The following guidelines are based on evidence assessment and published guidance at the time of review, and are subject to further changes as new COVID-19 treatment evidence emerges and new guidance is published.
This section focuses on specific antiviral, immunomodulatory and monoclonal antibody therapies for COVID-19. Comprehensive guidelines can be found at Guidance for prevention and management of COVID-19 in children and adolescents: A consensus statement from the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce.
The recommendations below were updated 9/10/24.
| Condition | Major Pathogens | First Choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
| Pre-exposure prophylaxis in certain hiigh risk patients unable to develop antibody response to immunization | SARS-CoV-2 | Vaccination is the most effective way to prevent COVID-19. For most up to date recommendation on monoclonal antibodies please refer to PIDS Guidelines | ||
| High risk patient with exposure to coronavirus disease 2019 (COVID-19) | Same |
No specific therapy |
Monitor for development of symptoms | |
| Coronavirus disease 2019 (COVID-19), asymptomatic | Same | No specific therapy | Monitor for development of symptoms | |
|
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 |
Same |
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 |
Same |
Remdesivir: Age <12 years and/or weight < 40 kg: Weight 3.5-40 kg: Age ≥12 years and weight >40 kg: Weight >40 kg: See 4th column for monitoring, last column for duration AND Dexamethasone* 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: ALT elevation AND signs or symptoms of liver inflammation: Discontinue remdesivir. |
ID approval is required for baricitinib use but not remdesivir use Duration: Critical disease: 5-10 days, guided by clinical course Dexamethasone: *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)
|
Post-infectious phenomenon following SARS-CoV-2 infection | Antiviral treatment is not routinely indicated, unless acute COVID-19 is also a diagnostic consideration, and patient would meet above criteria for severe or critical disease. Other management of MIS-C is currently outside the scope of this section. Refer to American College of Rheumatology Clinical Practice Guidelines for MIS-C for comprehensive recommendations |
Rheumatology consult recommended Consider ID consult if needed to distinguish other etiologies if MIS-C diagnosis is not clearly established |
References:
Chiotos K, et al. Multicenter interim guidance on use of antivirals for children with coronavirus disease 2019/severe acute respiratory system coronavirus 2. J Pediatr Infect Dis Soc 2021;10:34-48.
Wolf J, et al. Initial guidance on use of monoclonal antibody therapy for treatment of COVID-19 in children and adolescents. J Pediatr Infect Dis Soc 2021;10:629-634.
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health.
Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19
American Society of Health-System Pharmacists. Assessment of evidence for COVID-19-related treatments. Available at: ASHSP COVID-10 Resource Center.
Adamsick ML, Gandhi RG, Bidell MR, et al. Remdesivir in patients with acute or chronic kidney disease and COVID-19. J Am Soc Nephrol. 2020;31(7):1384-1386.
Willis ZI et al. Guidance for prevention and management of COVID-19 in children and adolescents: A consensus statement from the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce. J Pediatric Infect Dis Soc. 2024 Mar 19;13(3):159-185.
Henderson LA et al. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis Rheumatol. 2022 Apr;74(4):e1-e20
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.