Updated: May 26, 2020
Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) — CDC: Centers for Disease Control and Prevention	National Guidance	An absence of viral pneumonia and hypoxia is considered a mild clinical presentation and can likely be managed at home.  Patients who are at greater risk for severe illness (i.e., older adults, those with underlying medical conditions) should be monitored closely, particularly in the second week after symptom onset.  Last Updated: December 7, 2020
Clinical management of patients with COVID-19: Second interim guidance — The Government of Canada	National Guidance	Monitor for signs that prompt for urgent care. In children, signs may include difficulty, fast or shallow breathing (for infants: grunting and an inability to breastfeed), blue lips or face, chest pain or pressure, inability to drink or keep down liquids, and extreme weakness.   Last Updated: August 16, 2020
How to treat coronavirus symptoms at home — NHS: United Kingdom National Health Services	National Guidance	To treat a high temperature, the following are recommended: resting, drinking lots of fluids, and taking paracetamol or ibuprofen.  For a patient with a cough, it is suggested to lie on their side or sit upright rather than lie on their back.   A teaspoon of honey is also recommended for...   To help with symptoms of breathlessness, it is best to keep the room cool.   Breathing exercises, sitting upright in a chair, relaxing shoulders and leaning forward slightly are also recommended.   Last Updated: November 26, 2020
Therapeutic Management of Patients with COVID-19 — National Institute of Health	National Guidance	Preliminary data suggests that anti-SARS-CoV-2 monoclonal antibodies may be of benefit to outpatients when received early in their infection.   Bamlanivimab and casirivimab plus imdevimab are available through Emergency Use Authorizations for outpatients who are at risk for disease progression. Last Updated: December 2, 2020
Home-care guidelines for adult patients with mild COVID-19 — RACGP: Royal Australian College of General Practitioners	Professional Organization	Manage mild COVID-19 in a similar way to seasonal influenza, (i.e., plenty of rest, drinking fluids and eating well.)  Encourage paracetamol for management of fever, but if patient is taking ibuprofen or NSAIDs, they may continue to do so.  Patients requiring inhaled medication should continue using them but avoid using nebulizers to prevent aerosol spread.  Do not prescribe corticosteroids for patients with suspected COVID-19 unless they are indicated for another reason.  Do not discontinue angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) if the patient requires them.  Last Updated: July 31, 2020
Mild or Moderate COVID-19 — Gandhi et al.	Review	For mild to moderate illness, potential treatments include antibody or antiviral therapy, though dexamethasone and remdesivir are not recommended at this disease severity.  The effect of monoclonal antibodies against the SARS-CoV-2 spike protein is currently being evaluated as treatment for mild to moderate illness.  If a patient with an initially mild case develops new and worsening symptoms, a physical examination, test for other pathogens, and chest imaging if available are recommended.   Last Updated: October 28, 2020
Ambulatory Management of Moderate to High Risk COVID-19 Patients: The Coronavirus Related Outpatient Work Navigators (CROWN) Protocol — Lisker et al.	Single Study	Researchers designed a specialized, multidisciplinary, referral-based protocol for the ambulatory treatment of moderate to high risk COVID-19 patients called the Coronavirus Related Outpatient Care Navigator (CROWN) Program  Many hospitalized patients were treated with therapies that could be administered in a home setting under proper monitoring and as a result, a home-care based ambulatory protocol to evaluate, monitor, and treat moderate to high risk COVID-19 patients was developed with escalation to hospital care if needed.  Patients were evaluated via telehealth with a Pulmonologist and a home-care protocol included an RN visit, pulse oximetry, lab-work, intravenous fluids and medication if needed, and patient data, comorbidities and symptoms were collected.   Last Updated: October 14, 2020
COVID Care @ Home — St. Joseph’s Home Care, St. Joseph’s Health System, Niagara Health	Organizational Scan	Last Updated: January 12, 2021
Treating Coronavirus at Home — The University of Maryland Medical System	Organizational Scan	Last Updated: October 28, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.