As of March 30, 2021

The Philippine COVID-19 Living Recommendations document is brought to you by the Institute of Clinical Epidemiology, National Institutes of Health, UP Manila in cooperation with the Philippine Society of Microbiology and Infectious Diseases (PSMID). This was funded by the DOH Ahead Program through the DOST-Philippine Council for Health Research and Development (PCHRD). 

INTRODUCTION

Given the magnitude of the impact of COVID-19 in the country and the current priority given to it by clinicians, public health officials and the government, there is the need for clinical practice guidelines to contribute to the effective management and control of the spread of this disease. While there are existing international guidelines and living systematic reviews (LSRs) on COVID-19, there is a need to localize the recommendations from the evidence in our setting by local experts, end-users and other relevant stakeholders. With the rapidly evolving science behind the management of COVID-19, the Living CPG development method will be used wherein recommendations will be switched to a living status based on the likelihood of new evidence and the importance of the recommendation in health care policy decision making. LSRs will be maintained to develop a living CPG that will provide up-to-date, evidence-based guidance on the treatment, diagnosis and infection control of COVID-19.

LIVING CPG DEVELOPMENT METHODS

The figure below summarizes the Living CPG process, following the Philippine Department of Health’s Manual for Clinical Practice Guideline Development [DOH 2018] and the Grading of Recommendations, Assessment, Development and Evaluation or GRADE Approach [Schünemann et al 2013].

LSRs are systematic reviews “that is continually updated, incorporating relevant new evidence as it becomes available.” [Elliott et al, 2017]. From the initial recommendations generated in the standard guideline development process, all questions will be updated as needed. Evidence reviewers working on living recommendations will (1) perform continual surveillance of literature to update the living systematic review with new evidence and (2) update the Evidence Summary tables and draft recommendations for panel discussion. The Consensus Panel concerned will then be convened again in an online meeting to discuss the new evidence and any changes in the living recommendation.

This Living CPG tackles six central themes in COVID-19, and each theme is represented by a separate CPG Consensus Panel: Screening and diagnosis, Treatment, Critical care and respiratory management, Non-pharmacologic interventions, Vaccines and prophylactic interventions, and Adjunctive interventions.

LIVING RECOMMENDATIONS

The Consensus Panel evaluated the direction and strength of recommendation using the GRADE approach, based on the (1) over-all quality of evidence for each question, (2) balance between benefits and harms, (3) values, preferences and burden on patients, (4) cost and resource use, and (5) other relevant considerations. Each member voted on the draft recommendation as follows: yes, no or abstain. Consensus was defined as at least 75% agreement among the members both for the direction and strength of recommendation.

If consensus was not reached, each member discussed their vote and their ideas on the topic. The voting was repeated, up to three times, until a consensus is reached. Any issues left unsettled after the en banc meeting were finalized through a modified Delphi activity.

The quality of evidence is one of the bases of the Consensus Panel in making the final recommendation.

Table 1

Table 2

CONTACT US

Do you have questions, clarifications or suggestions on the recommendations of this Living CPG? Or do you want to submit a clinical question for the consideration of the Living CPG Task Force? Send us an email at: covidcpg.ph@gmail.com.

DISCLAIMER

As a living guideline, the recommendations will be updated, and new recommendations will be added as the evidence evolves. This living CPG is based on the best evidence available in scientific literature as of the time of its formulation. This CPG, however, is not a comprehensive guide to all practice questions and management options on COVID-19. This is not meant to restrict the practitioner in using sound clinical judgement and sharing the decision with the patient, and from considering other management options as deemed appropriate to the patient’s circumstances. This CPG can serve to inform policy, but it is not meant to serve as the sole basis for approving or denying financial coverage or insurance claims merely because of nonconformance with recommendations. Neither are the recommendations supposed to be considered as legal rules for dictating certain modes of action to the exclusion of others.

DOWNLOAD

You may download the Summary Recommendations here. (File version March 30, 2021)

Click on the interventions below to see the recommendations.

