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Covid-PSMID
Updates as of June 27, 2023
The Philippine COVID-19 Living Recommendations document is brought to you by the Institute of Clinical Epidemiology, National Institutes of Health, UP Manila in cooperation with the Philippine Society of Microbiology and Infectious Diseases (PSMID). This was funded by the Department of Health (DOH) AHEAD Program through the DOST-Philippine Council for Health Research and Development (PCHRD) and the DOH-Disease Prevention and Control Bureau.
Given the magnitude of the impact of COVID-19 in the country and the current priority given to it by health care providers, public health officials and the government, the need for clinical practice guidelines to optimize health care through effective management and control of the spread of this disease is imperative. Furthermore, an infodemic from the rapid pace of scientific developments on COVID-19 management is running side-by-side with the pandemic. We offer these living recommendations to health care providers to guide their diagnosis and treatment decisions on individual patient care. For policy makers and program managers, these living recommendations can serve to inform policy and provide timely guidance on effective interventions to be prioritized, implemented and made accessible to health care providers and the public.
While there are existing international guidelines and living systematic reviews on COVID-19, there is a need to localize the recommendations from the evidence in our setting by local experts, end-users and other relevant stakeholders. With the rapidly evolving science, the Living CPG development process is used wherein recommendations are switched to a living status based on the likelihood of new evidence and the importance of the recommendation in health care policy decision making. Living systematic reviews will be maintained to provide up-to-date, evidence-based living recommendations on the treatment, diagnosis, prevention and control of COVID-19.
Updated as of 25 January 2023
We recommend the use of dexamethasone for up to 10 days among adult patients with severe and critical COVID-19 (Moderate certainty of evidence, Strong recommendation)
We suggest the use of methylprednisolone 1-2mg/kg/day for 5 to 10 days as an alternative to dexamethasone among adult patients with severe and critical COVID-19 (Very low certainty of evidence, Weak recommendation)
We recommend the use of standard-dose dexamethasone at 6 mg to 12 mg per day among adult patients with severe and critical COVID-19. (Moderate certainty of evidence, Strong recommendation)
We suggest that steroid therapy be initiated as soon as diagnosed or categorized as severe or critical COVID-19. (Very low certainty of evidence, Weak recommendation)
We suggest the use of dexamethasone at 0.15 mg/kg/day or a maximum dose of 6 mg per day for up to 10 days among children with severe and critical COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
Updated as of 20 February 2023
We suggest the use of prophylactic over therapeutic dose anticoagulation among hospitalized adults with moderate, severe or critical COVID-19 disease unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest the use of standard dose prophylactic anticoagulation over intermediate dose prophylactic anticoagulation among hospitalized adults with COVID-19 disease unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest against the routine use of any anticoagulation among adults with mild COVID-19 in the outpatient setting unless there is a pre-existing non-COVID indication for anticoagulation use. (Low certainty of evidence, Weak recommendation)
We suggest the use of oral anticoagulation after hospital discharge among adults admitted for moderate to severe COVID-19 and who are suspected to have a high risk for VTE at-or-near hospital discharge. (Low certainty of evidence, Weak recommendation)
We suggest prophylactic dose anticoagulation among hospitalized pediatric patients more than 12 years of age with moderate to critical COVID-19 or MIS-C, unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest prophylactic anticoagulation among hospitalized pregnant women with moderate to critical COVID-19, unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We recommend against the routine use of antibiotics in patients with severe and critical COVID-19 infection, unless with suspicion of secondary bacterial co-infection. For patients on empiric antibiotics, they should be assessed daily for the need for discontinuation, continuation or escalation based on clinical and laboratory parameters. (Very low quality of evidence; Strong recommendation)
Updated as of 01 December 2021
There is insufficient evidence to recommend the use of hemoperfusion in patients diagnosed with COVID-19. (Low certainty of evidence)
You can find the Evidence Summary here.
We suggest the use of conservative fluid management rather than liberal fluid management strategy in mechanically ventilated adult COVID-19 patients with acute respiratory distress syndrome who are adequately resuscitated*. (Low quality of evidence; Conditional recommendation)
*without tissue hypoperfusion and fluid responsiveness
Updated as of October 26, 2021
We suggest self-proning position in non-intubated patients with severe and critical COVID-19 (Very low certainty of evidence; Weak recommendation)
There is insufficient evidence to recommend the use of side lying in non-intubated patients with severe to critical COVID-19 (Very low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 01 December 2021
We suggest the use of high flow nasal cannula for patients with severe to critical COVID-19 who do not respond to conventional oxygen therapy (low flow nasal cannula/face mask) (Low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
We suggest the use of a lung protective ventilation strategy (tidal volume 4-8 mL/kg predicted body weight and plateau pressure less than 30 cmH2O in patients with COVID-19 infection and ARDS. (Very low quality of evidence; Conditional recommendation)
There is insufficient evidence to recommend the use of a higher PEEP strategy. We suggest to individualize PEEP or employ a PEEP strategy based on respiratory mechanics (i.e., compliance) in patients with COVID-19 infection. (Low quality of evidence; Conditional recommendation)
There is insufficient evidence to recommend a driving pressure limited strategy in patients with COVID-19 infection. We suggest to keep the driving pressure ≤ 14 cmH2O. (Low quality of evidence; Conditional recommendation)
We suggest the use of rapid sequence intubation for COVID-19 patients to reduce infection among healthcare workers performing the procedure. (Very low quality of evidence; Conditional recommendation)
Updated as of 03 Jan 2022
We suggest the use of ECMO for judiciously selected COVID-19 patients with severe Acute Respiratory Distress Syndrome (ARDS) based on the Extracorporeal Life Support Organization (ELSO) criteria (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 01 December 2021
At present, we suggest against the use of hyperbaric oxygen therapy for the management of COVID-19 patients due to insufficient evidence. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We recommend against the use of etoposide among patients with COVID-19 pneumonia in cytokine storm (Very low quality of evidence; Strong recommendation)
We recommend individualized pulmonary rehabilitation with pre intervention medical clearance for long COVID patients who show residual respiratory symptoms (Moderate quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of October 26, 2021
We recommend against the use of nitric oxide among patients with COVID-19. (Low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of October 26, 2021
There is insufficient evidence to recommend the use of pirfenidone or nintedanib among patients with post-COVID-19 pulmonary fibrosis (Very low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 03 January 2022
We suggest light over deep sedation in COVID-19 patients who are mechanically ventilated and who are anxious or agitated. (Very low certainty of evidence, Weak recommendation)
We suggest against routine use of NMB in mechanically ventilated COVID-19 ARDS patients. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 03 January 2022
We suggest the use of either high flow nasal cannula or non-invasive positive pressure ventilation in COVID-19 patients with hypoxemic respiratory failure, in the absence of any indication for emergent invasive mechanical ventilation. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Click on the sections below to see the recommendations.
Updated as of 22 May 2023
We recommend the use of a 7-day symptom based* test, instead of 14 days, to assess for possible COVID-19 infection among adults and children.** (Very low certainty of evidence, Strong recommendation)
*Symptoms listed in the WHO Case Definition: acute onset of fever and cough (ILI) OR acute onset of ANY THREE or MORE of the following signs or symptoms: fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dypsnea, nausea/diarrhea, anorexia
**Please refer to previous recommendations on testing using RT-PCR and Rapid Antigen Tests
You can find the Evidence Summary here.
