Discontinuing infection control precautions for patients with COVID-19 in the healthcare setting

*Patients without* moderate or severe immunocompromise**
Patients with asymptomatic SARS-CoV-2 infection	Time-based (before discontinuing precautions, all of the following conditions must be met): At least 10 days have passed since the date of their first positive viral diagnostic test. No subsequent illness developed.
Patients with mild to moderate disease*	Symptom-based (before discontinuing precautions, all of the following conditions must be met): At least 10 days have passed since symptoms first appeared. At least 1 day (24 hours) has passed since resolution of fever without the use of fever-reducing medications. There is improvement in symptoms (eg, cough, shortness of breath).
Patients with severe or critical disease*	Symptom-based (before discontinuing precautions, all of the following conditions must be met): At least 10 and up to 20 days have passed since symptoms first appeared. At least 1 day (24 hours) has passed since resolution of fever without the use of fever-reducing medications. There is improvement in symptoms (eg, cough, shortness of breath). A test-based strategy is useful to help guide when to discontinue precautions within this time frame.
Moderately to severely immunocompromised patients – Conditions associated with moderate to severe immunocompromise include various hereditary and acquired immune deficiencies (eg, combined primary immunodeficiency disorder, receiving certain chemotherapy for cancer, being within 1 year of receiving a hematopoietic stem cell or solid organ transplant, HIV and a CD4 count <200 cells/microL, receiving CAR-T cell therapy or B-cell-depleting therapies, receipt of prednisone ≥20 mg/day for more than 14 days, or a tumor necrosis factor blocker).
Patients with asymptomatic SARS-CoV-2 infection	Test-based^¶^Δ (before discontinuing precautions, all of the following conditions must be met): Results are negative from at least two consecutive respiratory specimens collected ≥48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. No subsequent illness developed.
Patients with symptomatic disease	Test-based^Δ (before discontinuing precautions, all of the following conditions must be met): Resolution of fever without the use of fever-reducing medications, and Symptoms (eg, cough, shortness of breath) have improved, and Results are negative from at least two consecutive respiratory specimens collected ≥48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.

This table describes the approach to discontinuing infection control precautions in patients with COVID-19 in the health care setting based upon recommendations from the United States Centers for Disease Control and Prevention (CDC). Protocols in other countries and at specific institutions may differ. Hospitalized patients who are ready to be discharged prior to meeting criteria for discontinuation of precautions can be sent home with instructions to self-isolate until they meet the above criteria. If discharged to a nursing home or other long-term care facility, the patient should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of residents with COVID-19. Once infection control precautions are discontinued, all patients should still continue to follow hospital policies regarding masking.

When using a time-based strategy (ie, for patients who are asymptomatic), day 0 is the date the specimen was collected for the positive test. When using a symptom-based strategy, day 0 is the first day of symptoms.

COVID-19: coronavirus disease 2019; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; CAR-T: chimeric antigen receptor T; NAAT: nucleic acid amplification test; RT-PCR: reverse-transcription polymerase chain reaction.

* Patients with mild to moderate COVID-19 typically have signs and symptoms of COVID-19 without hypoxia (eg, oxygen saturation ≥94% on room air); by contrast, those with severe or critical disease usually have an oxygen saturation <94% on room air and/or need oxygenation or ventilatory support. Refer to the UpToDate topic that discusses the clinical features of COVID-19 for a discussion of disease severity.

¶ Some experts prefer a non-test-based strategy for moderately immunocompromised patients who are clinically improved; in this setting isolation can be discontinued after day 20.

Δ The CDC states an antigen test or NAAT (eg, RT-PCR) can be used for a test-based strategy. However, we prefer to use a molecular test when testing is performed in the health care settings since it is more sensitive than antigen testing. The first test should typically be performed on day 20.

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Discontinuing infection control precautions for patients with COVID-19 in the healthcare setting