Screening and Diagnosis

We suggest an initial screening for COVID-19 by checking for any influenza-like illness symptom within the past 14 days in apparently healthy adults. (Low quality of evidence; Conditional recommendation)

We recommend the use of oropharyngeal swab as an alternative clinical specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19. (Moderate quality of evidence; Strong recommendation)

We recommend the use of saliva drool/spit and oral saliva specimens as an alternative to nasopharyngeal swab for RT-PCR diagnosis of COVID-19 in symptomatic and asymptomatic patients with suspected COVID- 19 in hospital and community/outpatient settings. (Moderate quality of evidence; Strong recommendation)

We suggest the use of saliva swab and posterior oropharyngeal saliva specimens as an alternative for RT-PCR diagnosis of COVID-19 in symptomatic and asymptomatic patients with suspected COVID-19 in hospital and community/outpatient settings. (Low quality of evidence; Conditional recommendation)

We recommend the use of nasal swab/wash as an alternative clinical specimen to nasopharyngeal swab RT- PCR for the diagnosis of COVID-19. (Moderate quality of evidence; Strong recommendation)

We recommend the use of throat swab as an alternative clinical specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19. (Low quality of evidence; Strong recommendation)

We recommend against the use of sputum as an alternative clinical specimen to nasopharyngeal swab RT- PCR for the diagnosis of COVID-19. (Very low quality of evidence; Strong recommendation)

There is no evidence to recommend the use of bronchoalveolar lavage as an alternative clinical specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19.

You can find the Evidence Summary here.

We recommend against the use of rapid antigen test alone in diagnosing COVID-19 in asymptomatic patients suspected of COVID-19 infection. (Moderate to high quality of evidence; Strong recommendation)

We recommend the use of rapid antigen test under all these conditions in patients suspected of COVID-19 infection: (Moderate quality of evidence; Strong recommendation)

  • Symptomatic AND
  • Early phase </=7 days from onset of symptoms AND
  • Specific brands that demonstrated sensitivity ≥80% and have very high specificity (≥97-100%))

We recommend against the use of saliva as specimen for rapid antigen test in patients suspected of COVID- 19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the HPAAC Community Test-Trace-Treat Guide here.

We suggest the use of pooled RT-PCR testing in targeted* low-risk and low-prevalence populations using a pool size of 5 in individuals suspected of COVID-19 infection. (Moderate quality of evidence; Conditional recommendation)

*Target population refer to the list of PSP and DOH

We suggest to repeat RT-PCR testing when the initial RT-PCR test is negative among symptomatic patients with high index of suspicion for COVID-19 infection. (Low quality of evidence; Conditional recommendation)

Treatment

We recommend against the use of hydroxychloroquine/chloroquine, with or without azithromycin among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of azithromycin among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

There is insufficient evidence to recommend the use of ivermectin for the treatment of patients with COVID-19 infection. (Very low quality of evidence)

There is insufficient evidence to recommend the use of favipiravir for the treatment of patients diagnosed with COVID- 19. (Very low quality of evidence)

We suggest against the use of remdesivir in patients with COVID-19 infection who have O2 saturation ≥94% and do not require oxygen supplementation. (Low quality of evidence; Conditional recommendation)

We suggest the addition of remdesivir to dexamethasone in patients with COVID-19 infection who have O2 saturation < 94% and/or requiring oxygen supplementation. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence for or against the use of remdesivir in patients with COVID-19 infection who are already on high flow oxygen, non invasive or invasive mechanical ventilation. (Low quality of evidence)

You can find the Evidence Summary here.

We recommend the addition of tocilizumab to systemic steroids in patients showing rapid respiratory deterioration and/or requiring high doses of oxygen (high-flow nasal cannula, noninvasive or invasive mechanical ventilation) and with elevated biomarkers of inflammation (CRP). (Moderate quality of evidence; Strong recommendation)

We recommend against the use of tocilizumab in patients with COVID-19 infection who do not require oxygen supplementation. (Strong recommendation)

We recommend against the use of convalescent plasma in patients with COVID-19 infection regardless of severity. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of ibuprofen as treatment among patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)

There is no evidence to recommend the use of VCO as treatment among patients with COVID-19 infection.

You can find the Evidence Summary here.

We recommend against the use of Lianhua as treatment among patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)

Critical Care and Respiratory Management

We recommend the use of dexamethasone in patients with COVID-19 infection who require supplemental oxygenation (i.e., including high-flow device, non-invasive, invasive mechanical ventilation and ECMO). (High quality of evidence; Strong recommendation)

We recommend against the use of systemic corticosteroids among patients with COVID-19 infection who do not require oxygen supplementation. (Moderate to high quality of evidence; Strong recommendation)

We suggest the use of prophylactic anticoagulation among hospitalized patients with COVID-19 infection, unless with contraindications. (Very low quality of evidence; Conditional recommendation)

We suggest the use of prophylactic dose anticoagulation over therapeutic anticoagulation in critically ill patients with COVID-19 infection. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence on the use of hemoperfusion at this time among patients with COVID-19 infection. (Very low quality of evidence)

You can find the Evidence Summary here.

