Discharge criteria for patients with COVID-19 to long-term care facilities requires modification

Editor – Residents of long-term care facilities (LTCF) have suffered much in the current COVID-19 pandemic.¹ Current guidance for the discharge of patients with COVID-19 to LTCF requires testing for SARS-CoV-2 by PCR 48 hours prior to discharge, with the result relayed to the receiving organisation.² The intention of this guidance is presumably to prevent those who are infectious from entering a shared living space and triggering an outbreak, by either delaying their discharge or isolating them within the LTCF.

Viable SARS-CoV-2 viral cultures, not ribonucleic acid PCR, are the best surrogate markers of infectivity. Studies show that, in most patients, cultures become negative after day 10 of symptom onset in COVID-19 patients, despite PCR positivity being detected up to 21 days and beyond, with the exception of those who are heavily immunosuppressed.^3,4 Unfortunately, viral cultures are no longer used in most UK diagnostic laboratories, due to it being labour-intensive and requiring category 3 / biosafety level 3 facilities. Viral loads, as measured by cycle threshold values, are under investigation as markers for infectivity. However, they are not interchangeable between assays due to heterogenous gene target(s), amplification chemistry and nucleic acid extraction systems.

In short, a ‘positive/negative’ PCR test prior to discharge to a LTCF is not appropriate because it does not relate to infectivity. A negative test may be a false negative with rates up to 30%; a positive test does not mean that the patient is infectious and shedding active virus.⁵ Until more reliable markers of infectivity are found, we recommend modifying the discharge criteria to state that patients who have recovered from COVID-19 can be discharged to a LTCF if it is 10 days after their first positive swab or 10 days after clear symptom onset; with exceptions being those who are heavily immunosuppressed (transplant patients or those with severe genetic immunodeficiencies) as shown in Table 1. This is simple and more in line with the UK's self-isolation guidance for those who test positive for COVID-19 in the community, as well as the most recent World Health Organization guidance and should be continuously updated.^6,7