management of COVID-19 in the community setting

Last edited 11/2021 and last reviewed 01/2022

Summary of NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19

Management in the community

Care planning

• Put treatment escalation plans in place in the community after sensitively discussing treatment expectations and care goals with people with COVID-19, and their families and carers.
• People with COVID-19 may deteriorate rapidly. If it is agreed that the next step is a move to secondary care, ensure that they and their families understand how to access this with the urgency needed. If the next step is other community-based support (whether virtual wards, hospital at home services or palliative care), ensure that they and their families understand how to access these services, both in and out of hours.

Managing cough

• Encourage people with cough to avoid lying on their backs, if possible, because this may make coughing less effective.
• Be aware that older people or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions are more likely to develop severe pneumonia. This could lead to respiratory failure and death.
• Use simple measures first, including advising people over 1 year with cough to take honey.
  • The dose is 1 teaspoon of honey
• Consider short-term use of codeine linctus, codeine phosphate tablets or morphine sulfate oral solution in people 18 years and over to suppress coughing if it is distressing. Seek specialist advice for people under 18 years
  • See practical info for dosages for treatments to manage cough in people 18 years and over below:
    
    
• Treatments for managing cough in people 18 years and over

  Treatment	Dosage
  Initial management: use simple non-drug measures, for example, taking honey	A teaspoon of honey
  First choice, only if cough is distressing: codeine linctus (15 mg/5 ml) or codeine phosphate tablets (15 mg, 30 mg)	15 mg to 30 mg every 4 hours as required, up to 4 doses in 24 hours If necessary, increase dose to a maximum of 30 mg to 60 mg four times a day (maximum 240 mg in 24 hours)
  Second choice, only if cough is distressing: morphine sulfate oral solution (10 mg/5 ml)	2.5 mg to 5 mg when required every 4 hours Increase up to 5 mg to 10 mg every 4 hours as required If the person is already taking regular morphine increase the regular dose by a third

  
  Notes: See the BNF and MHRA advice for appropriate use and dosage in specific populations.
  All doses are for oral administration.
  Consider the addiction potential of codeine linctus, codeine phosphate and morphine sulfate. Issue as an ‘acute’ prescription with a limited supply. Advise the person of the risks of constipation and consider prescribing a regular stimulant laxative.
  Avoid cough suppressants in chronic bronchitis and bronchiectasis because they can cause sputum retention

Antibiotic treatment in the community

• Do not use antibiotics for preventing or treating COVID-19.
• Antibiotics should only be used if there is strong clinical suspicion of additional bacterial infection.
• Antibiotics do not work on viruses, and inappropriate antibiotic use may reduce availability. Also, inappropriate use may lead to Clostridioides difficile infection and antimicrobial resistance, particularly with broad-spectrum antibiotics
• Evidence as of March 2021 suggests that bacterial co-infection occurs in less than about 8% of people with COVID-19, and could be as low as 0.1% in people in hospital with COVID-19. Viral and fungal co-infections occur at lower rates than bacterial co-infections
  • Secondary infection or co-infection (bacterial, viral or fungal) is more likely the longer a person is in hospital and the more they are immunosuppressed (for example, because of certain types of treatment).
  • The type and number of secondary infections or co-infections will vary depending on the season and any restrictions in place (for example, lockdowns)
• If a person has suspected or confirmed secondary bacterial pneumonia, start antibiotic treatment as soon as possible. Take into account any different methods needed to deliver medicines during the COVID-19 pandemic (see the recommendation on minimising face-to-face contact in communication and shared decision making).
• For antibiotic choices to treat community-acquired pneumonia caused by a secondary bacterial infection, see the recommendations on choice of antibiotic in the NICE antimicrobial prescribing guideline on community-acquired pneumonia.
• Advise people to seek medical help without delay if their symptoms do not improve as expected, or worsen rapidly or significantly, whether they are taking an antibiotic or not.
• On reassessment, reconsider whether the person has signs and symptoms of more severe illness (see the recommendation on signs and symptoms to help identify people with COVID-19 with the most severe illness) and whether to refer them to hospital, other acute community support services or palliative care services.

Managing fever

• Advise people with COVID-19 and fever to drink fluids regularly to avoid dehydration. Support their families and carers to help when appropriate. Communicate that fluid intake needs can be higher than usual because of fever.
• Advise people to take paracetamol or ibruprofen if they have fever and other symptoms that antipyretics would help treat. Tell them to continue only while both the symptoms of fever and the other symptoms are present.
• People can take paracetamol or ibuprofen when self-medicating for symptoms of COVID-19, such as fever (see the Central Alerting System: novel coronavirus-anti-inflammatory medications for further details of ibuprofen including dosage)
  • For people 18 years and over, the paracetamol dosage is 1 g orally every 4 to 6 hours (maximum 4 g per day). See the BNF and Medicines and Healthcare products Regulatory Agency advice for appropriate use and dosage in specific adult populations.
  • For children and young people over 1 month and under 18 years, see the dosing information on the pack or the BNF for children.
  • Rectal paracetamol, if available, can be used as an alternative. For rectal dosage information, see the BNF and BNF for children.