We suggest the use of conservative fluid management over liberal fluid management strategy in mechanically ventilated adult COVID-19 patients with acute respiratory distress syndrome who are adequately resuscitated*. (Low quality of evidence; Conditional recommendation)

*without tissue hypoperfusion and fluid responsiveness

We suggest self-proning to improve oxygenation status of non-intubated hospitalized patients with COVID- 19 infection requiring oxygen supplementation. (Very low quality of evidence; Conditional recommendation)

We suggest the use of high-flow nasal cannula oxygenation over non-invasive ventilation (e.g., helmet CPAP, mask NIV) in patients with COVID-19 infection and acute hypoxemic respiratory failure who do not respond to conventional oxygen therapy. (Very low quality of evidence; Conditional recommendation)

We suggest the use of a lung protective ventilation strategy (tidal volume 4-8 mL/kg predicted body weight and plateau pressure less than 30 cmH2O in patients with COVID-19 infection and ARDS. (Very low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of a higher PEEP strategy. We suggest to individualize PEEP or employ a PEEP strategy based on respiratory mechanics (i.e., compliance) in patients with COVID-19 infection. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend a driving pressure limited strategy in patients with COVID-19 infection. We suggest to keep the driving pressure ≤ 14 cmH2O. (Low quality of evidence; Conditional recommendation)

Non-Pharmacologic Interventions

We recommend that healthcare workers not directly taking care of COVID-19 patients, and other persons with high risk of exposure to COVID-19 should use properly fitted surgical masks instead of cloth masks. (Moderate quality of evidence; Strong recommendation)

We suggest using a cloth mask that fits snugly on the face and made of at least two layers of cotton (e.g., t- shirt fabric) or non-woven nylon with aluminum nose bridge by the general public with low risk of exposure to COVID-19 in outdoor or indoor areas to prevent COVID-19 infections (Low quality of evidence; Conditional recommendation)

We recommend against the use of ionizing air purifier to reduce COVID-19 transmission in the community. (Low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of footbaths for the prevention and control of COVID-19 transmission. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of misting tents or disinfection chambers for preventing and controlling COVID-19 transmission. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of UV lamps or other UV devices in any place outside of a controlled clinic or hospital setting to prevent and control COVID-19 transmission. (Low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest the use of HEPA filter as an option to improve air quality for COVID-19 prevention and control in indoor spaces with inadequate ventilation. (Low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

In situations where there is shortage of filtering facepiece respirators (FFR), we suggest the use of Hydrogen Peroxide Vapor (HPV), Ultraviolet Germicidal Irradiation (UVGI), moist heat and peracetic acid dry fogging system (PAF) as options for N95 mask decontamination as recommended by the manufacturer based on their ability to reduce SARS-COV-2 load and infectivity while still maintaining N95 mask integrity. (Low quality of evidence; Conditional recommendation)

We recommend against the use of autoclave and alcohol as these methods alter filtering facepiece respirator’s (N95) integrity and degrade filtration efficacy. (Very low quality of evidence; Strong recommendation)

Vaccines and Prophylactic Interventions

We recommend the use of the following vaccines to prevent symptomatic SARS-CoV-2 infection among adults: (Moderate quality of evidence; Strong recommendation)

  1. BNT162b2 (given as 0.3ml (30ug) intramuscular injections, in 2 doses, 21 days apart)
  2. mRNA-1273 (given as 0.5ml (100ug) intramuscular injections, in 2 doses, 28 days apart)
  3. ChAdOx1 (given as 0.5 ml (5 x 106 vp) intramuscular injections, in 2 doses, at least 12 weeks apart)
  4. Gam-COVID-Vac (given as 0.5ml rAd-26S 0.5ml intramuscular injection, then rAd-5S 0.5ml intramuscular injection 21 days after)

We recommend the use of these vaccines in older adults (>64-year-old) to prevent symptomatic SARS- CoV-2 Infection. (Low quality of evidence; Strong recommendation)

We recommend the use of these vaccines in pregnant and lactating women after consultation with their healthcare provider. (Very low quality of evidence; Conditional recommendation)

We recommend the use of these vaccines in adults who have stable medical comorbidities and are at risk for severe infection to prevent SARS-CoV-2 infection. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of these vaccines in children to prevent SARS-CoV-2 infection: (Low to very low quality of evidence; Conditional recommendation)

  • BNT162b2: <16 years old
  • mRNA-1273, ChAdOx1, Gam-COVID-Vac: <18 years old

We recommend the use of these vaccines in immunocompromised patients (i.e., diagnosed with HIV, hepatitis B and C), after clearance from their physician, to prevent SARS-CoV-2 infections. (Low quality of evidence; Conditional recommendation)

