COVID-19 is an acute infectious disease caused by the coronavirus SARS-CoV-2. Transmission most commonly occurs via exposure to respiratory fluids. The incubation period varies between 2–14 days and may be shorter with newer variants. Common presenting symptoms include fatigue, fever, and symptoms of an upper respiratory tract infection; affected individuals may also be asymptomatic. Clinical courses range from asymptomatic infection, to mild with minimal symptoms, to severe with pneumonia and life-threatening complications (e.g., acute respiratory distress syndrome, shock, organ dysfunction). Diagnostic confirmation is made based on COVID-19 testing, which includes nucleic acid amplification testing (e.g., PCR) or antigen testing on a respiratory specimen. Imaging findings are nonspecific, resemble those in other viral respiratory tract infections, and should not be used to confirm the diagnosis of COVID-19. Individuals with mild COVID-19 can typically be managed with supportive care at home. Pharmacotherapy can be considered for outpatients with . Patients with moderate or severe COVID-19 or those with risk factors for severe disease may require hospitalization for oxygen therapy, pharmacotherapy, and antithrombotic therapy. The risk of infection can be reduced through preventive efforts, which include vaccination, public health measures (e.g., social distancing, mask-wearing), and getting tested after close contact with infected individuals.
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- Incidence and prevalence: Refer to the resources below for up-to-date statistics.
- The number of cases is similar between men and women. 
- Affects people of all ages; serious disease is more likely in individuals ≥ 65 years of age. 
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
- SARS-CoV-2 is an enveloped, nonsegmented, β-coronavirus, ssRNA . 
- The viral genome encodes:
SARS-CoV-2 variants 
- Several variants have been detected worldwide.
- The CDC considers a variant of concern to be one with any of the following:
|Current SARS-CoV-2 variants of concern (Last updated: February 2022) |
|Variant||Pango lineage||First detected||Features (relative to the orignal strain)|
|Delta|| || || |
|Omicron|| || || |
|Previous SARS-CoV-2 variants of concern |
|Variant||Pango lineage||First detected||Features (relative to the original strain)|
|Alpha|| || || |
|Beta|| || || |
|Epsilon|| || || |
|Gamma|| || || |
- The R0) of the original strain is estimated to be ∼ 2–3. (
- The R0 is higher in newer variants compared to the original strain.
- Factors affecting R0 include:
- Duration of infectiousness: Individuals with COVID-19 are infectious from ∼2–3 days before symptom onset until ∼ 8 days after symptom onset. 
- Likelihood of infection spreading between individuals (see “Modes of transmission”)
- Rate of close contacts between individuals with and without infection
- Efforts to reduce the contact rate (e.g., social distancing, quarantine) aim to lower the R0
“Flattening the curve”, a reference to the number of new cases depicted on a graph, refers to reducing the number of people infected by each infectious individual. Flattening the curve means that new infections are distributed over a longer period of time.
Modes of transmission 
The primary mode of transmission is exposure to respiratory fluids via either:
Inhalation of droplets or aerosol particles
- The concentration of aerosol particles is highest within 3–6 feet of the infectious source.
- Small aerosol particles can remain suspended in the air for minutes to hours.
- The risk of transmission is increased in poorly ventilated areas.
- Mucous membrane contact with respiratory particles
- Inhalation of droplets or aerosol particles
- Fomite transmission is possible but unlikely to be a major mode of transmission. 
- Vertical transmission: See “ .”
SARS-CoV-2 can be transmitted by asymptomatic individuals.
Viral life cycle 
- Invasion of host cells
- Replication cycle
- Direct cytopathic effects: Particularly on the alveolar epithelium; other organs (e.g., liver, heart) can be affected as well. 
- Dysregulated immune response ; 
- Incubation period: 2–14 days, usually ∼ 5 days 
- Symptoms 
- Severity ranges from asymptomatic to critical.
- A patient's clinical presentation may change over the course of the disease.
- See “COVID-19 disease spectrum” for details.
General principles 
Diagnostic confirmation is based on .
