National Guidelines on

Clinical Management
of COVID-19
(Short Edition of 9th Version)
6.5.2021

Communicable Disease Control

Directorate General of Health Services
Classification

Asymptomatic No symptoms but test positive

Mild case: Influenza Like The clinical symptoms are mild, and there is no evidence of pneumonia.
illness (ILI)
 Symptoms may be Fever  Diarrhoea
 Cough  Vomiting
 Loss of taste or smell  Rhinorrhoea
 Myalgia  Sore throat
 Fatigue  Red eye
 Anorexia  Abdominal pain
 Headache  Skin lesion (chilblain, nodule) etc.
 Ageusia

Moderate case (Pneumonia)  Adolescent or adult with clinical signs of pneumonia (fever, cough,
dyspnoea, fast breathing) but no signs of severe pneumonia,
including SpO2 ≥ 90% on room air.

 Child with clinical signs of non-severe pneumonia (cough or

difficulty breathing + fast breathing and/or chest indrawing) and no
signs of severe pneumonia. Fast breathing (in breaths/min): < 2
months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40.

 While the diagnosis can be made on clinical grounds, chest imaging

(radiograph, CT scan, ultrasound) may assist in diagnosis and
identify or exclude pulmonary complications.

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Severe case (Severe Adolescent or adult with clinical signs of pneumonia (fever, cough,
Pneumonia) dyspnoea, fast breathing) plus one of the following: severe respiratory
distress, respiratory rate > 30 breaths/min or SpO2 < 90% on room air.

Child with clinical signs of pneumonia (cough or difficulty in breathing)

+ at least one of the following:

 Central cyanosis or SpO2 < 90%; severe respiratory distress (e.g.,

fast breathing, grunting, very severe chest indrawing); general
danger sign: inability to breastfeed or drink, lethargy or
unconsciousness, or convulsions.

 Fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11 months:

≥ 50; 1–5 years: ≥ 40.

Critical cases (Cases Severe COVID-19 case meeting any of the following criteria:
requiring ICU care)  Respiratory failure and requiring mechanical ventilation
 Sepsis
 Septic shock
 ARDS
 Any organ failure that requires ICU care

N.B: Pregnant women with COVID-19 should be considered as a severe case if the
saturation level is below 94%.

Risk factors for severe COVID-19

 DM  CLD
 HTN  IHD
 High risk Pregnancy  Heart failure
 CKD  Dementia
 Asthma  Mental disorder
 COPD  Stroke
 Obesity  On steroids
 Malignancy  Chemotherapy

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Triage

Ask about symptoms of COVID-19

Main symptoms: Other symptoms:

 Fever  Myalgia  Ageusia  Sore throat

 Cough  Fatigue  Diarrhoea  Red eye
 Dyspnoea  Anorexia  Vomiting  Abdominal pain
 loss of taste or smell  Headache  Rhinorrhoea  Skin lesion (chilblain,
nodule) etc.

Yes No

Confirmed COVID-19 if test Suspected COVID-19

COVID-19 Unlikely
already positive.

Clinical evaluation and classification Refer to NON-COVID section of the

hospital. Investigate and manage
accordingly
• Visible respiratory distress
• Respiratory rate >30(severe) <30(moderate) • No visible respiratory distress.
• SPO2 on air <93% • Normal clinical exam
• Patient looks unwell • SPO2 ≥93 %
• Absence of other possible causes • No tachypnoea
• Can do usual activities

Moderate/Severe/Critical illness
Mild case but no need for admission except in
Start oxygen from Triage area if SPO2 < 90% some specific conditions
(Severe case) and Admit the patient Do antigen testing and if it is negative then
advice for RT-PCR

For critical cases : start resuscitating the

patient at Triage area. Contact ICU/ HDU or
referral centers for vacancy Manage mild case accordingly

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Admission Criteria

All suspected/ confirmed cases of COVID-19 presenting as

 Moderate case- clinical or radiological evidence of pneumonia

 Severe Pneumonia- clinical or radiological evidence of pneumonia with signs of severe pneumonia (RR > 30 /min
or oxygen saturation <90%)
 Critical COVID-19: ARDS, Sepsis, Septic shock
 Hypoxia (SPO2 <93%) even in the absence of any clinical signs
 Patient with multiple uncontrolled comorbidities or prothrombotic state such as high-risk pregnancy, active
malignancy, DVT irrespective of severity etc.