We recommend against the use of these vaccines in persons with known allergies to polysorbate and/or PEG. (Moderate to high quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of melatonin as prevention for COVID-19 infection. (Very low quality of evidence; Strong recommendation)

We recommend against the use of Vitamin D supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)

We recommend against the use of zinc supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)

We recommend against the use of HCQ for pre-exposure prophylaxis in adults who are at high risk of exposure to COVID-19 cases. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of HCQ for post-exposure prophylaxis in adults who are exposed to COVID- 19 cases. (Low quality of evidence; Strong recommendation)

We recommend against the use of lopinavir/ritonavir for chemoprophylaxis in individuals exposed to COVID-19 patients. (Very low quality of evidence; Strong recommendation)

There is insufficient evidence to recommend the use of saline nasal irrigation (SNI) to prevent COVID-19 in healthy individuals. (Very low quality of evidence)

We recommend against the use of steam inhalation in the prevention of COVID-19. (Very low quality of evidence; Strong recommendation)

We recommend against the use of steam inhalation in the treatment of COVID-19. (Very low quality of evidence; Strong recommendation)

There is insufficient evidence to recommend the use of antiseptic mouthwash or gargle to prevent COVID- 19 in healthy individuals. (Very low quality of evidence)

Adjunct Interventions

There is insufficient evidence to recommend the use of zinc as adjunct treatment for patients with COVID- 19 infection both in the outpatient and in-patient setting. (Very low quality of evidence)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of intravenous Vitamin C as adjunct treatment for patients with COVID-19 infection. (Low quality of evidence)

There is insufficient evidence to recommend the use of Vitamin D supplementation as adjunct treatment for patients with COVID-19 infection. (Low to very low quality of evidence)

 

There is insufficient evidence to recommend the use of melatonin as adjunct treatment for patients with COVID-19 infection. (Very low quality of evidence)

There is no evidence to recommend the use of virgin coconut oil as adjunct treatment for patients with COVID-19 infection.

You can find the Evidence Summary here.

We recommend against the use of intravenous N-acetylcysteine as adjunct treatment for patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend continuing maintenance RAAS blockers for hypertension among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest that ibuprofen may still be used as symptomatic treatment of patients with COVID-19 infection if clinically warranted. Concurrent use of ibuprofen is not associated with worsening of COVID-19 outcomes. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

STEERING COMMITTEE

  • Jemelyn U. Garcia. MD, FPCP, FPSMID
  • Evalyn A. Roxas, MD, MPH, FPCP, FPSMID
  • Mario M. Panaligan, MD, FPCP, FACP, FPSMID, FIDSA
  • Noel L. Espallardo, MD, MSc, FPAFP
  • Ivan N. Villespin, MD, FPCP, FPCCP
  • Aileen R. Espina, MD, MPH, MHA, FPAFP
  • Maria Rosario S. Vergeire, MD, MPH, CESO IV

 

  • Marissa M. Alejandria, MD, MSc, FPCP, FPSMID (Chair)
  • Leonila Dans, MD, MSc, FPPS, FPRA (Co-Chair)

CONSENSUS PANEL

Screening and Diagnosis

  • Clemencia D. Bondoc, MD
  • Alpha Grace B. Cabic, MD, DPSP
  • Jocelyn Myra R. Caja, MD, FPSP
  • Virgina de los Reyes, MD
  • Mary Ann D. Lansang, MD, FPCP, FPSMID
  • Jane Eflyn L. Lardizabal-Bunyi, RPh, MD, OHP, DFM, FPAFP, CSPSH
  • Imelda B. Mateo, MD, MBAH, FPCP, FPCCP
  • Vernon M. Serafico, MD, FPCP

Treatment

  • Maria Elinore Alba-Concha, MD, FPAFP
  • Mary Ann C. Bunyi, MD, FPPS, FPIDSP
  • Erwin R. De Mesa, MD, FPOGS, FPIDSOG
  • Karl Evans R. Henson, MD, FPCP, FPSMID
  • Faith Joan C. Mesa-Gaerlan, MD, MS, FPCEM
  • Roland M. Panaligan, MD, LLM, FPCP, FPCCP
  • Rommel B. Punongbayan, RMT, MD, MBA, FPCP, FPSMS, CSPSH, DPCOM
  • Iris Conela A. Tagaro, MD, DPPS, MPM-MHSD