- Test all individuals with symptoms of and/or exposure to COVID-19 for current infection (see the latest CDC indications for testing at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html).
- Collect specimens from the upper respiratory tract (e.g., nasopharyngeal, oropharyngeal).
- Obtain a viral test (e.g., nucleic acid amplification test) or antigen test to diagnose current infection.
- Should not be used as a screening modality or the sole diagnostic modality for COVID-19
- May be indicated to assess disease severity and rule out alternative diagnoses
- See “ ” for details.
Collection of specimens 
- For all individuals: Obtain an upper respiratory tract specimen.
- For mechanically ventilated individuals with a negative upper respiratory tract specimen: Obtain a lower respiratory tract aspirate or bronchoalveolar lavage.
|COVID-19 tests |
|Characteristics||Virological tests for COVID-19||Serological testing |
|Nucleic acid amplification testing (NAAT; RT-PCR-based test)||Antigen testing|
|Specimen|| || |
|Advantages|| || |
- Triage patients via telemedicine when possible.
Determine site of care based on disease severity and the presence of .
- Asymptomatic or mild disease in low-risk patients: outpatient management
- Moderate to severe disease, or 9: in-person evaluation; hospitalization if needed
- Patients requiring in-person evaluation: Consult institutional guidelines regarding the appropriate site of care.
- See also “ .”
Severity assessment 
|COVID-19 disease spectrum |
|Asymptomatic COVID-19|| |
Risk factors for severe COVID-19 
- Age (strongest risk factor): older adults, especially ≥ 65 years of age
- Cardiovascular disease
- Cerebrovascular disease
- Chronic kidney disease
- Chronic liver disease
- Chronic lung diseases
- Diabetes mellitus type I and type II
- Mental health disorders
- Obesity (BMI ≥ 30)
- Pregnancy or recent pregnancy
- Smoking (current and/or former)
General principles 
Patients with mild or asymptomatic disease who do not have can usually be managed in an outpatient setting.
- Advise patients on methods to minimize the spread of infection, e.g.:
- Discuss symptom monitoring and advise patients to seek medical attention if they experience any of the following:
Medical management 
- Rest, adequate hydration, and nutrition
- Antipyretics and analgesia as needed (e.g., acetaminophen, ibuprofen)
- Antitussives as needed (e.g., dextromethorphan, benzonatate)
- Prone positioning may relieve dyspnea.
- Indications: patients with
- Preferred agents: ritonavir-boosted nirmatrelvir, remdesivir
- Alternatives (only if preferred agents are not available): molnupiravir, bebtelovimab
- Not currently recommended: systemic glucocorticoids, chloroquine, hydroxychloroquine, azithromycin, ivermectin
- For possible drug interaction, see “https://www.covid19-druginteractions.org/checker.”
|Pharmacotherapy for nonhospitalized high-risk adults with COVID-19 |
|Medication||Timing of administration after symptom onset||Clinical considerations|
|Ritonavir-boosted nirmatrelvir|| || |
| || |
|Bebtelovimab|| || |
Monitoring and follow-up 
- Monitor oximetry readings and symptom progression via telemedicine or in-person visits.
- Evaluate patients with worsening symptoms in-person.
- Advise patients that the time to recovery from COVID-19 varies.
- Encourage self-isolation until criteria for are met.
Patients with moderate to severe COVID-19 often require hospitalization.
- Determine patient's goals of care and obtain advance directives, if available.
- Determine severity of illness and admit patients to the appropriate level of care.
- Tailor additional diagnostics (laboratory studies, imaging) to the clinical presentation.
- For patients with complications related to COVID-19, see also the management sections in the following articles:
Laboratory studies 
Laboratory parameters in COVID-19 are nonspecific but are useful in evaluating for organ dysfunction
- Routine studies
Further evaluation based on clinical presentation 
- Inflammatory markers: ↑ CRP, ↑ ferritin, ↑ lactate dehydrogenase
- Coagulation studies: ↑ prothrombin time, ↑ D-dimer
- Cardiac enzymes: ↑ troponin and ↑ NT-proBNP may indicate cardiac injury related to COVID-19
- Arterial blood gas: may reveal hypoxemic respiratory failure
- Blood cultures: Order if there is concern for bacterial coinfection.
