COVID-19 in 2026: What's Changed in the ED

Most emergency physicians (EPs) have vivid memories of the early pandemic days—critically ill patients, isolation, and, above all, uncertainty. In January 2026, more than 5 years after COVID emerged, the picture is significantly different. “I have seen it go from a disease that made us convert every available space—including hallways—into makeshift ICU beds to take care of all the severe COVID cases, to now, where it has been at least 2 years since I have admitted anyone for COVID,” said Brian Kendall, MD, an EP working as an independent contractor in Charleston, South Carolina. For physicians, COVID has now taken its place alongside influenza and respiratory syncytial virus as another common upper respiratory infection—one that's often mild but can become serious for certain patients, said Jon McGreevy, MD, MSPH, division chief of pediatric emergency medicine at Phoenix Children's. Testing Developments Early in the pandemic, testing was difficult to access. Currently, at-home antigen tests are widely available and have high specificity, although lower sensitivity may necessitate re-testing after a negative result.1 Most facilities now utilize gold-standard polymerase chain reaction (PCR) testing, said Adit Ginde, MD, professor of emergency medicine at the University of Colorado Anschutz School of Medicine.. Previously, the cycle threshold (Ct) of PCR tests—the number of cycles necessary to detect the virus—was sometimes used when making decisions about treatment and isolation. But such measurements aren't standardized and can vary even within assays from the same manufacturer.2 Guidelines from the Infectious Diseases Society of America (IDSA) note that data aren't sufficient to support the use of Ct values to determine infectiousness.3 Ct doesn't currently play a role in clinical decision-making; most EPs receive simply a negative or positive result from the lab or panel, Dr Ginde said. Like many clinicians, he supports a test-to-treat strategy. Factors to consider include risk profile, symptom onset, and others in the residence. “When there's the 5-year-old who's in there to be seen, but they have an 8-year-old who has leukemia at home, or a grandparent who has COPD at home,” Dr McGreevy said, “that may raise my threshold for testing and potentially treatment.” Patient expectations also factor in, Dr Kendall said. Some may feel dissatisfied without testing, while others need evidence of illness for their employer. Such issues can often be resolved with a straightforward conversation about treatment goals and shared decision-making. Treatment Protocols In those with suspected or confirmed COVID, IDSA guidelines recommend evaluating both patient- and pathogen-specific factors, including symptom severity, date of onset, variant, and risk factors for progression.4 In most patients, COVID is mild to moderate.5 Typical symptoms—cough, runny nose, fever, and headache—resolve with supportive care. “Most patients go home with instructions on using over-the-counter medications for symptom control, instructions to drink plenty of clear fluids to stay hydrated, and to make sure they follow up with their primary care physician,” Dr Kendall said. The IDSA guidelines recommend antiviral therapy for patients at increased risk for severe illness—including those who are 65 years or older or with a condition such as diabetes or cystic fibrosis—who present within 5 days of symptom onset, when such treatment is most efficacious.4 For most outpatients aged 12 and older, IDSA recommends nirmatrelvir/ritonavir (Pfizer's Paxlovid). A Cochrane systematic review published in 2023 found the drug reduced hospitalization or death within 28 days by 87%.6 However, drug interactions are common, so it's important to screen patients' medications carefully. In addition, an observational study published in the Annals of Internal Medicine in 2023 found virologic rebound in approximately one in five patients taking the drug.7 Dr Kendall stresses to patients that while Paxlovid may prevent hospitalization, symptoms may not improve or may even worsen when the 5-day course is completed. Many patients decline, a reasonable decision, per the IDSA.4 Remdesivir is another option for high-risk patients; Dr Ginde was part of the co-author team for the PINETREE trial, results of which confirmed the safety and efficacy of remdesivir for preventing progression to severe COVID in outpatients.8 But because remdesivir requires three consecutive daily infusions, it's logistically difficult to administer to outpatients. When nirmatrelvir/ritonavir isn't available or is contraindicated, and remdesivir isn't feasible, IDSA guidelines suggest considering the antiviral molnupiravir for patients 18 and older at high risk of progression to severe disease.4 Guidelines from the American College of Physicians also recommend considering molnupiravir, noting that it may improve recovery and reduce time to recovery.9 For patients with severe COVID—those who are hypoxemic and/or have COVID pneumonia—immunomodulatory treatments such as corticosteroids are recommended, and it's reasonable to initiate them in the emergency department (ED) under these circumstances, Dr Ginde said.4 However, they're contraindicated in those with lower severity of COVID, even if they're being admitted. While several other treatments that showed early promise didn't prove effective, Dr Ginde said, additional clinical trials are underway. That includes the ongoing Outpatient Treatment with Anti-Coronavirus Immunoglobulin (OTAC) trial, assessing a single infusion of anti-COVID-19 hyperimmune intravenous immunoglobulin.10 In the future, these or other trials may lead to additional proven options. As the situation continues to evolve, frequently updated, evidence-based treatment guidelines offer EPs clear recommendations for managing both routine and high-risk cases.