Pan American Health Organization · Abbreviated version, October 2021
Evidence-based GRADE recommendations for outpatient COVID-19 management, pharmacotherapy, and monitoring for clinicians in resource-variable settings.
- Issuer
- Pan American Health Organization
- Edition
- Abbreviated version, October 2021
- Audience
- General practitioners, emergency physicians, pulmonologists, internists, family physicians, infectious disease specialists, nursing staff, pharmacists, decision-makers
- Evidence
- GRADE-rated recommendations from systematic reviews; living guideline subject to continuous update
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This abbreviated PAHO guideline, updated October 2021, provides rapid evidence-based recommendations using GRADE methodology for managing mild and moderate COVID-19 in Latin America and the Caribbean. The guideline addresses prophylaxis, risk stratification, triage, diagnostic imaging, home care, pharmacological treatment, supplements, anticoagulation, and discharge criteria.
The central message is overwhelmingly conservative: no pharmacological prophylaxis or treatment (including ivermectin, hydroxychloroquine, antibiotics, corticosteroids, remdesivir, convalescent plasma, vitamin D, or chlorine dioxide) is recommended for mild or moderate COVID-19 outside clinical trials. Management focuses on isolation, symptomatic treatment with acetaminophen for fever/pain (maximum 4 g/day), adequate hydration and nutrition, pulse oximetry monitoring for moderate cases with risk factors, and education on warning signs requiring urgent care.
The guideline emphasizes risk stratification using clinical factors (age >60 years, comorbidities including hypertension, obesity, cardiovascular disease, diabetes, chronic lung/kidney/liver disease, immunodeficiency, cancer) and vital signs (SpO₂ 20/min in adults). For moderate cases, home monitoring with pulse oximeters is suggested where available, with medical evaluation triggered by SpO₂ decline or respiratory distress independent of saturation readings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- <strong>No prophylaxis:</strong> Do not use any medication for prophylaxis in people at risk of SARS-CoV-2 infection (strong recommendation against, moderate evidence).
- <strong>No specific pharmacotherapy:</strong> Do not administer ivermectin, hydroxychloroquine, chloroquine (±azithromycin), remdesivir, colchicine, lopinavir/ritonavir, aspirin, tocilizumab, convalescent plasma, or corticosteroids for mild/moderate COVID-19 (all strong recommendations against).
- <strong>No antibiotics:</strong> Do not administer antibiotics without suspicion of superadded bacterial infection (strong recommendation against, low evidence).
- <strong>Symptomatic treatment only:</strong> Acetaminophen 500 mg every 6–8 hours (maximum 4 g/day) for fever or pain; maintain adequate hydration and nutrition.
- <strong>Risk factors for progression:</strong> Age >60 years, >1 comorbidity, hypertension, obesity, cardiovascular disease, chronic lung/kidney/liver disease, cerebrovascular disease, immunodeficiency, cancer, active smoking, malnutrition (geriatric patients).
- <strong>Moderate COVID-19 definition:</strong> Clinical pneumonia (fever, cough, dyspnea, rapid breathing) with SpO₂ ≥90% on room air; in children: rapid breathing <2 months ≥60/min, 2–12 months ≥50/min, 1–5 years ≥40/min.
- <strong>Pulse oximetry monitoring:</strong> For moderate cases with risk factors managed at home; seek care if SpO₂ decreases (altitude-adjusted) or respiratory distress occurs regardless of SpO₂.
- <strong>Warning signs for urgent care:</strong> Increased dyspnea, blood pressure drop, cyanosis (lips/face), confusion, inability to wake, increased weakness, SpO₂ <90%, persistent chest pain, limb inflammation, dizziness, loss of consciousness, respiratory rate >20/min.
WHO definitions of mild and moderate COVID-19
Table extracted from the guideline
| Severity | Clinical features | Oxygen saturation | Additional criteria |
|---|---|---|---|
| Mild disease | Symptomatic patients meeting COVID-19 case definition without viral pneumonia or hypoxia; no respiratory distress or dyspnea | Normal | Diagnostic images normal |
| Moderate disease (adult/adolescent) | Clinical pneumonia signs (fever, cough, dyspnea, rapid breathing) without severe pneumonia | SpO₂ ≥90% on room air (≥94% at sea level for patients with normal baseline) | Chest imaging may assist diagnosis |
| Moderate disease (child) | Non-severe pneumonia (cough or difficulty breathing + rapid breathing or chest tightness) | Normal for age/altitude | Rapid breathing: <2 months ≥60/min; 2–12 months ≥50/min; 1–5 years ≥40/min |
Source: Pan American Health Organization, Guidelines for Prophylaxis and Management of Patients with Mild and Moderate COVID-19 in Latin America and the Caribbean. Reproduced in summary form.