Updated as of 22 November 2021
We suggest pulse oximetry with close clinical monitoring by qualified medical personnel in suspected and confirmed COVID-19 patients especially those who are at high risk for deterioration. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
We recommend the use of the following specimens as alternative specimens to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19 among symptomatic and asymptomatic patients suspected of COVID-19 in hospital and outpatient settings:
We suggest the use of saliva swab and posterior oropharyngeal saliva specimens as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19 among symptomatic and asymptomatic patients with suspected COVID-19 in hospital and community/outpatient settings. (Low quality of evidence; Conditional recommendation)
We recommend against the use of sputum as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19. (Very low quality of evidence; Strong recommendation)
There is no evidence to recommend the use of bronchoalveolar lavage as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19.
*SARS COV-2 RT-PCR of nasopharyngeal swabs remains the diagnostic test of choice to confirm the diagnosis of COVID-19 among suspected individuals.
You can find the Evidence Summary on RT-PCR of saliva samples here.
You can find the Evidence Summary on choice of specimens for RT-PCR here.
Updated as of 2 May 2023
Among adults and children suspected to have COVID-19 who are symptomatic, we suggest the use of RAT for the diagnosis of COVID-19 as an alternative to RT-PCR. (Very low certainty of evidence, Weak recommendation)
Among adults and children exposed to COVID-19 who are asymptomatic, we suggest against the use of RAT for the diagnosis of COVID-19. (Very low certainty of evidence, Weak recommendation)
Updated as of 22 November 2021
We suggest against the use of rapid antigen test for screening purposes. (Low certainty of evidence; Weak recommendation)
We suggest against the use of saliva as specimen for rapid antigen test in patients suspected of COVID-19 infection. (Low certainty of evidence; Weak recommendation)
We suggest the use of rapid antigen tests for the diagnosis of individuals suspected of COVID-19 during the setting of an outbreak provided that all the following conditions are met: (Very low certainty of evidence; Weak recommendation)
There is insufficient evidence to recommend for or against the use of repeat antigen testing for screening or diagnosis of COVID-19. (Very low certainty of evidence)
A negative rapid antigen test should be confirmed with an RT-PCR in settings or situations wherein COVID-19 is highly suspected (e.g., symptomatic or asymptomatic close contacts of probable or confirmed COVID-19 individuals).
You can find the Evidence Summaries here:
1. November 22, 2021
2. May 2, 2023.
Updated as of 01 February 2023
We recommend the use of self-administered rapid antigen test for the diagnosis of SARS-Cov-2 in symptomatic individuals provided that ALL OF THE FOLLOWING conditions are met:
(Moderate certainty of evidence, Strong recommendation)
We recommend against the use of self-administered rapid antigen test for the diagnosis of SARS-CoV-2 in asymptomatic individuals. (Moderate certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 02 March 2023
There is insufficient evidence to recommend the use of breath test in detecting COVID-19. (Low certainty of evidence)
You can find the Evidence Summary here.
We suggest the use of pooled RT-PCR testing in targeted* low-risk and low-prevalence populations using a pool size of 5 in individuals suspected of COVID-19 infection. (Moderate quality of evidence; Conditional recommendation)
*Target population refer to the list of PSP and DOH
You can find the Evidence Summary here.
We suggest to repeat RT-PCR testing when the initial RT-PCR test is negative among symptomatic patients with high index of suspicion for COVID-19 infection. (Low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
Updated as of 22 November 2021
There is insufficient evidence to recommend an RT-PCR cycle threshold cut-off value* to determine infectivity among COVID-19 confirmed patients. (Very low certainty of evidence)
*Interpretation of RT-PCR cycle threshold values may vary and is dependent on the PCR assay used, gene target, sample type, and timing of sample collection.
You can find the Evidence Summary here.
Updated as of 22 November 2021
We suggest using antibody tests that accurately measure IgG or total antibodies to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)
We suggest against using antibody tests detecting IgM to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)
We suggest against using lateral flow immunoassay (LFIA) tests to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)
We recommend against routine measurement of SARS-CoV-2 antibody titers after vaccination. (No evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of SARS-CoV-2 Ab testing to diagnose presumptive COVID-19 reinfection among symptomatic patients previously diagnosed with COVID-19* (Very low quality of evidence; Strong recommendation).
*NAAT (RT-PCR) and Genomic sequencing are the recommended diagnostic tests to confirm COVID-19 reinfection.
You can find the Evidence Summary here.
Updated as of 02 May 2023
There is no evidence to recommend for or against antibody testing to diagnose COVID-19 disease among vaccinated patients.
We suggest against the routine measurement of SARS-CoV-2 antibody titers after vaccination. In the rare situations where we need to determine prior COVID-19 disease or infection, with infectious disease specialist consultation, we suggest the use of nucleocapsid antibody testing among vaccinated individuals. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 27 June 2023
Among asymptomatic individuals scheduled for non-emergent/non-urgent surgery, we suggest using clinical risk assessment alone to screen for COVID-19.
Among asymptomatic individuals scheduled for non-emergent/non-urgent surgery who have been diagnosed to have COVID-19 within the last 90 days, we suggest against the use of SARS-CoV-2 RT-PCR.
(Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 27 June 2023
For asymptomatic fully vaccinated adults, or symptomatic fully vaccinated adults with mild COVID19, we suggest the use of the criterion for ending isolation:
For asymptomatic not fully vaccinated adults, or symptomatic not fully vaccinated adults with mild COVID19, we suggest the use of the criterion for ending isolation:
For symptomatic adults with moderate COVID-19 diagnosis and any vaccination status, we suggest the use of the following symptom-based criteria for ending isolation:
For symptomatic fully vaccinated adults with severe-to-critical COVID-19 diagnosis, we suggest the use of the following symptom-based criteria for ending isolation:
For symptomatic not fully vaccinated adults with severe-to-critical COVID-19 diagnosis, we suggest the use of the following symptom-based criteria for ending isolation:
(Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 13 December 2021
Chest X-Ray
We suggest against the use of chest x-ray to diagnose COVID-19 infection among asymptomatic individuals.(Very low certainty of evidence; Weak recommendation)
We suggest chest x-ray to facilitate rapid triage, infection control, and clinical management among any of the following: (Very low certainty of evidence; Weak recommendation)
Lung Ultrasound
We suggest against the use of lung ultrasound alone in diagnosing patients with suspected COVID-19 infection. (Very low certainty of evidence; Weak recommendation)
Chest CT Scan
We suggest against the routine use of CT scan for diagnosing COVID-19 among suspected patients with COVID-19 presenting at the emergency department if RT-PCR testing is readily available with timely results.(Very low certainty of evidence; Weak recommendation)
If RT-PCR is not available, we suggest using non-contrast chest CT scan for symptomatic patients suspected of having COVID-19 to guide early triage and management under the following conditions: (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 17 December 2021
To guide the decision to admit adult patients with COVID-19 to the hospital:
We suggest the use of age, BUN, number of comorbidities, CRP, SpO2/FiO2 ratio, platelet count, Heart rate (ABC2-SPH) risk score, Confusion Urea Respiration Blood Pressure (CURB-65) severity score, Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE-UP) score, and Rapid Emergency Medicine Score (REMS). (Low certainty of evidence; Weak recommendation)
There is insufficient evidence to recommend the use of 4C Mortality Score, COVID Outcome Prediction in the Emergency Department (COPE) model, and Quick Sepsis-related Organ Failure Assessment (qSOFA) score. (Very low certainty of evidence)
To guide in the expectant monitoring of hospitalized adult patients:
We suggest the use of the 4C Deterioration model. (Low certainty of evidence; [Weak] recommendation)
There is insufficient evidence to recommend the use of Modified Early Warning Score (MEWS) and National Early Warning Score 2 (NEWS2), Clinical Frailty Scale (CFS), and the COVID-GRAM model. (Very low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 13 December 2021
There is insufficient evidence to recommend the use of specific cut-off values of CRP, LDH and Ferritin to guide the initiation of immunotherapy in patients with COVID-19 (Very low certainty of evidence)
You can find the Evidence Summary here.
