PassFinals
Infectious Disease

COVID-19

COVID-19 is illness caused by SARS-CoV-2, ranging from a self-limiting respiratory infection to hypoxic pneumonia and multi-organ complications; management depends on severity, oxygen requirement, risk of progression, timing, comorbidity and current UK treatment pathways.

In a nutshell

COVID-19 management is severity- and risk-based. Confirm infection when it changes management, measure oxygenation and physiology, and safety-net aggressively. Highest-risk adults who do not need oxygen may qualify for prompt nirmatrelvir plus ritonavir assessment; oxygen-requiring patients may need corticosteroids and selected immunomodulation, plus VTE prophylaxis. Do not use antibiotics or corticosteroids for uncomplicated non-hypoxic COVID-19 without another indication.

Classic presentation

A patient with fever, cough, fatigue and sore throat or anosmia develops worsening breathlessness and hypoxia, with COVID-19 pneumonia or another complication needing hospital assessment.

Key points

  • Symptoms overlap with flu; testing is needed when it changes treatment, infection control or access to antivirals.
  • Nirmatrelvir plus ritonavir is for selected highest-risk adults who do not need oxygen; ritonavir interactions are a major prescribing hazard.
  • Dexamethasone is for COVID-19 with oxygen requirement, not uncomplicated non-hypoxic disease.
  • Hospital-managed COVID-19 needs bleeding/VTE assessment and standard prophylactic LMWH when indicated; use the current NICE pathway.
  • Do not use antibiotics to treat COVID-19 alone, and do not let a positive test prevent investigation of PE, bacterial infection or other deterioration.
  • Symptoms persisting from 4 weeks need holistic assessment and personalised follow-up or rehabilitation, not automatic attribution to long COVID.

First-line investigation

Clinical severity assessment with pulse oximetry and observations, plus SARS-CoV-2 testing when it will alter management; investigate pneumonia, PE, sepsis and other complications when indicated.

Management

Recognise severity and create a safety net

  • Assess work of breathing, oxygen saturation, respiratory rate, mental state, circulation and urine output; escalate severe breathlessness, hypoxia, confusion, collapse, haemoptysis or suspected PE/sepsis.3,5,1
  • Give supportive care, hydration and symptom relief for uncomplicated illness, and advise people who are febrile or too unwell for normal activity to reduce contact with others under current UKHSA advice.4,2,1

Test and stratify treatment eligibility

  • Test when the result will change antiviral access, clinical management or infection-control decisions; symptoms alone cannot reliably distinguish COVID-19 from flu or other respiratory infection.1,11,12
  • Identify highest-risk conditions and medicines early, document renal/hepatic function and check pregnancy, breastfeeding and interactions before antiviral prescribing.17,7,11,9

Match early or hypoxic treatment

  • For an eligible highest-risk adult without an oxygen requirement, arrange prompt assessment for nirmatrelvir plus ritonavir; use current NICE and local pathways rather than routine prescribing.7,17,6,11
  • For COVID-19 requiring oxygen, give controlled oxygen and offer dexamethasone or an appropriate alternative for up to 10 days unless stopped earlier; do not use corticosteroids for non-hypoxic COVID-19 alone.6,4,9

Escalate respiratory and inflammatory disease

  • Discuss worsening oxygen requirement or respiratory distress with respiratory and critical-care teams; use selected awake prone positioning, CPAP or HFNO only with skilled monitoring and explicit goals of care.4,5
  • Consider tocilizumab with systemic corticosteroids in eligible adults needing oxygen or ventilation, or baricitinib in eligible hospitalised people needing oxygen when corticosteroid and infection criteria are met.6,7,9

Prevent complications and plan recovery

  • Assess bleeding and VTE risk and offer standard prophylactic LMWH when indicated in hospital-managed disease; reassess if the clinical condition changes and treat confirmed VTE through the current VTE pathway.13,19,9
  • At discharge document oxygen, function, medicines and safety-netting; for symptoms continuing or developing from 4 weeks, investigate red flags and provide personalised multidisciplinary follow-up or rehabilitation.14,15,16,4

Exam traps

  • Do not give dexamethasone for COVID-19 in a patient who does not need supplemental oxygen unless there is another indication.
  • Nirmatrelvir plus ritonavir is not routine treatment for low-risk community infection and has major drug interactions.
  • Sotrovimab is no longer a current UK NICE option after UK discontinuation; always check the current technology appraisal.
  • D-dimer alone does not determine an intensified anticoagulation dose; investigate suspected PE clinically.
  • COVID-19 and influenza can coexist; do not stop looking for bacterial infection, PE, heart failure or other causes of deterioration.
  • A long-COVID label should follow assessment of red flags and alternative diagnoses, with rehabilitation tailored to fluctuating symptoms.

