Clinical Guidelines

Therapy

For mechanically ventilated adults with COVID-19

  1. With respiratory failure (without ARDS), we suggest against the routine use of systemic corticosteroids. 
  2. With ARDS, we suggest using systemic corticosteroids, over not using corticosteroids.

    Remark: The majority of our panel support a weak recommendation (i.e. suggestion) to use steroids in the sickest patients with COVID-19 and ARDS. However, because of the very low-quality evidence, some experts on the panel preferred not to issue a recommendation until higher quality direct evidence is available. 

  3. With respiratory failure, we suggest using empiric antimicrobials/antibacterial agents, over no antimicrobials.

    Remark: if the treating team initiates empiric antimicrobials, they should assess for de- escalation daily, and re-evaluate the duration of therapy and spectrum of coverage based on the microbiology results and the patient's clinical status. 


For critically ill adults with COVID-19

  1. For those who develop fever, we suggest using acetaminophen/paracetamol for temperature control, over no treatment. 

  2. We suggest against the routine use of standard intravenous immunoglobulins (IVIG). 

  3. We suggest against the routine use of convalescent plasma. 

  4. We suggest against the routine use of lopinavir/ritonavir. 


Insufficient Evidence 

  1. On the use of other antiviral agents in critically ill adults with COVID-19. 

  2. On the use of recombinant rIFNs, alone or in combination with antivirals, in critically ill adults with COVID-19. 

  3. On the use of chloroquine or hydroxychloroquine in critically ill adults with COVID-19. 

  4. On the use of tocilizumab in critically ill adults with COVID-19. 


From: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Antiviral Recommendations

Executive Summary from a consensus group of 18 infectious diseases physicians and pharmacists (DRAFT, UNDER REVIEW)

There is limited clinical evidence to guide antiviral management for critically ill patients with COVID-19 infection. Using a consensus-based approach, infectious diseases physicians and pharmacists-in consultation with peers, and critical care physicians and pharmacists-make the following recommendations for standardized care:

1 Investigational anti-COVID-19 therapeutics (i.e. antiviral and/or immunomodulatory agents) should be used only in approved, randomized, controlled trials.

2 Tocilizumab should not be offered routinely to critically ill patients infected with COVID-19 outside of approved clinical trials. Tocilizumab may be considered on an individual basis if there is evidence of cytokine storm (e.g. markedly elevated interleukin-6 or ferritin levels), but known serious drug toxicities may outweigh any potential/unknown benefit.

3 Remdesivir should not be offered routinely to critically ill patients infected with COVID-19 outside of approved clinical trials. Remdesivir was available through the Special Access Program via Health Canada in partnership with Gilead Sciences, but is currently unavailable with the following exceptions: pregnant women or children less than 18 years of age with confirmed COVID-19 and severe manifestations of disease.

4 Lopinavir/Ritonavir should not be offered routinely to critically ill patients infected with COVID-19 outside of approved clinical trials.

5 Due to lack of consensus, no recommendations can be made on the use of hydroxychloroquine in critically ill patients infected with COVID-19 outside of approved clinical trials or where other indications would justify its use (e.g. chronic rheumatological conditions).

6 Azithromycin should not be offered routinely to critically ill patients infected with COVID-19 outside of approved clinical trials or where other indications would justify its use (e.g. Legionellapneumonia).

The CCEPP team has worked to have the content of this site informally peer-reviewed. However, it does not constitute official advice or guidance unless otherwise indicated. Please use your own discretion and judgement when applying information from this site to your practice.