We suggest the use of D-dimer to guide anticoagulation of adult patients with COVID-19, because of its significant association with mortality, thromboembolism, and worsening of disease (Low quality of evidence; Conditional recommendation).
You can find the Evidence Summary here.
Updated as of 13 December 2021
For initiating antibiotic therapy
We suggest against the use of procalcitonin alone as a basis for initiating antibiotic therapy among COVID-19 confirmed patients. (Very low certainty of evidence; Weak recommendation)
For discontinuing antibiotic therapy
If available, we recommend using a procalcitonin level of less than or equal to 0.25 ng/mL for discontinuing antibiotic therapy among COVID-19 confirmed patients. (Very low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
There is insufficient evidence in using symptoms*, biologic factors or severity of acute COVID-19 in predicting the development of long covid symptoms. (Very low certainty of evidence)
*The most common symptoms of long COVID identified were fatigue, dyspnea, sleep disturbance, anxiety or depression, and memory impairment.
You can find the Evidence Summary here.
Updated as of 29 November 2021
We suggest against the use of PF4 antibody ELISA Heparin Induced Thrombocytopenia (HIT) test kits and non-ELISA rapid HIT test kits for COVID-19 Vaccine Induced Thrombosis and Thrombocytopenia (VITT). (Low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 29 November 2021
We suggest against using serum tryptase for patients who had anaphylaxis after receiving COVID-19 vaccine. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of October 28, 2021
| CLASSIFICATION | CRITERIA |
| Mild COVID-19 |
|
| Moderate COVID-19 | a. With pneumonia* BUT no difficulty of breathing or shortness of breath, RR < 30 breaths/min, oxygen saturation# >/= 94% at room air OR b. Without pneumonia but with risk factors for progression: elderly (60 years old and above) and/or with comorbidities |
| Severe COVID-19 |
|
| Critical COVID-19 |
|
*Pneumonia – evidence of lower respiratory disease during clinical assessement (e.g. cough, fever plus crackles) and/or imaging (CXR, ultrasound, CT scan)
#Proper recording of the O2 saturation: finger should be inserted in the oximeter for about 10-20 seconds; patient should be still and not talking.
Consensus Issues
The current COVID-19 Severity Classification is updated for better understanding and applicability. A footnote is added to clearly define pneumonia and how O2 saturation should be properly obtained. Levels of O2 saturation are specified to be in taken in room air and the elderly age group is specified to be 60 years old and above.
We recommend against the use of hydroxychloroquine / chloroquine, with or without azithromycin among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 01 December 2021
We recommend against the use of azithromycin in treatment of COVID-19 regardless of disease severity. (Moderate certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 03 April 2023
We recommend against the use of favipiravir among patients with COVID-19 (Moderate certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 05 December 2022
We suggest the use of remdesivir among hospitalized adult patients with mild to moderate COVID-19 infection with at least 1 risk factor* for progression to severe disease. (Low quality of evidence; Weak recommendation)
*60 years old or older, hypertension, cardiovascular or cerebrovascular disease, diabetes mellitus, obesity (a body-mass index [BMI; the weight in kilograms divided by the square of the height in meters] of ≥30), immune compromise, chronic mild or moderate kidney disease, chronic liver disease, chronic lung disease, current cancer, or sickle cell disease
We recommend the use of remdesivir among non-hospitalized adult patients with mild to moderate COVID-19 infection with at least 1 risk factor* for progression to severe disease. (Moderate quality of evidence; Strong recommendation)
*60 years old or older, hypertension, cardiovascular or cerebrovascular disease, diabetes mellitus, obesity (a body-mass index [BMI; the weight in kilograms divided by the square of the height in meters] of ≥30), immune compromise, chronic mild or moderate kidney disease, chronic liver disease, chronic lung disease, current cancer, or sickle cell disease
We suggest the use of remdesivir in children (hospitalized or ambulatory) with mild to moderate COVID-19 infection with at least 1 risk factor for disease progression. (Very low quality of evidence, Weak recommendation)
We suggest the addition of remdesivir to dexamethasone in adult patients with COVID-19 infection requiring oxygen supplementation but do not require mechanical ventilation*. (Low quality of evidence; Weak recommendation)
*For patients who progress to invasive mechanical ventilation while on remdesivir, the drug can be continued.
We suggest the addition of remdesivir to dexamethasone in children with COVID-19 infection requiring oxygen supplementation but do not require mechanical ventilation. (Very low quality of evidence, Weak recommendation)
We suggest against the use of remdesivir among adult patients with COVID-19 infection who are already on non-invasive or invasive mechanical ventilation. (Low certainty of evidence; Weak recommendation)
We suggest against the use of remdesivir among children with COVID-19 infection who are already on non-invasive or invasive mechanical ventilation. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 25 January 2023
We suggest the use of molnupiravir within 5 days of symptom onset in adult patients with COVID-19 infection who are non-oxygen requiring and with at least one risk factor* for progression. (Very low certainty of evidence, Weak recommendation)
*Risk factors for progression include: age >60 years, active cancer, chronic kidney disease, chronic obstructive pulmonary disease, obesity, serious heart conditions or diabetes mellitus
We suggest against the use of molnupiravir for the treatment of children with COVID-19. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
We suggest against the use of baloxavir as treatment for COVID-19 infection. (Very low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
Updated as of 05 December 2022
We recommend the use of nirmatrelvir+ritonavir among unvaccinated, non-hospitalized symptomatic adult patients with high risk* for progression to severe disease within 5 days from symptom onset. (Moderate certainty of evidence, Strong recommendation)
* Risk factors include any of the following: ≥60 years of age; BMI >25 kg/m2; cigarette smoking; immunosuppressive disease (including HIV infection with CD4 cell count <200mm3 and viral load <400 copies/mL) or prolonged iatrogenic immunosuppression; chronic lung, cardiovascular, kidney, or sickle cell disease; hypertension; diabetes; cancer; neurodevelopmental disorders or other medically complex conditions; or medical-related technological dependence
We suggest the use of nirmatrelvir+ritonavir among unvaccinated, non-hospitalized symptomatic pediatric patients 12 years of age and older weighing at least 40kg with high risk for progression to severe disease. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We recommend against the use of oseltamivir as treatment for patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of lopinavir/ritonavir as treatment for COVID-19 infection (Moderate quality of evidence; Strong recommendation)
Updated as of October 28, 2021
We recommend the addition of tocilizumab to systemic steroids in patients showing rapid respiratory deterioration and/or requiring high doses of oxygen (high-flow nasal cannula, noninvasive or invasive mechanical ventilation) and with elevated biomarkers of inflammation (CRP). (Moderate certainty of evidence, Strong recommendation)
We recommend against the use of tocilizumab among patients with COVID-19 infection who do not require oxygen. (Very low certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 25 January 2023
We recommend the use of baricitinib in addition to corticosteroids among critical COVID-19 patients on high-flow nasal cannula oxygenation, non-invasive ventilation, or invasive mechanical ventilation. (Moderate certainty of evidence, Strong recommendation)
We suggest against the use of baricitinib for the treatment of children with COVID-19 (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of November 8, 2021
There is insufficient evidence to recommend the use of imatinib among patients with COVID-19 infection. (Low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 16 January 2023
We suggest against the use of tofacitinib for the treatment of adult patients with COVID-19. (Low certainty of evidence, Weak recommendation)
We suggest against the use of tofacitinib for the treatment of children with COVID-19. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of October 28, 2021
We suggest against the use of leronlimab as treatment for COVID-19. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We suggest against the use of infliximab among patients with COVID-19 infection (Very low quality of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 06 December 2021
We suggest against the use of bevacizumab as treatment for COVID-19. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 16 January 2023
We recommend against the use of ivermectin for the treatment of children and adults with COVID-19 regardless of disease severity. (Very low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 18 November 2021
We suggest against the use of artesunate, artemisinin or pyronaridine tetraphosphate + artesunate in the treatment of COVID-19. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 15 March 2023
We recommend against the use of colchicine in the treatment of COVID-19 patients.
