A 75-year-old man who lives in a nursing home presents to the urgent care with fever, chills, rhinorrhea, nasal congestion, and cough for 12 hours. The nursing home staff reports that multiple residents have tested positive for influenza and COVID-19 in the past week. On examination, the patient has mild fatigue with no acute distress. The cardiac and pulmonary examinations are normal. He has no known drug allergies. Current medications are atorvastatin and losartan. Your clinic does not have point-of-care molecular testing capabilities.
Which of the following options would be most appropriate for this patient?
- Send out molecular multiplex testing for COVID-19 and influenza A+B.
- Initiate empiric treatment without initial testing.
- Perform a CLIA-waived point-of-care RSV antigen test.
- Perform COVID-19 and influenza antigen tests.
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Correct Answer: d. Perform COVID-19 and influenza antigen tests.
You recalled that clinical presentation alone without diagnostic testing is insufficient in distinguishing between COVID-19 and influenza and that there are antiviral therapies for both COVID-19 and influenza. Since your facility does not have in-house point-of-care molecular testing, you performed COVID-19 and influenza antigen testing, which showed that this patient was positive for COVID-19 and negative for influenza. You decided against sending out a multiplex molecular upper respiratory infection panel because your in-house testing is adequate in this case and you also do not want to incur unwarranted costs to your clinic and the patient.
You discussed the results with the patient and recommended nirmatrelvir/ritonivir because the patient is in the high-risk category for COVID-19 complications. You reviewed his chart and saw that he had a creatinine clearance >60 mL/min performed 3 months ago. The patient was instructed to withhold atorvastatin and restart it 3 to 5 days after completion of nirmatrelvir/ritonavir due to drug interactions. When the nursing home staff called back to ask whether PCR testing was needed to determine when the patient is no longer contagious, you recommended against it, as molecular testing can detect very low viral loads for weeks to months after infection, even when the patient is not contagious anymore.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