Chest imaging in COVID-19 
- Features of or
- Worsening respiratory status
- Patients with with
- Modalities: Initial imaging studies may include chest x-ray, chest ultrasound, and chest CT.
- Important consideration: Imaging findings in COVID-19 are generally nonspecific and resemble findings in other viral respiratory infections.
Imaging alone cannot confirm a diagnosis of COVID-19. Imaging findings suggestive of COVID-19 should be verified via . 
Chest x-ray 
- Indications: : often the initial test to asses disease severity and rule out differential diagnoses (e.g., pneumothorax, pleural effusion)
- Supportive findings
Chest ultrasound 
- Indications: an alternative to chest x-ray to assess disease severity and rule out other chest pathologies (e.g., pneumothorax, pleural effusion) in critically ill patients; often performed in emergency department and ICU settings (lung POCUS)
- Supportive findings
Chest CT (noncontrast) 
- Indications: : hospitalized symptomatic patients with other specific clinical indications for a chest CT 
Imaging studies can not be used to diagnose COVID-19.
Screening for VTE 
- Patients with PE) and/or (
- Patients with sudden or rapid clinical deterioration
There is insufficient evidence to recommend routine screening for VTE in patients with COVID-19, even in those with elevated coagulation markers. 
Supportive care 
- Intravenous fluid therapy as needed
- Vasopressors as needed (i.e., for shock):
- Antipyretics and analgesia as needed (e.g., acetaminophen, ibuprofen)
- Antitussives as needed (e.g., benzonatate)
- If available, hemodialysis for patients with acute kidney injury and . is preferred over
Oxygen therapy 
- Goal: Maintain SpO2 levels between 92–96% (≥ 95% in pregnant individuals).
High flow nasal cannula (HFNC)
- Indications: hypoxemic respiratory failure despite the use of (e.g., nasal cannula, face mask)
- HFNC unavailable: Consider noninvasive positive pressure ventilation.
- Persistent hypoxemia despite HFNC (and no indications for invasive mechanical ventilation): Consider a trial of awake prone positioning to improve oxygenation. 
- Mechanical ventilation
- Extracorporeal membrane oxygenation (ECMO): There is insufficient evidence to recommend for or against the use of ECMO in patients with COVID-19 and refractory hypoxemia.
- See also “ ” for more information.
A trial of awake prone positioning can be considered in individuals with hypoxemia that persists despite HNFC, but the procedure is not routinely recommended in patients who require supplemental oxygen without mechanical ventilation. 
- Pharmacotherapy for hospitalized patients with COVID-19 varies according to disease severity.
- Pharmacologic options include remdesivir, dexamethasone, and other immunomodulators.
- For the latest guideline recommendations, see https://www.covid19treatmentguidelines.nih.gov/therapeutic-management.
- For possible drug interaction, see “https://www.covid19-druginteractions.org/checker.”
|Pharmacotherapy regimens of hospitalized patients with COVID-19 |
|Disease severity|| |
(See table below for dosage information)
|Not requiring O2 therapy|| |
|Requiring O2 therapy|
|Requiring or noninvasive ventilation|
|Requiring mechanical ventilation or ECMO|
Pharmacotherapy is indicated for all hospitalized patients who require supplemental oxygen. 
|Overview of medications for COVID-19 in hospitalized patients |
|Medication class||Specific agents||Mechanism of action||Clinical considerations|
|IL-6 pathway inhibitors|| |
|JAK inhibitors || |
Patients started on remdesivir should complete the full treatment course, even if they experience disease progression. 
Antithrombotic therapy in COVID-19 
- Indications: all hospitalized patients who do not have
- Agents: LMWH or UFH is preferred over oral anticoagulants; LMWH is preferred over UFH.
