ESCMID COVID-19 living guidelines: drug treatment and clinical management

Clin Microbiol Infect. 2022 Feb;28(2):222-238. doi: 10.1016/j.cmi.2021.11.007. Epub 2021 Nov 22.


Scope: In January 2021, the ESCMID Executive Committee decided to launch a new initiative to develop ESCMID guidelines on several COVID-19-related issues, including treatment of COVID-19.

Methods: An ESCMID COVID-19 guidelines task force was established by the ESCMID Executive Committee. A small group was established, half appointed by the chair, and the remaining selected with an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the PICO (population, intervention, comparison, outcome) format was developed at the beginning of the process. For each PICO, two panel members performed a literature search with a third panellist involved in case of inconsistent results. Voting was based on the GRADE approach.

Questions addressed by the guideline and recommendations: A synthesis of the available evidence and recommendations is provided for each of the 15 PICOs, which cover use of hydroxychloroquine, bamlanivimab alone or in combination with etesevimab, casirivimab combined with imdevimab, ivermectin, azithromycin and empirical antibiotics, colchicine, corticosteroids, convalescent plasma, favipiravir, remdesivir, tocilizumab and interferon β-1a, as well as the utility of antifungal prophylaxis and enoxaparin. In general, the panel recommended against the use of hydroxychloroquine, ivermectin, azithromycin, colchicine and interferon β-1a. Conditional recommendations were given for the use of monoclonal antibodies in high-risk outpatients with mild-moderate COVID-19, and remdesivir. There was insufficient evidence to make a recommendation for use of favipiravir and antifungal prophylaxis, and it was recommended that antibiotics should not be routinely prescribed in patients with COVID-19 unless bacterial coinfection or secondary infection is suspected or confirmed. Tocilizumab and corticosteroids were recommended for treatment of severe COVID-19 but not in outpatients with non-severe COVID-19.

Scope: The aim of the present guidance is to provide evidence-based recommendations for management of adults with coronavirus disease 2019 (COVID-19). More specifically, the goal is to aid clinicians managing patients with COVID-19 at various levels of severity including outpatients, hospitalized patients, and those admitted to intensive care unit. Considering the composition of the panel, mostly clinical microbiologists or infectious disease specialists with no pulmonology or intensive care background, we focus only on pharmacological treatment and do not give recommendations on oxygen supplement/support. Similarly, as no paediatricians were included in the panel; the recommendations are only for adult patients with COVID-19. Considering the current literature, no guidance was given for special populations such as the immunocompromised.

Keywords: COVID-19; Disease progression; Guidelines; Mortality; Treatment.

MeSH terms

  • Adult
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Antibodies, Neutralizing / therapeutic use
  • Antiviral Agents / therapeutic use*
  • COVID-19 Drug Treatment*
  • COVID-19 Serotherapy
  • COVID-19* / therapy
  • Humans
  • Immunization, Passive
  • Practice Guidelines as Topic
  • SARS-CoV-2


  • Antibodies, Monoclonal, Humanized
  • Antibodies, Neutralizing
  • Antiviral Agents
  • imdevimab
  • bamlanivimab
  • casirivimab
  • etesevimab