(Very low certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 06 December 2021
We recommend against the use of interferon in the treatment of COVID-19 patients (Very low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 05 December 2022
We suggest against the use of fluvoxamine among adult patients with mild to moderate COVID-19 infection (Very low certainty of evidence, weak recommendation)
We suggest the against the use of fluvoxamine among children and adolescent patients with mild to moderate COVID-19 infection (Very low certainty of evidence, weak recommendation)
You can find the Evidence Summary here.
Updated as of 16 January 2023
We suggest against the use of bamlanivimab – etesevimab for the treatment of children and adult patients with COVID-19. (Low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 15 March 2023
We suggest the use of casirivimab-imdevimab as an alternative to antivirals among symptomatic, non-hospitalized COVID-19 adult patients with risk factor/s for severe disease only when the predominant circulating variant is not Omicron SARS-CoV-2. (Very low certainty of evidence, Weak recommendation)
We recommend against the use of casirivimab-imdevimab as treatment for hospitalized COVID-19 patients. (Very low certainty of evidence, Strong recommendation)
We recommend against the use of casirivimab-imdevimab as treatment for asymptomatic, non-hospitalized COVID-19 patients. (Very low certainty of evidence, Strong recommendation)
We recommend against the use of casirivimab-imdevimab in children with COVID-19. (Very low certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 20 December 2021
We suggest against the use of regdanvimab for the treatment of mild to moderate COVID-19 (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 12 December 2022
We suggest the use of tixagevimab-cilgavimab as treatment for unvaccinated non-hospitalized adult patients with mild to moderate COVID-19 with at least 1 risk factor* for progression to severe disease. (Low quality of evidence; Weak recommendation)
*Risk factors for severe COVID-19: age ≥65 years, body-mass index ≥35 kg/m2, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions
We suggest the use of tixagevimab-cilgavimab as treatment for unvaccinated hospitalized adult patient with COVID-19 in addition to standard of care. (Low quality of evidence; Weak recommendation)
We suggest against the use of AZD7442 (tixagevimab-cilgavimab) in children and adolescents. (Low quality of evidence; Weak recommendation)
You can find the Evidence Summary here.
Updated as of 16 January 2023
We suggest against the use of sotrovimab for the treatment of children and adult patients with COVID-19. (Very low certainty of evidence, weak recommendation)
You can find the Evidence Summary here.
Updated as of 18 November 2021
We recommend against the use of convalescent plasma in patients with COVID-19 infection. (Moderate certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
We suggest against the use of intravenous immunoglobulin as treatment for moderate to severe COVID-19. (Very low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
There is insufficient evidence to recommend using umbilical cord-derived mesenchymal stem cell therapy among adults with severe COVID-19 (PaO2/FiO2 ratio ≤ 300 mmHg). (Very low quality of evidence)
You can find the Evidence Summary here.
Updated as of 18 November 2021
There is insufficient evidence to recommend the use of inhaled corticosteroids in treatment of non-hospitalized COVID-19 patients. (Very low certainty of evidence)
You can find the Evidence Summary here.
We recommend against the use of steam inhalation in the treatment of COVID-19. (Very low quality of evidence; Strong recommendation)
There is no evidence to recommend the use of VCO as treatment among patients with COVID-19 infection.
You can find the Evidence Summary here.
Updated as of 03 April 2023
We suggest the use of Lianhua for the symptomatic relief of adult patients with non-severe COVID-19 (Very low certainty of evidence, Weak recommendation)
We suggest against the use of Lianhua in children with COVID-19 (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We suggest against the use of famotidine in the treatment of COVID-19. (Very low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
We recommend against the use of ibuprofen as treatment among patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 19 May 2023
We suggest against the use of Metformin as treatment for COVID-19 (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 25 January 2023
We recommend the use of dexamethasone for up to 10 days among adult patients with severe and critical COVID-19 (Moderate certainty of evidence, Strong recommendation)
We suggest the use of methylprednisolone 1-2mg/kg/day for 5 to 10 days as an alternative to dexamethasone among adult patients with severe and critical COVID-19 (Very low certainty of evidence, Weak recommendation)
We recommend the use of standard-dose dexamethasone at 6 mg to 12 mg per day among adult patients with severe and critical COVID-19. (Moderate certainty of evidence, Strong recommendation)
We suggest that steroid therapy be initiated as soon as diagnosed or categorized as severe or critical COVID-19. (Very low certainty of evidence, Weak recommendation)
We suggest the use of dexamethasone at 0.15 mg/kg/day or a maximum dose of 6 mg per day for up to 10 days among children with severe and critical COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 20 February 2023
We suggest the use of prophylactic over therapeutic dose anticoagulation among hospitalized adults with moderate, severe or critical COVID-19 disease unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest the use of standard dose prophylactic anticoagulation over intermediate dose prophylactic anticoagulation among hospitalized adults with COVID-19 disease unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest against the routine use of any anticoagulation among adults with mild COVID-19 in the outpatient setting unless there is a pre-existing non-COVID indication for anticoagulation use. (Low certainty of evidence, Weak recommendation)
We suggest the use of oral anticoagulation after hospital discharge among adults admitted for moderate to severe COVID-19 and who are suspected to have a high risk for VTE at-or-near hospital discharge. (Low certainty of evidence, Weak recommendation)
We suggest prophylactic dose anticoagulation among hospitalized pediatric patients more than 12 years of age with moderate to critical COVID-19 or MIS-C, unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
We suggest prophylactic anticoagulation among hospitalized pregnant women with moderate to critical COVID-19, unless there are any contraindications. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We recommend against the routine use of antibiotics in patients with severe and critical COVID-19 infection, unless with suspicion of secondary bacterial co-infection. For patients on empiric antibiotics, they should be assessed daily for the need for discontinuation, continuation or escalation based on clinical and laboratory parameters. (Very low quality of evidence; Strong recommendation)
Updated as of 01 December 2021
There is insufficient evidence to recommend the use of hemoperfusion in patients diagnosed with COVID-19. (Low certainty of evidence)
You can find the Evidence Summary here.