From the guideline
Verbatim
“It is recommended not to administer remdesivir, colchicine, convalescent plasma, lopinavir + ritonavir, aspirin, ivermectin, chloroquine, or hydroxychloroquine, with or without azithromycin, acetylcysteine, tocilizumab, or any other medication, for the management of patients with mild and moderate COVID-19.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who advised WHO on health systems resilience during the pandemic, I recognise that this PAHO guideline addresses one of the most pressing challenges Georgia faced in 2020–2021: the widespread empirical use of unproven therapies in outpatient COVID-19 management. The strong recommendations against ivermectin, hydroxychloroquine, and antibiotics—drugs that were widely prescribed in our region despite weak evidence—provide the clarity our primary care providers urgently needed. For Georgian clinicians, I would stress the risk stratification criteria (age >60, comorbidities) and the SpO₂ thresholds (≥90% on room air defines moderate disease; <90% or ≥94% at sea level triggers escalation), because timely hospital referral prevented ICU overload in our October 2021 surge. The implementation caveat is realistic: pulse oximeters remain scarce in rural ambulatories, so our National Centre for Disease Control must prioritise distribution to high-burden regions and train feldshers in correct measurement technique and altitude adjustment, or the home monitoring strategy cannot succeed.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, these evidence-based recommendations provide critical guidance for resource-appropriate COVID-19 outpatient management. The guideline’s emphasis on not using unproven pharmacotherapy addresses widespread off-label use of ivermectin, hydroxychloroquine, and antibiotics documented in the region during 2020–2021. Georgia’s primary health care system, strengthened through the UHC programme since 2013, is well-positioned to implement home monitoring protocols, though pulse oximeter availability in rural areas may be limited. National programmes should prioritize clear public communication that acetaminophen and supportive care—not antibiotics or antivirals—constitute appropriate outpatient treatment, and ensure primary care providers can reliably identify the risk factors and warning signs that trigger hospital referral. The altitude-adjusted SpO₂ thresholds are particularly relevant for Armenia’s highland populations.
Questions this guideline answers
Quick answers
Should I prescribe ivermectin or hydroxychloroquine for outpatient COVID-19?
No. PAHO strongly recommends against ivermectin, hydroxychloroquine, chloroquine (with or without azithromycin), and all other specific pharmacotherapy for mild or moderate COVID-19 outside clinical trials, based on low to very low quality evidence showing no benefit.
What treatment should I give patients with mild or moderate COVID-19?
Isolate the patient; treat symptoms with acetaminophen 500 mg every 6–8 hours (maximum 4 g/day) for fever or pain; ensure adequate hydration and nutrition; educate on warning signs; and for moderate cases with risk factors, monitor with pulse oximetry if available.
Which patients are at high risk of progression to severe disease?
Those aged >60 years or with ≥1 comorbidity: hypertension, obesity, cardiovascular disease, chronic lung/kidney/liver disease, diabetes, cerebrovascular disease, thrombocytopenia, active smoking, malnutrition (elderly), cancer, or immunodeficiency. In children: persistent fever, diarrhea, abdominal pain, nausea/vomiting, altered neurology, heart rate variations (especially bradycardia), or low SpO₂.
When should a patient with moderate COVID-19 at home seek urgent medical care?
If SpO₂ drops below 90% (adjusted for altitude), respiratory rate exceeds 20/min, or warning signs appear: increased dyspnea, hypotension, cyanosis, confusion, inability to wake, persistent chest pain, limb inflammation, dizziness, or loss of consciousness—regardless of oxygen saturation.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Abbreviated version, October 2021
- Status
- Current
- Published
- 2021-01-01
- Languages
- English, Spanish
- Scope
- Prophylaxis, triage, diagnostic imaging, pharmacological treatment, supplements, anticoagulation, home care, discharge criteria for mild and moderate COVID-19
- Audience
- General practitioners, emergency physicians, pulmonologists, internists, family physicians, infectious disease specialists, nursing staff, pharmacists, decision-makers
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated recommendations from systematic reviews; living guideline subject to continuous update
- Next review
- Continuous updating (living guidance)
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidelines for Prophylaxis and Management of Patients with Mild and Moderate COVID-19 in Latin America and the Caribbean. Abbreviated Version, October 2021. Washington, D.C.: PAHO; 2021. (PAHO/IMS/EIH/COVID-19/21-024). Available from: https://iris.paho.org/handle/10665.2/55068GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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