Illustrations

COVID-19 pneumonitis on chest CTAxial chest CT showing multiple bilateral, predominantly peripheral rounded ground-glass and consolidative opacities in COVID-19 pneumonia.Jin, Y., Cai, L., Cheng, Z. et al, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NHS, COVID-19 symptoms and what to do (Current NHS symptom, self-care, urgent and emergency escalation information; media reviewed 2 June 2026)Updated 2 Jun 2026
  2. UKHSA, People with symptoms of a respiratory infection including COVID-19 (UKHSA advice on symptoms, staying home, reducing transmission and higher-risk people)Published 1 Apr 2022 | Updated 10 Jun 2022
  3. NICE NG191, COVID-19 rapid guideline: managing COVID-19 - assessment (Current NICE assessment recommendations; published 23 March 2021 and last updated 1 May 2025)Published 23 Mar 2021 | Updated 1 May 2025
  4. NICE NG191, COVID-19 rapid guideline: managing COVID-19 - management (Current NICE community, escalation and respiratory-support recommendations; last updated 1 May 2025)Published 23 Mar 2021 | Updated 1 May 2025
  5. NICE NG253, Suspected sepsis in people aged 16 or over (Current NICE sepsis recognition, escalation and source-control framework used for severe COVID-19)Published 19 Nov 2025
  6. NICE NG191, COVID-19 rapid guideline: managing COVID-19 - therapeutics (Current NICE antiviral, corticosteroid, tocilizumab, baricitinib, antibiotic and investigational-treatment recommendations; last updated 1 May 2025)Published 23 Mar 2021 | Updated 1 May 2025
  7. NICE TA878, Nirmatrelvir plus ritonavir and tocilizumab for treating COVID-19 (Current technology appraisal; recommendations last updated 26 February 2026, with the sotrovimab recommendation deleted after UK discontinuation)Published 29 Mar 2023 | Updated 26 Feb 2026
  8. NICE TA1056, Molnupiravir for treating COVID-19 (Current NICE technology appraisal; recommendations last updated 26 February 2026)Published 16 Apr 2025 | Updated 26 Feb 2026
  9. BNF online, COVID-19 antivirals, corticosteroids, anticoagulants and immunomodulators (Current BNF monographs to check at prescribing time for doses, interactions, contraindications, renal or hepatic adjustment, pregnancy and breastfeeding, and monitoring)
  10. UKHSA Green Book chapter 14a, COVID-19 vaccination (Current UK vaccination chapter updated 18 March 2026 for the Spring 2026 campaign, vaccine information and schedules)Published 27 Nov 2020 | Updated 18 Mar 2026
  11. NHS, Treatments for COVID-19 (NHS pathway for highest-risk people, prompt testing and treatment assessment)Published 21 Mar 2023
  12. NICE NG191, COVID-19 rapid guideline: identifying and managing co-infections (Current NICE guidance on bacterial and viral co-infection assessment and avoiding antibiotics for COVID-19 alone)Published 23 Mar 2021 | Updated 1 May 2025
  13. NICE NG191, COVID-19 rapid guideline: preventing and managing acute complications (Current NICE VTE prophylaxis recommendations for hospital-managed COVID-19, including risk assessment, standard LMWH and duration)Published 23 Mar 2021 | Updated 1 May 2025
  14. NICE NG188, COVID-19 rapid guideline: managing the long-term effects of COVID-19 (Current NICE long-COVID guideline covering symptoms from 4 weeks onward; last updated 25 January 2024)Published 18 Dec 2020 | Updated 25 Jan 2024
  15. NICE NG188, long-COVID management and rehabilitation (NICE recommendations for holistic assessment, personalised rehabilitation and symptom fluctuation)Published 18 Dec 2020 | Updated 25 Jan 2024
  16. NICE NG188, long-COVID follow-up, monitoring and discharge (NICE shared follow-up, red-flag monitoring and discharge recommendations)Published 18 Dec 2020 | Updated 25 Jan 2024
  17. NICE TA878, supporting information on risk factors for progression to severe COVID-19 (Current NICE-linked risk-factor definitions used to determine eligibility for nirmatrelvir plus ritonavir; last updated 26 February 2026)Published 29 Mar 2023 | Updated 26 Feb 2026
  18. NICE TA971, Remdesivir and tixagevimab plus cilgavimab for treating COVID-19 (NICE technology appraisal for remdesivir and tixagevimab plus cilgavimab, published 8 May 2024)Published 8 May 2024
  19. NICE NG89, Venous thromboembolism in over 16s (Current NICE general VTE prophylaxis guidance, cross-referenced by NICE NG191 for COVID-19 pneumonia)Published 21 Mar 2018

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.