Clinical
Management
A. Asymptomatic patients
Supportive care + Isolation protocol (either home or institutional depending on national strategy).

Advice for cases in home isolation:

 Rest at home in self-isolation. If self-isolation at home is not possible because of lack of care giver, overcrowding
at home or for any other cause, patient should be brought to the hospital for institutional isolation in a designated
area.
 Physical distancing with family members. If possible, remain in a separate single room.
 No visitor.
 Regular Hand Wash (20 seconds each time)
 Cough etiquette: use tissue paper or elbow followed by hand wash.
 Medical mask (both patient and caregiver)

B. Mild cases
 Mild case without comorbidities- Only symptomatic management and home isolation in a single room. (above
mentioned home isolation protocol should be strictly followed).

 Mild case with controlled comorbidities- such as DM, HTN, IHD, Asthma/COPD/ILD, CKD, CLD, Malignancy,
Pregnancy, Obesity can be managed at home. However, patient should be carefully monitored at home with
finger pulse oximetry and be watchful about danger signs.

 Mild case with multiple uncontrolled comorbid conditions such as HTN, DM, IHD, CKD, CLD,
COPD/Asthma/ILD and prothrombotic state such as high risk-pregnancy and active malignancy etc. should
receive thromboprophylaxis along with symptomatic management and should be admitted.

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Management of mild cases
 For fever: Tab Paracetamol (500mg) 1-2 tablet 3-4 times daily.

 For Rhinorrhea: Antihistamine.

 For cough: Antitussive for dry cough, inhaled budesonide 200mcg 2 puff 12 hourly.

 Thromboprophylaxis: Thromboprophylaxis is not routinely indicated for mild cases except for Mild COVID 19
cases with multiple uncontrolled comorbidities and prothrombotic conditions: Enoxaparin 40 mg, SC, once daily
(OD) [for obese patients (BMI>40), 40 mg BID]. When CrCl< 30ml/min: Enoxaparin 20 mg SC OD for both obese
and non-obese patient. or Unfractionated Heparin 5000 unit SC/BD.

 Monitor oxygen saturation at rest and minimum exertion such as walking for 3-6 minutes.

 Look for any danger signs of COVID as for example- Breathing difficulties, chest pain, light headedness,
disorientation, extreme weakness which results in even difficulties in walking and drop in oxygen saturation to or
<93% etc.

 Investigations: No routine investigations are required for mild cases.

N.B There is no role of systemic steroid in mild cases. Rather it may be harmful if given during the viremic phase of
the disease especially in the first 7 days.

C. Moderate cases
 Symptomatic management as like as mild case

 Oxygen through nasal cannula (Maximum 5 L/min) if required. Target SPO2 is 94% during initial resuscitation
and 90% for stable patients. For pregnant patients and patients with other organ failure target SPO2 is 94%

 Proning- Maintain prone position for a total of 4-6 hours/day (divided in shorter period over the day)

 Thromboprophylaxis:

LMWH(Enoxaparin) at standard dose of 40 mg SC OD

For obese patients (BMI >40) LMWH, 40 mg SC BD

If CrCl < 30 reduce the dose to 20 mg SC OD (both for obese and non-obese patient)

 If LMWH cannot be given or contraindicated, use unfractionated heparin (UFH). Dose of unfractionated heparin:
5000unit/day SC BD

 Thromboprophylaxis should be given till discharge or for 7 days whichever is longer and followed by Tab.
Rivaroxaban 10 mg once daily Or Tab Apixaban 2.5 mg twice daily for 1 month (especially patients at high risk for
thromboembolism and based on clinician’s discretion)

 Antiviral: Remdesivir should be used within 10 days of symptom onset and at the discretion of consultant
working in the hospital in all hospitalized adult and pediatric patients (>12 years old) with suspected or
laboratory-confirmed COVID-19 case

— Who is hypoxic (SPO2 <93%) or

— Having increased breathing difficulties or
— Who needs oxygen
 Steroid should be given in patients having respiratory distress and becoming hypoxic SPO2<93%. Dosing:
Dexamethasone (0.5 mg): 12 tablets daily for adults

 Antibiotic: there is no role of antibiotic in COVID-19 infection. Oral antibiotic such as Amoxicillin Clavulanic acid
or Doxycycline may be given if bacterial infection is suspected.

