Coronavirus Disease 2019 (COVID-19)

No specific therapy

Coronavirus disease 2019 (COVID-19), mild-moderate  

Mild: No new or increased supplemental oxygen requirement, with symptoms limited to upper respiratory tract 

Moderate: No new or increased supplemental oxygen requirement, with symptoms involving the lower respiratory tract, or radiographic findings on chest X-ray 

Supportive care is recommended for most patients

Inpatient antiviral therapy may be considered on a case-by-case basis. 

Outpatient therapy may be considered for high risk patients if indicated per Emergency Use Authorization, please refer to PIDS guidelines

See severe-critical section below if treating with antiviral therapy 

Coronavirus disease 2019 (COVID-19), severe-critical 

Severe: new or increased requirement for supplemental oxygen 

Critical: new or increased requirement for invasive or noninvasive mechanical ventilation, sepsis, multiorgan failure, or rapidly worsening clinical trajectory that does not yet meet these criteria 

Remdesivir:

Age <12 years and/or weight < 40 kg: 
Remdesivir  lyophilized powder only 

Weight 3.5-40 kg:
5 mg/kg/dose IV on day 1, then 2.5 mg/kg/dose IV q24h 

Age ≥12 years and weight >40 kg: 
Remdesivir injection solution or lyophilized powder 

Weight >40 kg:
200 mg/dose IV on day 1, then 100 mg/dose IV q24h 

See 4th column for monitoring, last column for duration 

AND 

Dexamethasone*
0.15 mg/kg/dose (max 6mg/dose) IV or enterally q24h (see last column for duration)  

For patients especially adolescents with substantially escalating respiratory support needs (requiring critical care) after initiation of remdesivir and dexamethasone, consider adding IL-6 inhibitor or JAK inhibitor in consultation with ID. There is not yet sufficient data to recommend routinely adding these medications in pediatric patients.

Use the age-appropriate remdesivir order panel to ensure adherence to criteria.  

Monitoring for remdesivir:  
 
Monitor hepatic panel at baseline and during therapy 

ALT >10 times the upper limit of normal and asymptomatic: Consider discontinuing remdesivir. 

ALT elevation AND signs or symptoms of liver inflammation: Discontinue remdesivir. 

Although the manufacturer's labeling recommends against use in patients with eGFR <30 mL/minute, significant toxicity with a short duration of therapy (e.g., 5 to 10 days) is unlikely.  

ID approval is required for  baricitinib use but not remdesivir use

Duration:  
Remdesivir: 
Severe disease: 5 days 

Critical disease: 5-10 days, guided by clinical course 

Dexamethasone:  
Up to 10 days or until hospital discharge, whichever comes first   

*Consider risks vs. benefits of dexamethasone in relationship to underlying conditions (e.g. prior immunosuppression, metabolic disease, etc.) especially in patients with less severe respiratory illness e.g. not requiring mechanical ventilation.  

Multisystem inflammatory syndrome in children (MIS-C) 

Rheumatology consult recommended 

Consider ID consult if needed to distinguish other etiologies if MIS-C diagnosis is not clearly established