We suggest the use of conservative fluid management rather than liberal fluid management strategy in mechanically ventilated adult COVID-19 patients with acute respiratory distress syndrome who are adequately resuscitated*. (Low quality of evidence; Conditional recommendation)
*without tissue hypoperfusion and fluid responsiveness
Updated as of 22 March 2023
We suggest awake prone positioning or self-proning in non-intubated adult patients with severe and critical COVID-19 (Very low certainty of evidence, Weak recommendation)
We suggest prone positioning among intubated adult patients with critical COVID-19 in ARDS (Very low certainty of evidence, Weak recommendation)
We suggest the use of side lying in non-intubated adult patients with severe and critical COVID-19 who cannot tolerate proning. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 15 March 2023
We suggest the use of high flow nasal oxygen therapy for patients with severe to critical COVID-19 who do not respond to conventional oxygen therapy (low flow nasal cannula/face mask). (Low certainty of evidence, Weak recommendation)
We suggest the use of either high flow nasal oxygenation therapy or non-invasive positive pressure ventilation in patients with severe to critical COVID-19 who do not respond to conventional oxygen therapy in the absence of any indication for emergent invasive mechanical ventilation. (Very low certainty of evidence, Weak recommendation)
We suggest the use of high flow nasal oxygen therapy for children with severe to critical COVID-19 who do not respond to conventional oxygen therapy (low flow nasal cannula/face mask). (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 03 January 2022
We suggest the use of either high flow nasal cannula or non-invasive positive pressure ventilation in COVID-19 patients with hypoxemic respiratory failure, in the absence of any indication for emergent invasive mechanical ventilation. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 24 April 2023
We recommend the use of a lung protective ventilation strategy (tidal volume 4-6 mL/kg ideal body weight, plateau pressure less than 30 cmH2O and an appropriate PEEP) among mechanically ventilated adult patients with COVID-19-associated ARDS. (Very low certainty of evidence, Strong recommendation)
We suggest against the routine use of high PEEP strategy among mechanically ventilated adult patients with COVID-19-associated ARDS. We further suggest to individualize PEEP or employ a PEEP strategy based on respiratory mechanics (i.e., compliance) in patients with COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
We suggest to keep the driving pressure less than 15 cmH2O among mechanically ventilated adult patients with COVID-19-associated ARDS. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We suggest the use of rapid sequence intubation for COVID-19 patients to reduce infection among healthcare workers performing the procedure. (Very low quality of evidence; Conditional recommendation)
Updated as of 19 May 2023
We suggest to offer the use of extracorporeal membrane oxygenation for judiciously selected adult COVID-19 patients with severe acute respiratory distress syndrome refractory to optimal mechanical ventilation based on ELSO or NHS England criteria. (Very low certainty of evidence, Weak recommendation)
*after careful consideration of cost, resources, expertise available
We suggest to offer the use of extracorporeal membrane oxygenation for judiciously selected pediatric COVID-19 patients with severe acute respiratory distress syndrome refractory to optimal mechanical ventilation based on ELSO criteria. (Very low certainty of evidence, Weak recommendation)
*after careful consideration of cost, resources, expertise available
You can find the Evidence Summary here.
Updated as of 01 December 2021
At present, we suggest against the use of hyperbaric oxygen therapy for the management of COVID-19 patients due to insufficient evidence. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 03 January 2022
We suggest light over deep sedation in COVID-19 patients who are mechanically ventilated and who are anxious or agitated. (Very low certainty of evidence, Weak recommendation)
We suggest against routine use of NMB in mechanically ventilated COVID-19 ARDS patients. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of October 26, 2021
We recommend against the use of nitric oxide among patients with COVID-19. (Low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of etoposide among patients with COVID-19 pneumonia in cytokine storm (Very low quality of evidence; Strong recommendation)
Updated as of 03 April 2023
We suggest individualized pulmonary rehabilitation with pre-intervention medical clearance for adult patients with long COVID syndrome who show residual pulmonary symptoms to improve pulmonary function and quality of life (Very low certainty of evidence, weak recommendation)
You can find the Evidence Summary here.
Updated as of October 26, 2021
There is insufficient evidence to recommend the use of pirfenidone or nintedanib among patients with post-COVID-19 pulmonary fibrosis (Very low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 19 May 2023
We suggest the use of steroids (methylprednisolone) rather than IVIg alone among children diagnosed with multisystem inflammatory syndrome (MIS-C). (Very low certainty of evidence, Weak recommendation)
We suggest to offer the use of IVIg in combination with steroids among children diagnosed with multisystem inflammatory syndrome associated with significant organ involvement. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 02 May 2023
In the community setting, we recommend the use of a face mask for preventing COVID-19 in crowded, enclosed, and poorly ventilated spaces. (Low certainty of evidence, Strong recommendation)
You can find the Evidence Summary here.
Updated as of 03 December 2021
We recommend the proper use of either a well-fitted cloth mask or medical mask in the community setting. If a cloth mask will be used, we suggest that it should be made of at least two layers of cotton (e.g., t- shirt fabric) or non-woven nylon with aluminum nose bridge. (Very low certainty of evidence; strong recommendation)
You can find the Evidence Summary here.
Updated as of November 5, 2021
We suggest against requiring the use of face shields in addition to face masks among the general public in non-healthcare settings. (Very low certainty of evidence; Weak recommendation)
We recommend the addition of face shields to face masks among the general public in areas with sustained community transmission of SARS-CoV-2. (Very low certainty of evidence; Strong recommendation)
We recommend the use of face shield plus medical face mask and standard personal protective equipment among health care workers not directly involved in the care of COVID-19 patients in areas with sustained community transmission of SARS-COV2. (Very low certainty of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 03 December 2021
There is no evidence to recommend the use of copper-containing over non-copper-containing masks to decrease SARS-CoV-2 transmission.
You can find the Evidence Summary here.
We recommend against the use of ionizing air purifier to reduce COVID-19 transmission in the community. (Low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of footbaths for the prevention and control of COVID-19 transmission. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of misting tents or disinfection chambers for preventing and controlling COVID-19 transmission. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of UV lamps or other UV devices in any place outside of a controlled clinic or hospital setting to prevent and control COVID-19 transmission. (Low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of 22 May 2023
We recommend the use of natural ventilation* in indoor spaces to prevent COVID-19 transmission, if possible and safe to do so (Good practice statement)
*includes opening doors, windows and electric fans
We recommend the use of mechanical ventilation systems with appropriate filtration systems* in indoor spaces to prevent COVID-19 transmission, if natural ventilation is not feasible or adequate. (Very low certainty of evidence, Strong recommendation)
*Includes HVAC systems and portable air cleaners
You can find the Evidence Summary here.