 Investigation: CBC, CRP, D-dimer, S. LDH, S. ferritin, S. creatinine, ALT, CXR PA view/HRCT of chest or other
markers as per treating clinician’s decision.

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D. Severe cases
 Symptomatic management for cough and fever described for mild cases

 Oxygen therapy: Escalate oxygen flow as per patient’s SPO2 and degree of respiratory distress. Change of oxygen
delivery device as required to maintain SPO2: Nasal cannula (up to 5 litre), Oxygen mask (6-10 litre) and
Non-Rebreather bag with reservoir bag (10-15 litre). We recommend immediate administration of supplemental
oxygen to any patient with emergency signs during resuscitation to target SPO2 ≥ 94% and to any patient without
emergency signs and hypoxaemia (i.e. stable hypoxaemic patient) to target SPO2 > 90% or ≥ 92–95% in pregnant
women

 Proning- Maintain awake prone position for a total of 4-6 hours/day or more (divided in shorter period over the
day). Please avoid proning if patient is severely dyspneic and if there is any contraindication. In this case try
lateral and sitting position

 Steroid- Inj. Dexamethasone 6 mg once daily for 7 to 10 days

 Maintain euvolemia

 Avoid fluid overload

 Anticoagulation:

 Initiate Thromboprophylaxis (LMWH) in standard doses of 1mg/kg/day and assess the bleeding risk

 There is lack of high-quality evidence of therapeutic anticoagulation in severe cases. Consider

therapeutic anticoagulation (1 mg/kg body weight 12 hourly) only if patient has proven
thromboembolism and suspected thromboembolism

 Thromboprophylaxis should be given till discharge or for 7 days whichever is longer and followed by Tab
Rivaroxaban 10 mg once daily Or Tab Apixaban 2.5 mg twice daily for 1 month especially patients at high
risk for thromboembolism and based on clinician’s discretion

 Antiviral: Remdesivir should be used within 10 days of symptom onset and at the discretion of consultant
working in the hospital in all hospitalized adult and pediatric patients (>12 years old) with suspected or
laboratory-confirmed COVID-19 case

— who is hypoxic (SPO2 <93%) or

— having increased breathing difficulties or

— who needs oxygen

 Antibiotic— IV broad spectrum antibiotic at the discretion of consultant if bacterial infection is suspected

 Investigation: CBC, CRP, D-dimer, S. ferritin, S. creatinine, ALT, CXR P/A view or other labs or imaging as per
treating clinician’s decision. HRCT of chest should not be routinely advised. It can only help in diagnostic
dilemma. There is no role HRCT scan of chest in the management of COVID-19

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Recommendations About Other Drugs

1. Tocilizumab
It should not be routinely used to manage severe to critical COVID-19. It can only be used under consultant’s
supervision only if following clinical and biochemical criteria are fulfilled. Discuss efficacy, possible adverse events
and cost with patient or patient’s guardian before starting Tocilizumab.

Indication
A) Clinical Criteria:

Patients (Adult (≥18 years) who have been admitted to the intensive care unit (ICU) within the last 24 hours
and who require invasive mechanical ventilation, noninvasive mechanical ventilation (NIV), or high-flow
nasal canula (HFNC) oxygen (needing >30 L/min of oxygen and FiO2>0.4

B) Biochemical criteria: CRP> 75 mg/dl.

Dosing
Consider only 1 dose at 8 mg/kg (max: 800 mg/dose). Can be repeated after 12-24 hours if no clinical improvement.
Max 2 doses.

