Viral Syndromes (Flu, COVID, etc) MDM

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MDM Templates

Viral Syndrome

Patient with suspected Viral Syndrome given fever, cough, sore throat, myalgias, and malaise.
They do not demonstrate high risk comorbid states such as immunosuppression, significant cardiopulmonary disease, SNF residence.
They are nontoxic appearing, with no hypoxia, and are tolerating PO.

History and exam lower suspicion for emergent cardiopulmonary etiologies (Bacterial Pneumonia, significant Asthma/COPD exacerbation, PE, decompensated Heart Failure, ACS), emergent otolaryngeal processes (PTA, RPA, Ludwig’s, Epiglottitis), and other serious infection (Meningitis, acute HIV).

Plan: Conservative management with antipyretics, hydration, rest.
Disposition: Discharge with strict return precautions for worsening dyspnea, persistent high fevers, inability to tolerate PO, chest pain, or altered mental status. PCP follow-up within 48-72 hours.

Influenza

Patient with confirmed Influenza testing presenting with acute onset fever, myalgias, cough, and malaise. They do not demonstrate high-risk features. They are nontoxic appearing, without hypoxia, and tolerating PO.

History and exam lower suspicion for emergent cardiopulmonary etiologies (Bacterial Pneumonia, significant Asthma/COPD exacerbation, PE, decompensated Heart Failure, ACS), emergent otolaryngeal processes (PTA, RPA, Ludwig’s, Epiglottitis), and other serious infection (Meningitis, acute HIV).

Within 48 hours of symptom onset OR high risk at any time point:
Plan: Oseltamivir 75mg PO BID x 5 days OR Baloxavir (Xofluza) single dose.
Disposition: Discharge with strict return precautions.

Beyond 48 hours, low risk:
Plan: Conservative care. Antivirals unlikely to provide meaningful benefit at this time point in a low-risk patient.
Disposition: Discharge with strict return precautions.

Admit if: Hypoxia, respiratory distress, inability to tolerate PO, hemodynamic instability, AMS. Start Oseltamivir regardless of timing. Consider IV Peramivir 600mg x1 if unable to tolerate PO.

COVID-19

Patient with confirmed COVID-19 presenting with cough, fever, myalgias, and fatigue. They do / do not demonstrate high-risk features (see criteria below). They are nontoxic appearing, without hypoxia on room air, and tolerating PO.

History and exam lower suspicion for emergent cardiopulmonary etiologies (Bacterial Pneumonia, significant Asthma/COPD exacerbation, PE, decompensated Heart Failure, ACS) and other serious infection.

High risk and within 5 days of symptom onset:
Plan: Nirmatrelvir/ritonavir (Paxlovid) 300mg/100mg PO BID x 5 days. Drug interactions reviewed — no contraindications identified.
Disposition: Discharge with strict return precautions.

Low risk or >5 days from symptom onset:
Plan: Conservative care with antipyretics, hydration, rest.
Disposition: Discharge with strict return precautions.

Admit if: Hypoxia (SpO2 <94%), respiratory distress, inability to tolerate PO, hemodynamic instability, AMS. Start Remdesivir 200mg IV day 1 then 100mg daily. Add Dexamethasone 6mg daily x 10 days ONLY if requiring supplemental O2.[1]

Clinical Education

Antiviral Selection

Agent Dose Pearl
Oseltamivir (Tamiflu) 75mg PO BID x 5d First-line flu. Preferred in pregnancy, peds, hospitalized. Give regardless of timing if severe or high-risk.[2]
Baloxavir (Xofluza) Single dose (40mg <80kg, 80mg ≥80kg) Single dose = better compliance. Superior to oseltamivir for Flu B. Avoid in pregnancy (limited data).[3]
Peramivir (Rapivab) 600mg IV x1 IV option if can’t tolerate PO. Single dose.
Paxlovid 300mg/100mg PO BID x 5d COVID only. High-risk within 5 days. 83% reduction in hospitalization. CHECK DRUG INTERACTIONS.[4]
Remdesivir 200mg IV day 1, then 100mg daily COVID inpatient or high-risk outpatient who can’t take Paxlovid. 3-day course outpatient, 5-day inpatient.[5]

Flu testing pearl: Rapid influenza tests have ~50-70% sensitivity. A negative rapid in a classic flu presentation during flu season does not rule it out. Treat empirically in high-risk patients. Send PCR if clinical suspicion is high.[6]

Paxlovid Pearls

Drug interactions: Ritonavir is a potent CYP3A4 inhibitor. Major interactions: tacrolimus/cyclosporine (dose reduction, consult pharmacy), simvastatin/lovastatin (hold), rivaroxaban/apixaban (hold or dose reduce), colchicine (avoid). Use the NIH Paxlovid Drug Interaction Checker.[4]

Rebound: ~10-15% of patients. Generally mild, does not require retreatment. Counsel patients it’s possible.[7]

High-Risk Populations

Treat with antivirals regardless of timing (flu) or within 5 days (COVID). Lower threshold for admission:

Age ≥65, age <2 (flu), pregnancy or ≤2 weeks postpartum, immunosuppression (transplant, HIV, chemo, chronic steroids), chronic cardiopulmonary disease (COPD, asthma, CHF), CKD, liver disease, diabetes, morbid obesity (BMI ≥40), nursing home/long-term care residents.[2]

Steroids in Viral Illness

COVID + hypoxic: Dexamethasone 6mg daily x 10 days. NNT = 8 for mortality reduction (RECOVERY trial).[1]
COVID + non-hypoxic: Do NOT give. Trend toward harm in RECOVERY trial (HR 1.19 for mortality).[1]
Influenza: Not recommended. Associated with increased mortality and secondary infections.[8]
Asthma/COPD exacerbation triggered by viral illness: Steroids appropriate — treating the reactive airway disease, not the virus.

Bacterial Superinfection

When to suspect: Biphasic illness — initial improvement then worsening at days 5-7, new fever after defervescence, purulent sputum, focal consolidation on CXR. Common pathogens: S. pneumoniae, S. aureus (including MRSA), H. influenzae.[9]

Procalcitonin: Low (<0.25) makes bacterial co-infection less likely and supports withholding antibiotics. Not perfect — use in clinical context. Empiric antibiotics are not routine for uncomplicated flu or COVID.[9]

References

  1. RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021;384(8):693-704. PubMed
  2. CDC. Influenza Antiviral Medications: Summary for Clinicians. Updated 2025. CDC
  3. WHO Clinical Practice Guidelines for Influenza: An Update. 2025. PubMed
  4. NIH COVID-19 Treatment Guidelines: Ritonavir-Boosted Nirmatrelvir (Paxlovid). NIH
  5. IDSA Guidelines on the Treatment and Management of Patients with COVID-19. Updated 2025. IDSA
  6. Chartrand C et al. Accuracy of Rapid Influenza Diagnostic Tests: A Meta-Analysis. Ann Intern Med. 2012;156(7):500-511. PubMed
  7. Anderson AS et al. Nirmatrelvir-Ritonavir and Viral Load Rebound in Covid-19. N Engl J Med. 2022;387(11):1047-1049. PubMed
  8. Lansbury LE et al. Corticosteroids as Adjunctive Therapy in the Treatment of Influenza. Cochrane Database Syst Rev. 2019;(2):CD010406. PubMed
  9. Morris DE et al. Secondary Bacterial Infections Associated with Influenza Pandemics. Front Microbiol. 2017;8:1041. PubMed

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