- Therapeutic dose is recommended for:
- Prophylactic dose ( ) is recommended for:
Postdischarge management 
- All patients
- Supplemental O2 no longer required: Discontinue remdesivir, corticosteroids, and JAK inhibitors at the time of discharge.
- Continued requirement of supplemental O2 at discharge: Arrange for home oxygen monitoring.
Discontinuation of isolation
CDC recommendations; for discontinuation of isolation vary based on symptoms and disease severity; for the latest guidelines, see: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html 
- All individuals with COVID-19 should isolate for at least 5 days (day 0: day of symptom onset or positive COVID-19 test).
- Mildly symptomatic or asymptomatic individuals may consider an antigen test around day 5 to determine need for further isolation. 
Typically, patients with asymptomatic, mild, or moderate COVID-19 are no longer infectious 10 days after symptom onset. 
|Discontinuing isolation in patients with COVID-19 |
|Patient group||When isolation can stop|
|Moderately to severely immunocompromised patients|| |
- Thromboembolic events (e.g., ischemic stroke, pulmonary embolism)
- Hypoxemic respiratory failure
- Septic shock
- Cardiac disease (e.g., ischemic heart disease, heart failure) 
- Arrhythmias 
- Acute kidney injury
- Postacute COVID-19 syndrome (“long COVID”) 
We list the most important complications. The selection is not exhaustive.
Special patient groups
This section provides recommendations for specific patient groups during the COVID-19 pandemic.
- Pregnant and recently pregnant individuals are at higher risk of .
- Counsel pregnant individuals on ways to minimize the risk of infection (see “Protective measures for the general public” in the section “ ”).
- Vaccination against COVID-19 is recommended for pregnant and breastfeeding individuals. 
- Treatment options for pregnant patients with COVID-19 are generally the same as those for nonpregnant patients.
Management of COVID-19 during pregnancy 
- Determine the need for in-person evaluation and hospitalization based on symptoms and comorbidities. 
- Order imaging (e.g., chest x-ray or chest CT) if clinically indicated.
- Supplemental oxygen
- Consider fetal monitoring for hospitalized patients.
- Consider pharmacological treatment, if indicated.
- Anticoagulation is indicated for hospitalized patients with COVID-19 (see “ ”). 
Patients with symptoms suggestive of moderate to severe disease, or those with require in-person evaluation.
In pregnant patients with COVID-19, maintain oxygen saturation ≥ 95% on room air. 
Management of COVID-19 in the peripartum period 
- Infection with COVID-19 is not a contraindication for vaginal delivery.
- Mothers with COVID-19 do not need to isolate from their babies after birth.
Symptomatic COVID-19 during pregnancy is associated with an increased risk of:
- Children are less likely to get COVID-19.
- Clinical presentation
- Children are often asymptomatic or develop .
- Symptoms may be similar to other viral illnesses
- The ≥ 5 years of age is recommended for all children in the US
- See “” for details.
The Moderna and Janssen vaccines are not currently recommended for use in individuals < 18 years of age. 
Given limited data in children, the decision to use pharmacological treatments should be made after weighing the risks and benefits for each patient.
- Most children can be managed with symptomatic treatment only.
- COVID-19 pharmacotherapy for children (age ≥ 12 years; weight ≥ 40 kg)
Multisystem inflammatory syndrome in children (MIS-C) 
MISC-C is a complication of COVID-19 in children that manifests with hyperinflammation, severe illness, and involvement of multiple organ systems.
- Clinical features may include:
Diagnostic criteria: : All of the following must be met. 
- Age < 21 years
- Fever (documented fever ≥ 38°C (100.4°F) OR report of subjective fever lasting ≥ 24 hours
- Laboratory evidence of inflammation (e.g., ↑ CRP, ↑ ESR, ↑ neutrophils)
- Involvement of ≥ 2 organ systems (including the hematological system)
- Severe illness requiring hospitalization
- Confirmed current or recent SARS-CoV-2 infection OR exposure to an individual with COVID-19 < 4 weeks prior to symptom onset
- No other plausible diagnosis
Treatment: combination of immunomodulatory therapy and antithrombotic therapy 
- Immunomodulatory therapy
- Antithrombotic therapy (unless contraindicated)
- Factors that may increase the risk of infection in patients with physical or intellectual disabilities include:
- Need for a support person to assist with mobility
- Difficulty implementing personal protective measures, e.g., due to cognitive impairment
- Living in a congregate setting, e.g., a nursing home
- Delayed diagnosis, e.g., individuals with impaired speech or cognition may have difficulty communicating symptoms
- Some comorbidities that are are more common in individuals with disabilities.