Contraindication
 Significant immunosuppression, particularly in those with a history of recent use of other biologic
immunomodulating drugs
 Alanine transaminase (ALT) >5 times the upper limit of normal
 High risk for gastrointestinal perforation
 An uncontrolled, serious bacterial, fungal, or non-SARS-CoV-2 viral infection
 Absolute neutrophil count <500 cells/µL.
 Platelet count <50,000 cells/µL.

2. Baricitinib
In hypoxic patients where steroid cannot be used, the JAK inhibitor Baricitinib may be added at doses of 4 mg once
daily for 14 days. They should be given as add on to Remdesivir. There is no room for using Baricitinib alone unless
under a specific clinical trial.

3. Convalescent Plasma therapy

Till date, there is no quality evidence to recommend the use of convalescent plasma in severe COVID 19 cases for
treatment purpose.

4. Ivermectin
Till date, there is no quality evidence suggesting any role of Ivermectin in treating COVID-19 in any grade of severity
or preventing COVID-19. It can only be used in context of clinical trial.

5.Bevacizumab
There is no high-quality evidence of using the drug in COVID-19. It can only be used in context of clinical trial.

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Discontinuing of transmission-based precaution including isolation and return
to workplace criteria:
 For asymptomatic patients: 10 days after sample collection.

 For symptomatic Mild patients: 14 days after symptom onset provided patient has no fever and decreased
respiratory symptoms for 03 days.

 For hospitalized patients: 21 days after symptom onset provided patient has no fever and decreased respiratory
symptoms for 03 days.

Discharge Criteria

Resolution of fever without the use of anti-pyretics such as paracetamol and significant improvement in the
respiratory symptoms (e.g., cough, shortness of breath) for at least 03 days.

 There is no need for retesting the patient to give discharge from hospital.

 For severe or critical patients – physician’s discretion may be used for giving discharge.

Sequence of oxygen delivery devices used in the

management of COVID-19

Nasal Cannula 1-5 L/min

> 6 LPM & SpO2 < 88%

Simple Face Mask

SpO2 < 88%

NRB with reservoir bag Awake Proning Goal of therapy:

 PAO2/FiO2 ratio>150
SpO2 < 88% HFNC
 PaO2>55 mm hg
HFNC  SpO2>88%
 pH>7.30
SpO2 < 88%
 Plateau Pressure <30 cm H20
NIV  Driving Pressure (plateau
pressure-PEEP) <15
SpO2 < 88%

Mechanical Ventilation Sedation + Paralysis + Prone Ventilation

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Anticoagulation
Prophylactic dose Intermediate dose Therapeutic dose

Drug Low molecular weight Low molecular weight Low molecular weight
heparin (Enoxaparin) heparin (Enoxaparin) heparin (Enoxaparin)

40 mg SC OD 0.5 mg/kg body weight SC 1 mg /kg body weight SC BD

Dose
For obese patients (BMI BD
>40) 40 mg BID

Admitted mild case with Severe cases Critical cases , patient has
Candidate
uncontrolled comorbid proven thromboembolism or
(Assess bleeding
conditions, prothrombotic strong clinical suspicion of
risk)
states and moderate cases thromboembolism

Dose Yes. LMWH 20-30 mg OD. Yes. LMWH 0.5 mg OD. Or Yes. LMWH 20-30 mg OD.
adjustment if Or UFH 5000 IU SC OD UFH 7500 Unit, SC, TID OrUFH 80 unit /kg load +18
creatinine unit /kg/hr/day infusion
clearance is < 30

Dose of Steroid in Other COVID-19 Syndromes

ARDS due to COVID: Inj. Methylprednisolone 1-2 mg/kg q12 OR Inj. Dexamethasone 20 mg IV daily for 5 days & then
10 mg IV daily for 5 days & then 5 mg IV daily for 5 days

Refractory Sepsis: Hydrocortisone 50 mg IV 6 hourly

Cytokine Release Syndrome (CRS): Inj. Methylprednisolone 1-2 mg/kg q12 OR Inj. Dexamethasone 10 mg q6

Recommendations for Critical COVID-19 Patients

 In selected patients with COVID-19 and ARDS, a trial of HFNO, non-invasive ventilation – continuous positive
airway pressure (CPAP), bilevel positive airway pressure (BiPAP) may be used. If there is no improvement after
using these devices, further respiratory support is needed.