We suggest the use of HEPA filter as an option to improve air quality for COVID-19 prevention and control in indoor spaces with inadequate ventilation. (Low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
Updated as of 01 February 2023
We suggest the use of carbon dioxide (CO2) monitors in enclosed spaces to guide actions to improve ventilation and reduce the risk of transmission of SARS-CoV-2. (Low certainty of evidence, Weak strength of recommendation)
You can find the Evidence Summary here.
In situations where there is shortage of filtering facepiece respirators (FFR), we suggest the use of Hydrogen Peroxide Vapor (HPV), Ultraviolet Germicidal Irradiation (UVGI), moist heat and peracetic acid dry fogging system (PAF) as options for N95 mask decontamination as recommended by the manufacturer based on their ability to reduce SARS-COV-2 load and infectivity while still maintaining N95 mask integrity. (Low quality of evidence; Conditional recommendation)
We recommend against the use of autoclave and alcohol as these methods alter filtering facepiece respirator’s (N95) integrity and degrade filtration efficacy. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend the use of appropriate PPE to include mask (N95 or higher standard), fluid repellent sealed well-fitting long gown, double gloves, apron, full face shield or goggles or visor, scrub hat, and disposable shoe covers or dedicated closed footwear among surgeons engaged in aerosol generating procedures of suspected or confirmed COVID-19 patients. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend the use of the following PPE: disposable hat, medical protective mask (N95 or higher standard), goggles or face shield (anti-fog), medical protective clothing, disposable gloves and disposable shoe covers or dedicated closed footwear as an effective intervention in the prevention of COVID-19 among health care workers in areas with possible direct patient care of confirmed or probable COVID-19 patients and possible performance of aerosol generating procedures. (Moderate quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We suggest against the use of protective physical barrier enclosures (ex. aerosol box) for the prevention of COVID-19 among health care providers who perform aerosol generating medical procedures*. (Very low quality of evidence; Conditional recommendation)
We suggest the use of protective physical barriers in the prevention of COVID-19 in areas where physical distancing cannot be adhered to (e.g., offices, reception desk)**. (Very low quality of evidence; Conditional recommendation)
*Proper PPEs should be used by health care providers when performing aerosol-generating procedures.
**Adequate ventilation, physical distancing, use of facemasks and personal hygiene should still be maintained to prevent COVID-19 infections. Regular cleaning and disinfection of physical barriers should be practiced.
You can find the Evidence Summary here.
We recommend the practice of cleaning and disinfecting surfaces using the appropriate disinfecting chemical agents such as 0.5% sodium hypochlorite solution (bleach) or 70% alcohol to prevent COVID-19 infection.
For high touch surfaces and high traffic areas, such as in the workplace, disinfection should be done before shift, intermittently during shift and after the shift.
For household disinfection, once daily disinfection on high touch surfaces is recommended.
(Low quality of evidence; Strong recommendation)
Updated as of 28 October 2021
We recommend the use of the following vaccines to prevent symptomatic SARS-CoV-2 infection in adults: (Moderate certainty of evidence; Strong recommendation)
We recommend the use of CoronaVac (Sinovac) (given as 0.5ml (600SU) intramuscular injection, in 2 doses, at 28 days apart) to prevent symptomatic SARS-CoV-2 infection among healthy adults. (Low certainty of evidence; Strong recommendation)
We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent symptomatic SARS-CoV-2 infection in older adults (>64 year old). (Low certainty of evidence; Strong recommendation)
We suggest the use of CoronaVac (Sinovac) to prevent SARS-COV-2 infection in older adults (>60 years old) (Low certainty of evidence; Weak recommendation)
We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya), CoronaVac (Sinovac) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines in pregnant and lactating women after consultation with a physician. (Very low certainty of evidence; Conditional recommendation)
We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent SARS-CoV-2 infection in adults who have stable medical comorbidities and are at risk for severe infection. (Moderate certainty of evidence; Strong recommendation)
We suggest the use of CoronaVac (Sinovac) to prevent SARS-CoV-2 infection in adults who have stable medical comorbidities and are at risk for severe infection. (Very low certainty of evidence; Conditional recommendation)
We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya),CoronaVac (Sinovac) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent SARS-CoV-2 infection in immunocompromised patients (i.e., diagnosed with HIV, hepatitis B and C, those with cancer undergoing chemotherapy, transplant patients receiving immune-suppression) after medical clearance from a physician. (Low certainty of evidence; Strong recommendation)
We recommend against the use of these vaccines for those who have known allergies to the contents / excipients of the vaccine, such as polysorbate (ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson)) and polyethylene glycol or PEG200 DMG (BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna)). (Moderate to high certainty of evidence; Strong recommendation)
**Recommendations for vaccination in children have been updated and can be found in a separate review
Updated as of 02 December 2021
You can find the Evidence Summary here.
Updated as of October 28, 2021
You can find the Evidence Summary here.
Updated as of October 21, 2021
You can find the Evidence Summary here.
Updated as of 27 December 2021
We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic and severe SARS-CoV-2 infection in healthy adults. (Low certainty of evidence; Weak recommendation)
We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic SARS-CoV-2 infection in older adults (>65 years old). (Low certainty of evidence; Weak recommendation)
We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic SARS-CoV-2 infection in adults with comorbidities. (Moderate certainty of evidence; Weak recommendation)
We suggest against the use of NVX-CoV2373 (Novavax), for the prevention of symptomatic SARS-CoV-2 infection in the immunocompromised population (specifically HIV positive individuals). (Very low certainty of evidence; Weak recommendation)
We suggest against the use of NVX-CoV2373 for the prevention of symptomatic SARS-CoV-2 infection among pregnant and lactating women. (No direct evidence; Weak recommendation)
In areas where the Alpha variant is predominant, we suggest the use of the NVX-CoV2373 (Novavax) given as 5ug (with 50ug Matrix-M1 adjuvant), two doses, intramuscular, 21 days apart, to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; Weak recommendation)
In areas where the Beta variant is predominant, we suggest against the use of the NVX-CoV2373 (Novavax) to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; Weak recommendation)
There is insufficient evidence to recommend for or against the use of NVX-2373 for the prevention of symptomatic SARS-CoV-2 infection among children.
We recommend against the use of the NVX-CoV2373 (Novavax) in individuals who have known allergies to its contents/excipients, such as Matrix-M1. (Best practice statement)
You can find the Evidence Summary here.
Updated as of November 4, 2021
You can find the Evidence Summary here.
Updated as of 27 December 2021
We suggest the following homologous booster vaccination regimen for the general adult population:
There is insufficient evidence to recommend the following homologous booster vaccination in the general population:
We suggest the following heterologous booster vaccination regimen for the general adult population:
There is insufficient evidence to recommend the use of the heterologous booster vaccination regimens other than the combinations included above in the general adult population.
We suggest the following homologous booster vaccination for the immunocompromised population:
There is insufficient evidence to recommend the following homologous booster vaccination for the immunocompromised population:
We suggest the following heterologous booster vaccination regimen for the immunocompromised population:
There is insufficient evidence to recommend the use of the heterologous booster vaccination regimen other than the combinations included above in the immunocompromised population.
