A 65-year-old male with a liver transplant presents to the emergency department with fevers, chills, and 1 week of progressive dysuria with right flank pain. He is diagnosed with acute pyelonephritis and admitted to the hospital for further treatment. He is incidentally found to be COVID-19 positive on a pre-admission COVID screen. Upon further questioning, he also reports 3 days of sore throat after attending a family reunion last week and is not vaccinated against COVID-19. His oxygen saturation is 98% on room air and his lungs are clear to auscultation. His chest x-ray shows no infiltrates. It is currently January 2022.
Besides airborne precautions, what is the next best step in management?
- A) Dexamethasone 6 mg IV Q daily
- B) Regeneron monoclonal antibody Infusion
- C) Remdesivir infusion
- D) Full dosed therapeutic anticoagulation
- E) Early treatment with Ivermectin
C) Remdesivir infusion
Dexamethasone should be reserved for patients with hypoxia related to COVID pneumonia. The double-blind placebo-controlled RECOVERY trial only showed a mortality benefit in patients with hypoxia. Monoclonal antibody infusion is a good option in this patient; however, monoclonal antibodies have variable effectiveness against emerging COVID-19 variants. It is important to review specific COVID-19 variant prevalence in your area and choose the appropriate monoclonal antibody as indicated. At the time of this question, Regeneron was not effective against the prevalent omicron variant. Patients with COVID-19 are high risk for thrombosis, and indications for anticoagulation are evolving as we investigate further. However, he is essentially an outpatient with regards to his COVID-19 illness, and empiric therapeutic anticoagulation would not be indicated at this time. Ivermectin has not been consistently shown to be effective in preventing the progression of COVID-19 related illness.
Key Learning Point
Some patients admitted to the hospital are incidentally found to have COVD-19 on pre-admission screens. Appropriate management can be confusing because although they are technically inpatients, they initially should be considered as outpatients with regards to COVID-19 therapies. Remdesivir, especially when given early, has been shown to prevent progression to severe COVID-19 illness, and is appropriate for this high-risk individual. He is both unvaccinated and immunocompromised. Recently published data (N Engl J Med 2022; 386:305-315) has shown that an outpatient remdesivir infusion within 7 days of symptoms (at a dose of 200 mg a day for 3 days) reduced the risk of hospitalization by 87% in high-risk individuals.