 Prompt recognition of progressive acute hypoxaemic respiratory failure when a patient with respiratory distress
is failing to respond to standard oxygen therapy and adequate preparation to provide advanced
oxygen/ventilatory support.

 Endotracheal intubation be performed by a trained and experienced provider using airborne precautions.

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 Implementation of mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight [PBW])
and lower inspiratory pressures (plateau pressure < 30 cmH2O).

 In adult patients with severe ARDS (PaO2/FiO2 < 150) awake prone ventilation for 12–16 hours per day is
recommended.

 Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion and fluid
responsiveness.

 Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to
maintain mean arterial pressure (MAP) ≥ 65 mmHg AND lactate is ≥ 2 mmol/L, in the absence of hypovolaemia.

 Recognize septic shock in children with any hypotension (SBP < 5th centile or > 2 SD below normal for age) or
two or more of the following: altered mental status; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in
infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses;
tachypnoea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or
hypothermia.

 In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as rapid bolus in first 15–30 minutes.
In resuscitation for septic shock in children, give 10–20 mL/kg crystalloid fluid as a bolus in the first 30–60
minutes.

 Do not use hypotonic crystalloids, starches or gelatins for resuscitation.

 In adults, administer vasopressors when shock persists during or after fluid resuscitation. The initial blood
pressure target is MAP ≥ 65 mmHg in adults and improvement of markers of perfusion.

 In children, administer vasopressors if signs of fluid overload are apparent or the following persist after two fluid
boluses:

— signs of shock such as altered mental state.

— bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in
children);

— prolonged capillary refill (> 2 seconds) or feeble pulses.

— tachypnoea; mottled or cool skin or petechial or purpuric rash; increased lactate; oliguria persists after
two repeat boluses.

— or age-appropriate blood pressure targets are not achieved.

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Editorial Board
Chief Adviser
Prof. Md. Nazmul Islam, Director, Disease Control and Line Director, Communicable Disease Control (CDC),
Directorate General of Health services.

Editorial Board: (not according to seniority)

1. Prof ABM Abdullah, Personal Physician of Prime Minister Sheikh Hasina, Professor of Medicine
2. Prof. M. A. Faiz, Former Director General, DGHS and Professor of Medicine
3. Prof. Khan Abul Kalam Azad, Former Principal and Professor of Medicine, Dhaka Medical College
4. Prof Billal Alam, Professor of Medicine, Dhaka Medical College and President, Bangladesh Society of Medicine
5. Prof. Ahmedul Kabir, Principal Mugda Medical College and General Secretary, Bangladesh Society of Medicine
6. Prof. Md Robed Amin, Professor of Medicine, Line Director, Non-Communicable Disease Control Program, DGHS
7. Prof. Md. Ridwanur Rahman, Professor of Medicine, Universal Medical College Research Unit
8. Prof. Titu Miah, Principal and Professor of Medicine, Dhaka Medical College
9. Prof. Md. Jahangir Alam, Vice President, Bangladesh Paediatric Association
10. Dr. Jamal Uddin Chowdhury, Bangladesh Medical Association
11. Prof. Quazi Tarikul Islam, Professor of Medicine, Popular Medical College
12. Prof. H A M Nazmul Ahasan, Professor of Medicine, Popular Medical College
13. Prof. M. A. Jalil Chowdhury, Professor of Medicine, and Former Chairman, Dept. of Medicine, BSMMU.
14. Prof. Md. Mujibur Rahman, Professor of Medicine, BSMMU.
15. Professor Dr. Shahnila Ferdousi, Former Director, Disease Control and Former Line Director, Communicable
Disease Control (CDC), Directorate General of Health services
16. Professor Dr. Debabrata Banik, Department of Anaesthesia, analgesia & Intensive Care Medicine, BSMMU.
17. Lt. Col. Dr. AKM Faizul Huq, CMH, Dhaka
18. Dr. Abu Hena Md. Raihanuzzaman Sarker, Medical Superintendent, NIDCH
19. Dr. Rokeya Sultana, Health and family planning secretary, Bangladesh Awami League
20. Prof. M A Kashem, Professor of Medicine DMC &Treasurer, Bangladesh Society of Medicine
21. Prof. Manzoor Hussain, President, Bangladesh Paediatric Association
22. Prof. Mohammad Zahid Hossain, Secretary General, Bangladesh Paediatric Association
23. Prof. M A Hassan Chowdhury, Ex Director BITID
24. Prof. Aniruddha Ghose, Professor of Medicine, Chittagong Medical College