You can find the Evidence Summary here.
Updated as of 23 March 2023
Among adult individuals with previous COVID-19 infection who received standard doses of COVID-19 vaccine primary series, we suggest the use of a homologous first booster dose of monovalent mRNA vaccine*. (Very low certainty of evidence, Weak recommendation)
Among the elderly population, we suggest the following COVID-19 vaccines as homologous booster at least two months after the primary series.
Among the immunocompromised*, we suggest the following vaccines as homologous booster at least two months after the second dose:
Among the elderly population, we suggest the following heterologous COVID-19 booster vaccination regimen:
Among immunocompromised population*, we suggest the following heterologous booster vaccination regimen:
Among immunocompromised population, there is insufficient evidence to recommend the following heterologous booster vaccination regimen:
You can find the Evidence Summary here.
Updated as of 02 February 2023
We suggest the preferential use of the following bivalent vaccines over monovalent mRNA vaccines as a second homologous booster among the general population:
(Very low certainty of evidence, Weak recommendation)
There is no recommendation for Coronavac as a second homologous booster vaccination in the general population due to insufficient evidence. (Very low certainty of evidence)
*There is no available evidence on the use of the following as second homologous booster vaccination in the general population for Gam-COVID-Vac, ChAdOx1, BBV152, Ad26.CoV2.S, BBIBP-CorV, and other vaccines
We suggest the administration of the following second heterologous booster vaccination in the general population:
(Very low certainty of evidence, Weak recommendation)
*There is no available evidence on the use of the following as second homologous booster vaccination in the general population for Gam-COVID-Vac, ChAdOx1, BBV152, Ad26.CoV2.S, BBIBP-CorV, and other vaccines
You can find the Evidence Summary here.
Updated as of 19 December 2022
We recommend the use of the homologous monovalent BNT162b2 (Pfizer) second booster dose to prevent symptomatic COVID-19 infection in healthcare workers. (Very low certainty of evidence, Strong recommendation)
We recommend the use of the heterologous monovalent mRNA1273 (Moderna) second booster dose to prevent COVID-19 infection in healthcare workers. (Very low certainty of evidence, Strong recommendation)
*There is no available evidence on the use of CoronaVac, ChAdOx1, BBV152, Ad26.CoV2.S and other vaccines as a second booster in health care workers.
You can find the Evidence Summary here.
As of 06 March 2023
No recommendation can be made on the use of a third booster dose of COVID-19 vaccine (to complete 5 vaccine doses) for the high-risk population because there is no available evidence.
You can find the Evidence Summary here.
Updated as of 06 March 2023
Among adult individuals with previous COVID-19 infection who received standard doses of COVID-19 vaccine primary series, we suggest the use of a homologous first booster dose of monovalent mRNA vaccine*. (Very low certainty of evidence, Weak recommendation)
Among adults with previous COVID-19 infection who received standard doses of COVID-19 primary vaccine series, there is no recommendation for the use of a heterologous first booster dose of monovalent mRNA vaccine*, due to insufficient evidence.
a. Certainty of evidence: Very low
b. Strength of recommendation: None
*There is no available evidence for the use of bivalent mRNA vaccines, Coronavac (Sinovac), ChAdOx1 (AstraZenenca) and other vaccines as a first booster dose on adults with previous infection.
You can find the Evidence Summary here.
Updated as of October 22, 2021
We recommend the use of heterologous COVID-19 vaccination for those with serious adverse event to the first dose. (Very low certainty of evidence; Strong recommendation)
We suggest the use of heterologous COVID-19 vaccination in the event of the unavailability of the second dose in the recommended schedule. (Very low certainty of evidence; Weak recommendation)
You can find the Evidence Summary here.
We suggest the use of the BNT162b2 (Pfizer/BioNTech) vaccine, [given as 0.3 mL (30 ug) intramuscular injections, in 2 doses, 21 days apart] for children 12-15 years old to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; weak recommendation)
We suggest the use of the mRNA-1273 (Moderna) vaccine, [given as 0.5 mL (100 ug) intramuscular injections, in 2 doses, 28 days apart] for children 12-17 years old to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; weak recommendation).
There is insufficient evidence to recommend the use of the BNT162b2 (Pfizer/BioNTech) vaccine, [given as 0.3 mL (30 ug) intramuscular injections, in 2 doses, 21 days apart) for immunocompromised patients 12-21 years old to prevent symptomatic SARS-CoV-2 infection (Very low certainty of evidence).
There is insufficient evidence to recommend the use of the following for children 12-17 years old to prevent symptomatic SARS-CoV-2 infection:
You can find the Evidence Summary here.
Updated as of 02 February 2023
We suggest the use of monovalent mRNA-1273 (Moderna) vaccine in children 6 months to 4 years to prevent SARS-CoV-2 infection. (Very Low certainty of evidence, Weak recommendation)
Updated as of 19 December 2022
There is no recommendation being made this time on booster administration in healthy children 5 to 11 years old who received standard full doses of primary series to prevent SARS-COV-2 infection due to lack of evidence.
We suggest the use of monovalent BNT1262b2 mRNA (Pfizer/BioNTech) vaccine as booster in healthy children 12-17 years old who received standard full doses of primary series to prevent SARS -COV-2 infection*. (Very low certainty of evidence, weak recommendation)
*After optimal coverage in the high risk priority groups have been achieved
You can find the Evidence Summary here.
Updated as of 27 December 2021
We suggest the use of following vaccines, after the first trimester, for the prevention of COVID-19 infection in pregnant and lactating women.
We suggest against the use of the following vaccines for the prevention of COVID-19 infection in pregnant and lactating women:
You can find the Evidence Summary here.
Updated as of 02 December 2022
We suggest against the use of casirivimab-imdevimab as post-exposure prophylaxis against COVID-19 (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 02 March 2023
We suggest against the use of AZD7442 (tixagevimab-cilgavimab) as pre-exposure prophylaxis against COVID-19. (Very low certainty of evidence, Weak recommendation)
We suggest against the use of AZD7442 (tixagevimab-cilgavimab) as post-exposure prophylaxis against COVID-19. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
We recommend against the use of melatonin as prevention for COVID-19 infection. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of Vitamin D supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of zinc supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)
We recommend against the use of HCQ for pre-exposure prophylaxis in adults who are at high risk of exposure to COVID-19 cases. (Moderate quality of evidence; Strong recommendation)
We recommend against the use of HCQ for post-exposure prophylaxis in adults who are exposed to COVID- 19 cases. (Low quality of evidence; Strong recommendation)
We recommend against the use of lopinavir/ritonavir for chemoprophylaxis in individuals exposed to COVID-19 patients. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend against the use of ivermectin as COVID-19 prophylaxis for the general population. (Very low quality of evidence; Strong recommendation)
We recommend against the use of ivermectin for COVID-19 as post-exposure prophylaxis for household contacts of confirmed COVID-19 patients. (Very low quality of evidence; Strong recommendation)
We recommend against the use of ivermectin for COVID-19 as prophylaxis for healthcare workers. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
There is insufficient evidence to recommend the use of saline nasal irrigation (SNI) to prevent COVID-19 in healthy individuals. (Very low quality of evidence)
You can find the Evidence Summary here.