Patient considerations 
- Vaccinate eligible individuals.
- Work with the patient to develop an individualized plan for reducing infection risk.
- Organize backup support in case the current support person becomes sick or is quarantined.
- Establish reliable methods for seeking immediate assistance (e.g., preprogrammed phone numbers)
- Ensure that the patient has sufficient supplies of household items, medication, and medical equipment.
- See also “Protective measures for the general public” in the section “ .”
- The risk of death from COVID-19 increases with age. 
- Death rates are higher among unvaccinated individuals compared to vaccinated individuals. 
- Death rates are higher among vaccinated individuals who have not received a booster compared to those who have received a booster. 
Protective measures for the general public 
- Practice hand hygiene, cough etiquette, and avoid touching the face (see “” for details).
Masks can provide additional protection for individuals ≥ 2 years old.
- Masks should have a close fit over the nose and mouth.
- N95 and K95 masks offer greater protection than surgical masks.
- Cloth masks provide the least protection.
- Follow public health guidance to reduce spread of COVID-19
- E.g., guidance on , , and lockdowns
- See also “ .”
COVID-19 testing is recommended:
- After close contact with infected individuals
- Individuals with symptoms suggestive of COVID-19
- All eligible individuals should be vaccinated.
- See the CDC website for additional guidance: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
COVID-19 vaccines 
See https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#recommendations for the most recent guidelines.
- Types: Three COVID-19 vaccines are available in the US.
- Indication: all individuals ≥ 5 years of age
- Primary series
- A different vaccine may be used for initial vaccination and booster.
- Defer vaccination in patients with recent or current COVID-19 until full recovery and completion of isolation.
- Contraindication: history of a severe allergic reaction to any component of the vaccine
- Common: injection site pain and redness, headache, myalgia, fever, chills, fatigue
|COVID-19 vaccines |
|Name||Type||Age group (United States)|| Immunization schedule |
(All COVID-19 vaccines are administered intramuscularly )
|Pfizer-BioNTech COVID-19 vaccine || || |
|Moderna COVID-19 vaccine || || |
| || |
Individuals ≥ 12 years of age are considered fully vaccinated after receiving their first booster; individuals 5–11 years of age are considered fully vaccinated two weeks after receiving the second dose of the PfizerBioNTech COVID-19 vaccine.
While vaccinated individuals can still contract COVID-19, they have a significantly lower risk of severe disease and death than unvaccinated individuals. 
Management of high-risk exposures (close contact) 
- Close contact is defined as being < 6 feet from an infectious individual for ≥ 15 min.
- Indicated for all vaccinated and unvaccinated individuals who have not had COVID-19 in the past 90 days
- Testing should be performed at least five days after close contact.
- The need for and duration of isolation varies by vaccination status: See https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html for the most recent guidelines.
- All close contacts should wear well-fitting masks around others for 10 days and avoid contact with high-risk individuals.
Preexposure prophylaxis 
- Regimen: tixagevimab PLUS cilgavimab (long-acting )
Preventing spread of COVID-19 in healthcare settings
- Consider for triage and outpatient monitoring of patients with when feasible. 
- Personal protective equipment (PPE) 
- Strategies to reduce spread in healthcare settings include:
- Separate locations dedicated to the evaluation of patients with known or possible COVID-19
- Limiting the number of visitors allowed per patient
- Screening all people entering the health care facility for symptoms of COVID-19
- Nonurgent procedures and elective surgeries may be postponed to preserve hospital beds and resources.
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