Managing Editor
Dr. Aninda Rahman, Deputy Program Manager (antimicrobial resistance, viral hepatitis, diarrhoeal diseases
control), CDC, DGHS

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List of Contributors: (not according to seniority)
1. Dr. Ariful Basher, Junior Consultant (medicine), Dhaka Infectious Disease Hospital
2. Dr. Forhad Uddin Hasan Chowdhury, Registrar Medicine, DMCH
3. Dr. Sakib Aman, Indoor Medical Officer, DMCH
4. Dr. Fazle Rabbi Chowdhury, Asst. Professor, Department of Medicine, BSMMU
5. Dr Amiruzzaman , Joint Secretary, Bangladesh Society of Medicine
6. Dr Zahed Hasan Himel, Joint Secretary, Bangladesh Society of Medicine
7. Dr M A Sattar Sarker, Organising Secretary, Bangladesh Society of Medicine
8. Dr Sudip Ranjan Dev, Scientific Secretary, Bangladesh Society of Medicine
9. Dr Syed Golam Mugni Mawla, International affairs Secretary, Bangladesh Society of Medicine
10. Dr Md Motlebur Rahman, Cultural Secretary, Bangladesh Society of Medicine
11. Dr Md Tanvir Islam, Entertainment Secretary, Bangladesh Society of Medicine
12. Dr Md Murad Hossain, Organising Secretary, Bangladesh Society of Medicine
13. Dr Gobinda Chandra Banik , Publication Secretary, Bangladesh Society of Medicine
14. Dr Ashim Chakraborty, Office Secretary, Bangladesh Society of Medicine
15. Dr Rabiul Alam Md Erfan Uddin, Assistant Professor, Department of Medicine, CMC
16. Dr. Hafizur Rahman, Deputy Director, CDC, DGHS
17. Dr. Tahmina Akter, Assisstant Director (CDC) & PM, IHR, CDC, DGHS
18. Dr. Nasir Ahmed Khan, Senior Advisor, IHR, CDC, DGHS
19. Dr. Umme Ruman Siddiqi, DPM, Zoonotic Diseases Control Programme, CDC, DGHS
20. Dr. Mustufa Mahmud, DPM, IHR, Migration Health, ERD Control Programme, CDC, DGHS
21. Dr. Jahirul Karim, DPM, CDC
22. Dr. Abu Nayeem Mohammad Sohel, DPM, CDC
23. Dr. Afsana Alamgir Khan, DPM, CDC
24. Dr. Israt Jahan, Epidemiologist, CDC, DGHS.

International Contributors
1. Dr Tasbirul Islam, Clinical Associate Professor, Indiana University School of Medicine., Medical Director,
Indiana University Arnett Hospital, USA.
2. Dr. Muhammad Shamse Tabriz, Consultant, Infectious Disease, Advocate Christ Medical Center, Clinical
Associate Prof of Medicine, University of Illinois, Chicago, USA
3. Dr. Raiiq Ridwan. Specialty Registrar, Emergency Medicine, Cambridge University Hospitals, NHS Foundation Trust
4. Dr. Quazi Tamjidul Islam, Speciality Registrar, General Internal Medicine, NHS Trust, Royal Free Hospital,
London, UK

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