Critical Care and Respiratory Management

  • Joseph Adrian L. Buensalido, MD, FPCP, FPSMID
  • Pauline F. Convocar, MD, MCHM, DPBEM, FPCEM, DPCOM
  • Ricardo A. Francisco, Jr, MD, MHA, FPCP, FPSN
  • Mark Kristoffer U. Pasayan, MD, FPCP, FPSMID
  • Chito C. Permejo, MD, FPCP, FPCC, FPSCCM
  • Albert L. Rafanan, MD, FPCCP, FPCP, FCCP, FASSM, FPSSM
  • Rowena Marie T. Samares, MD, FPAFP, FPSHPM
  • Paul Michael S. Tan, RN, MAN, PhD

Non-Pharmacologic Interventions

  • Regina P. Berba, MD, MSc, FPCP, FPSMID
  • Vivien Fe F. Fadrilan-Camacho, MD, MPH, FPAFP
  • Rodley Desmond Daniel Carza, MPH, RN
  • Dominga Calalang-Gomez, RN
  • Anna Sofia Victoria S. Fajardo, MD, MBAH, DPCOM
  • Victoria Isla-Ching, RN, MGM-ESP
  • Nenacia Ranali Nirena P. Mendoza, MD, FPAFP
  • Ruth S. Punzalan, MD, MPH, FPAFP

Vaccines and Prophylactic Interventions

  • Maria Rhona G. Bergantin, MD, MSc, FPCP, FPSMID
  • Fatima Ignacio Gimenez, MD, FPPS, FPIDSP
  • Dax Ronald O. Librado, MD, FPCP, FACP
  • Anna Guia O. Limpoco, MD, MsCM, FPAFP
  • Edmyr M. Macabulos, M.D, MPH, FPCOM
  • Rosally P. Zamora, MD, FPCP
  • Gian Carlo Torres, PhD, MAN, RN
  • Karina Descartin, MD, MS, MPH, DIMPH, FRSPH

Adjunct Interventions

  • Anthony F. Cortez, MD
  • Katrina G. Gomez-Chua, MD MPH
  • Ana Melissa S. Guererro, MD, MPH (HTA)
  • Joan Mae M. Oliveros, MD, FPAFP
  • Maria Sonia Salamat, MD, MPH, FPCP, FPSMID
  • Julie Christie Gutierrez Visperas, MD, MHPEd, FPCP, FPCCP
  • Shirley P. Whisenhunt DNM, RN

Evidence Review Experts

  • Eva I. Bautista, MD, MSc, FPPS
  • John Jefferson V. Besa, MD
  • Julian M. A. Buban
  • Aldrich Ivan Lois D. Burog, MD, MSc (cand.)
  • Ian Theodore Cabaluna, RPh, MD, GDip (Epi)
  • Marie Gene D. Cruz, MD
  • Patricia Maria Gregoria M. Cuaño, MD
  • Lea Roselle O. De Castro, MD
  • Namnama P. Villarta-De Dios, MD, MSc, DPPS
  • Belen L. Dofitas, MD, MSc
  • Valentin C. Dones III, PhD
  • Gina Antonina S. Eubanas, MD, FPDS, D Clin Epi
  • Antonio L. Faltado Jr., MD, FPCP, FPSEDM
  • Anna Maria Vida P. Garcia, RPh, D Clin Epi
  • Rowena F. Genuino, MD, MSc
  • Germana Emerita V. Gregorio, MD, PhD
  • Myzelle Anne J. Infantado, PTRP, MSc (cand.)
  • Racquel Ibanez, MD, FPCP, DPCCP
  • Marquis Von Angelo Syquio Go Joson, MD
  • Anna Angelica Macalalad Josue, MD, FPCP, DPSEDM, MSc (cand)
  • Marie Carmela Lapitan, MD, FPUA, FPCS
  • Christopher G. Manalo, MD, DPBEM
  • Patricia Pauline M. Remalante, MD, FPCP, DPRA
  • Evelyn O. Salido, MD, FPCP, FPRA
  • Maria Cristina Z. San Jose, MD, FPNA
  • Maria Vanessa V. Sulit, BSN, RN, MSc
  • Frangelo Conrad Tampus, MD
  • Cary Amiel G. Villanueva, MD
  • Paoline Nicole P. Villanueva, RMT, MD

Project Staff

  • Project Manager
  • Dan Louie Renz P. Tating, MS(cand), RN
  • Technical Coordinators
  • Howell Henrian G Bayona, MSc, CSP-PASP
  • Maria Teresa S. Tolosa, MD, FPDS, D Clin Epi
  • Dan Louie Renz P. Tating, MS(cand), RN
  • Technical Writers
  • Kate D. Dunlao, RPh
  • Joyce Anne Ceria-Pereña, RPh, MPM
  • Mikarla M. Lubat, RND
  • Project Staff
  • Maria Eleanor L. Candelaria, MPH, RN
  • Kate D. Dunlao, RPh