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NPs and PAs: Outpatient COVID-19
Practical Insights for NPs and PAs: Assessment and Treatment Considerations for Acute Outpatient COVID-19

Released: April 26, 2023

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Key Takeaways
  • People who test positive for COVID-19 should isolate until Day 5 and wear a mask until Day 10.
  • COVID-19 tests are readily available and should be used to confirm a COVID-19 infection before prescribing treatment.
  • There is no proven benefit of treating nonhospitalized patients with COVID-19 with anticoagulation, corticosteroids, vitamin C, vitamin D, or zinc.

In this commentary, Renslow Sherer, MD, addresses the most important questions asked by healthcare professionals in a series of recent webinars on outpatient COVID-19 management. 

How long should people isolate when they test positive for COVID-19?
The CDC recommends that one should stay home for at least 5 days following a positive COVID-19 test and isolate from others within the home. If you are asymptomatic or symptomatic but improving, you may end isolation after Day 5. However, if you are symptomatic and symptoms are not improving, you should continue to isolate until your symptoms are improving and you are fever free for 24 hours without the use of any fever-reducing medications. Either way, it is important to wear a mask after ending isolation through Day 10.

Can you initiate COVID-19 treatment for patients based on symptoms alone, or do they need to have a positive COVID-19 test?
It is best if the patients have a confirmatory test because many symptoms of COVID-19 overlap with other respiratory illnesses, such as influenza and respiratory syncytial virus. In our emergency department, we have seen several patients who thought they had COVID-19 but were found to have acute HIV infection. COVID-19 at-home tests are readily available and take 30 minutes or less to administer. 

What would be your next step in managing a 68-year-old patient who had a positive COVID-19 rapid antigen test, was treated with a 5-day course of nirmatrelvir plus ritonavir, and is now experiencing viral rebound symptoms and retests positive for COVID-19?
It is not unusual for patients to experience viral rebound whether treated or not treated with a COVID-19 antiviral agent. Although many patients report a reduction in COVID-19 symptoms after starting antiviral treatment, some patients continue to have symptoms despite treatment, and others have recurring symptoms after treatment. In a patient who was just treated for COVID-19 and now tests positive again, this is part of the natural history of the SARS-CoV-2 infection, and we should offer supportive care such as resting and staying well hydrated.

Does a patient require hospitalization to receive IV remdesivir for an acute COVID-19 infection?
No, remdesivir can be administered in an infusion center or a clinic that is set up to administer IV medications. It can also be administered by a home healthcare nurse if the patient has access to that type of service. Remdesivir is indicated in ambulatory patients with mild to moderate COVID-19 who are at high risk for disease progression and hospitalized patients with COVID-19.

Is there a role for anticoagulation in nonhospitalized patients with mild to moderate COVID-19?
The National Institutes of Health (NIH) COVID-19 treatment guidelines recommend against the use of anticoagulation or antiplatelet therapy in nonhospitalized patients with COVID-19 unless they are enrolled on a clinical trial. Patients who are receiving anticoagulation or antiplatelet therapy for an underlying condition and then become infected with COVID-19 should continue these medications under the supervision of their healthcare professional.

Is there a role for treatment with vitamin C, vitamin D, zinc, or corticosteroids in nonhospitalized patients with mild to moderate COVID-19?
According to the NIH COVID-19 treatment guideline panel, there is insufficient evidence to recommend for or against the use of vitamin C, vitamin D, or zinc for the treatment of nonhospitalized patients with COVID-19. Because patients who are not critically ill with COVID-19 are less likely to experience oxidative stress or severe inflammation, the benefit of vitamin C in nonhospitalized patients is unknown. It is hypothesized that vitamin D may have immunomodulatory effects that could be beneficial in the prevention or treatment of COVID-19, but clinical trials have not confirmed any beneficial effects. Studies are evaluating the role of zinc in the treatment of COVID-19, but no data have yet confirmed any beneficial effects. Some studies have found that corticosteroid use in patients with mild to moderate COVID-19 may increase the risk of hospitalization and severe illness, and the NIH COVID-19 guideline panel specifically advises healthcare professionals to avoid the use of corticosteroids in these patients. 

Is it reasonable to prescribe a 5-day supply of an oral antiviral to people traveling abroad with risk factors for severe COVID-19 in the event they become infected with SARS-CoV-2?
Yes, in general, it is reasonable to prescribe a 5-day course of a COVID-19 oral antiviral for this purpose. Although more countries have approved antiviral therapies for use, access to the drugs can be delayed or difficult to receive in time. Any unused medication should be returned to the pharmacy or properly disposed of after the patients have returned from their travels. 

Your Thoughts?
What are the most commonly asked COVID-19 treatment questions in your clinical practice? Join the conversation by posting a comment below.