Sapere

Discontinuation of transmission-based precautions for patients with COVID-19:

The decision to discontinue Transmission-Based Precautions should be made using a test-based strategy or a non-test-based strategy (i.e., time-since-illness-onset and time-since-recovery strategy). Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge.

1. Test-based strategy.
   • Resolution of fever without the use of fever-reducing medications and
   • Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
   • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens) [1]. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).
2. Non-test-based strategy.
   • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
   • At least 7 days have passed since symptoms first appeared

When a Testing-Based Strategy is Preferred

Hospitalized patients may have longer periods of SARS-CoV-2 RNA detection compared to patients with mild or moderate disease. Severely immunocompromised patients (e.g., medical treatment with immunosuppressive drugs, bone marrow or solid organ transplant recipients, inherited immunodeficiency, poorly controlled HIV) may also have longer periods of SARS-CoV-2 RNA detection and prolonged shedding of infectious recovery. These groups may be contagious for longer than others.  In addition, placing a patient in a setting where they will have close contact with individuals at risk for severe disease warrants a conservative approach.

Hence, a test-based strategy is preferred for discontinuation of transmission-based precautions for patients who are

1. Hospitalized or
2. Severely immunocompromised or
3. Being transferred to a long-term care or assisted living facility

If testing is not readily available facilities may choose to use the non-test-based strategy for discontinuation of transmission-based precautions or extend the period of isolation beyond the non-test-based-strategy duration, on a case by case basis in consultation with local and state public health authorities.Discontinuation of empiric transmission-based precautions for patients suspected of having COVID-19:

The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of COVID-19 for a suspected COVID-19 patient can be made based upon having negative results from at least one FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2.

1. If a higher level of clinical suspicion for COVID-19 exists, consider maintaining Transmission-Based Precautions and performing a second test for SARS-CoV-2.
2. If a patient suspected of having COVID-19 is never tested, the decision to discontinue Transmission-Based Precautions can be made based upon using the non-test-based strategy described above.

Ultimately, clinical judgement and suspicion of SARS-CoV-2 infection determines whether to continue or discontinue empiric transmission-based precautions.Disposition of Patients with COVID-19:

Patients can be discharged from the healthcare facility whenever clinically indicated.

If discharged to home:

1. Isolation should be maintained at home if the patient returns home before discontinuation of Transmission-Based Precautions. The decision to send the patient home should be made in consultation with the patient’s clinical care team and local or state public health departments. It should include considerations of the home’s suitability for and patient’s ability to adhere to home isolation recommendations.  Guidance on implementing home care of persons who do not require hospitalization and the discontinuation of home isolation for persons with COVID-19 is available.

If discharged to a long-term care or assisted living facility, AND

1. Transmission-Based Precautions are still required, they should go to a facility with adequate personal protective equipment supplies and an ability to adhere to infection prevention and control recommendations for the care of COVID-19 patients. Preferably, the patient would be placed at a facility that has already cared for COVID-19 cases, in a specific unit designated to care for COVID-19 residents
2. Transmission-Based Precautions have been discontinued, but the patient has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room,
3. Transmission-Based Precautions have been discontinued and the patient’s symptoms have resolved, they do not require further restrictions, based upon their history of COVID-19.

References

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