Managing breathlessness

• Identify and treat reversible causes of breathlessness*, for example, pulmonary oedema, pulmonary embolism, chronic obstructive pulmonary disorder and asthma
• For further information on identifying and managing pulmonary embolism, see the NICE guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing.
• When significant medical pathology has been excluded or further investigation is inappropriate, the following may help to manage breathlessness as part of supportive care:
  • keeping the room cool
  • encouraging relaxation and breathing techniques, and changing body positioning
  • encouraging people who are self-isolating alone to improve air circulation by opening a window or door
• If hypoxia is the likely cause of breathlessness:
  • consider a trial of oxygen therapy
• discuss with the person, their family or carer possible transfer to and evaluation in secondary care

Breathlessness with or without hypoxia often causes anxiety, which can then increase breathlessness further.

* note that exclusion of some reversible causes of breathlessness e.g. pulmonary embolism, will require secondary care review and the utilisation of investigations not available to primary care

Managing anxiety, delirium and agitation

• Assess reversible causes of delirium. See the NICE guidance on delirium: prevention, diagnosis and management.
• Address reversible causes of anxiety by:
  • exploring the person's concerns and anxieties
  • explaining to people providing care how they can help.
• Consider trying a benzodiazepine to manage anxiety or agitation. See practical info for treatments for managing anxiety, delirium and agitation in people 18 years and over. Seek specialist advice for people under 18 years.

Managing medicines

• When supporting people with symptoms of COVID-19 who are having care in the community delivered by social care, follow the NICE guideline on managing medicines for adults receiving social care in the community. This includes processes for ordering and supplying medicines, and transporting, storing and disposing of medicines.
• When prescribing, handling, administering and disposing of medicines in care homes and hospices follow the NICE guideline on managing medicines in care homes and the UK government COVID-19 standard operating procedure for running a medicines re-use scheme in a care home or hospice setting.

Corticosteroids

Offer dexamethasone, or either hydrocortisone or prednisolone when dexamethasone cannot be used or is unavailable, to people with COVID-19 who:

• need supplemental oxygen to meet their prescribed oxygen saturation levels or
• have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it.

Practical Info - Adult dosage

• Dexamethasone:
  • 6 mg orally once a day for 10 days (three 2 mg tablets or 15 ml of 2 mg/5 ml oral solution) or
  • 6 mg intravenously once a day for 10 days (1.8 ml of 3.3 mg/ml ampoules [5.94 mg])
  • for people able to swallow and in whom there are no significant concerns about enteral absorption, prescribe tablets. Only use intravenous administration when tablets or oral solutions are inappropriate or unavailable
    
    
• Suitable alternatives:
  • Prednisolone: 40 mg orally once a day for 10 days or
  • Hydrocortisone: 50 mg intravenously every 8 hours for 10 days (0.5 ml of 100 mg/ml solution; powder for solution for injection or infusion is also available); this may be continued for up to 28 days for people with septic shock

Continue corticosteroids for up to 10 days unless there is a clear indication to stop early, which includes discharge from hospital or a hospital-supervised virtual COVID ward.

• being on a hospital-supervised virtual COVID ward is not classed as being discharged from hospital
• for full details of adverse events and contraindications, see the summaries of product characteristics
• for children with a greater than 44-week corrected gestational age, follow the risk criteria set out in Royal College of Paediatric and Child Health guidance for assessing children admitted to hospital with COVID-19. For preterm babies with a corrected gestational age of less than 44 weeks, seek specialist advice.

"..the panel acknowledged the lack of evidence outside the hospital setting. They also acknowledged that the supply and use of corticosteroids in other settings is based on clinical experience and knowledge of service delivery. It was the panel's opinion that, when corticosteroids are first started in community settings, GPs are suitably qualified to assess oxygen levels with pulse oximetry and the need for corticosteroids. They agreed that it is realistic that treatment with dexamethasone could be started in the community setting. They also agreed that the class effect of corticosteroids would allow for hydrocortisone or prednisolone as suitable alternatives if dexamethasone cannot be used or is unavailable.."

In hospital-led acute care in the community

• For people with COVID-19 managed in hospital-led acute care in the community settings:
  • assess the risks of VTE and bleeding
  • consider pharmacological prophylaxis if the risk of VTE outweighs the risk of bleeding

For full details then see NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19