We recommend against the use of steam inhalation in the prevention of COVID-19. (Very low quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
There is insufficient evidence to recommend the use of antiseptic mouthwash or gargle to prevent COVID- 19 in healthy individuals. (Very low quality of evidence)
You can find the Evidence Summary here.
There is insufficient evidence to recommend the use of zinc as adjunct treatment for patients with COVID- 19 infection both in the outpatient and in-patient setting. (Very low quality of evidence)
You can find the Evidence Summary here.
We suggest against the use of B vitamins as adjunct in the treatment of patients with COVID-19. (Very low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
Updated as of 21 December 2021
There is insufficient evidence to recommend the use of vitamin C as adjunct treatment for patients with COVID-19 infection (Low certainty of evidence)
You can find the Evidence Summary here.
Updated as of 03 December 2021
There is insufficient evidence to recommend the use of Vitamin D supplementation as adjunct treatment for patients with COVID-19 infection (Very low certainty of evidence)
You can find the Evidence Summary here.
There is insufficient evidence to recommend the use of melatonin as adjunct treatment for patients with COVID-19 infection. (Very low quality of evidence)
You can find the Evidence Summary here.
There is no evidence to recommend the use of virgin coconut oil as adjunct treatment for patients with COVID-19 infection.
You can find the Evidence Summary here.
Updated as of October 29, 2021
There is no evidence to recommend Lagundi (Vitex negundo) as adjunctive treatment for patients with COVID-19 infection.
You can find the Evidence Summary here.
Updated as of October 29, 2021
There is no evidence to recommend Tawa-tawa (Euphorbia hirta) as adjunctive treatment for patients with COVID-19 infection.
You can find the Evidence Summary here.
There is insufficient evidence to recommend the use of fatty acid supplements as adjunctive treatment for patients with COVID-19. (Low quality of evidence)
You can find the Evidence Summary here.
We recommend against the use of intravenous N-acetylcysteine as adjunct treatment for patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
We recommend continuing maintenance RAAS blockers for hypertension among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)
You can find the Evidence Summary here.
Updated as of October 29, 2021
There is insufficient evidence to recommend statins as adjunctive treatment in patients with COVID-19. (Very low certainty of evidence)
You can find the Evidence Summary here.
We suggest that ibuprofen may still be used as symptomatic treatment of patients with COVID-19 infection if clinically warranted. Concurrent use of ibuprofen is not associated with worsening of COVID-19 outcomes. (Very low quality of evidence; Conditional recommendation)
You can find the Evidence Summary here.
Updated as of 03 December 2021
We suggest against the use of nasal spray as an adjunct to treatment of COVID-19 infection. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 9 March 2022
As an alternative specimen to nasopharyngeal swab, we recommend the use of saliva specimen for RT-PCR* among non-hospitalized children suspected of COVID-19 infection. (Moderate certainty of evidence, Strong recommendation)
*Nasopharyngeal swab is the specimen of choice for RT-PCR for the diagnosis of COVID-19 infection in children. The use of three specific saliva RT-PCR assays is recommended: Allplex 2019-nCOV assay, Cobas 6800, QuantStudio 7 system.
As an alternate specimen to nasopharyngeal swab, we suggest the use of mid-turbinate swab for RT-PCR* among non-hospitalized children suspected of COVID-19 infection. Moderate certainty of evidence, Weak recommendation)
* Nasopharyngeal swab is the specimen of choice for RT-PCR for the diagnosis of COVID-19 infection in children. The use of two specific mid-turbinate RT-PCR assays is recommended: RealStar SARS-CoV-2 RT-PCR kit or Aptima SAR-CoV-2 Assay.
We suggest against the use of nasopharyngeal aspirate as an alternative clinical specimen among non-hospitalized children suspected of COVID-19 infection. (Moderate certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 2 March 2022
We suggest against the routine use of anticoagulation in children with COVID-19 infection or MIS-C. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 28 February 2022
We suggest the use of systemic corticosteroids (dexamethasone) among children with severe and critical COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 28 February 2022
We suggest against the routine use of intravenous immunoglobulin for children with COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 9 March 2022
There is insufficient evidence to recommend the use of casirivimab plus imdevimab as treatment of non-hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Low certainty of evidence)
*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.
There is insufficient evidence to recommend the use of casirivimab plus imdevimab as treatment of hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Very low certainty of evidence)
*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.
There is insufficient evidence to recommend the use of bamlanivimab plus etesevimab as treatment of non-hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Low certainty of evidence)
*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.
There is insufficient evidence to recommend the use of sotrovimab as treatment of non-hospitalized children with COVID-19 infection. (Low certainty of evidence)
We suggest against the use of sotrovimab as treatment of hospitalized children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)
We suggest against the use of amubarvimab plus romlusevimab as treatment of children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)
We suggest against the use of regdanvimab as treatment of children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 2 March 2022
We suggest the use of remdesivir in hospitalized children with severe COVID-19 infection. (Very low certainty of evidence, Weak recommendation)
We suggest the use of remdesivir in non-hospitalized children with COVID-19 infection with at least one (1) risk factor* for disease progression. (Low certainty of evidence, Weak recommendation)
*The risk factors for disease progression are hypertension, cardiovascular or cerebrovascular disease, diabetes mellitus, obesity, immune compromise, chronic mild or moderate kidney disease, chronic liver disease, chronic lung disease, current cancer or sickle cell disease.
You can find the Evidence Summary here.
Updated as of 2 March 2022
We suggest the addition of tocilizumab to systemic steroids in patients with moderate to severe COVID-19 infection, particularly where there is evidence of systemic inflammation. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 28 February 2022
We suggest against the routine use of vitamin C for the prevention of COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 23 February 2022
We suggest against the routine use of vitamin D for the prevention of COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 28 February 2022
We suggest against the routine use of zinc for the prevention of COVID-19 infection in children. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 23 February 2022
We suggest against the use of vitamin C as adjunctive treatment for COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 23 February 2022
We suggest against the use of vitamin D as adjunctive treatment for COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 28 February 2022
We suggest against the use of zinc as adjunctive treatment for COVID-19 infection in children. (Low certainty of evidence, Weak recommendation)
You can find the Evidence Summary here.
Updated as of 9 March 2022
We recommend the implementation of supportive strategies* to optimize mental health among children and adolescents during the COVID-19 pandemic. (Low certainty of evidence, Strong recommendation)
*Supportive strategies for mental health during the COVID-19 pandemic include psychological counseling, physical and leisure activities (outdoor and online exercise platforms, art and dance), mindfulness meditation training, personal and spiritual coping, strengthening social support and connecting online with peers, and health-promoting activities.
You can find the Evidence Summary here.
Updated as of 9 March 2022
We recommend a multi-layer approach using multiple non-pharmacologic interventions* in school settings to limit transmission of COVID-19 in schools. (Very low certainty of evidence, Strong recommendation)
*The non-pharmacologic interventions are wearing of masks of students, physical distancing, engineering controls (ventilation, personal hygiene and handwashing, disinfection of surfaces), administrative controls (blended learning, phased reopening, no/reduced mixing of classes, restriction of class size, minimized or staggered breaks, symptom monitoring, self-quarantine, contact tracing, and early testing).
You can find the Evidence Summary here.
Covid-PSMID
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