COVID-19 in 2026: A Familiar Respiratory Illness

More than five years after its emergence, COVID-19 has transitioned from a pandemic threat to a common respiratory infection, taking its place alongside influenza and respiratory syncytial virus (RSV). Whereas the early pandemic days brought critically ill patients and widespread uncertainty, the current landscape is markedly different, according to emergency physicians.

The Changing Face of COVID-19 in the Emergency Department

“I have seen it travel 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 emergency physician working as an independent contractor in Charleston, South Carolina.

Physicians now view COVID-19 as another upper respiratory infection, often mild but potentially serious for certain patient populations, explains Jon McGreevy, MD, MSPH, division chief of pediatric emergency medicine at Phoenix Children’s.

Advancements in Testing

Access to COVID-19 testing has significantly improved. Widely available at-home antigen tests offer high specificity, though re-testing may be necessary due to lower sensitivity according to the U.S. Food and Drug Administration. Most facilities now utilize polymerase chain reaction (PCR) testing, considered the gold standard.

The practice of relying on the cycle threshold (Ct) values from PCR tests to determine infectiousness has been largely abandoned. Guidelines from the Infectious Diseases Society of America (IDSA) state that current data do not support using Ct values to assess infectiousness. Emergency physicians typically receive a simple positive or negative result from the lab.

Test-to-Treat Strategies and Patient Considerations

A test-to-treat strategy is commonly employed, taking into account a patient’s risk profile, symptom onset, and household situation. Dr. McGreevy notes that the presence of vulnerable individuals at home—such as a child undergoing leukemia treatment or a grandparent with COPD—may raise the threshold for testing and potential treatment.

Patient expectations also play a role. Some patients desire testing for confirmation, while others require documentation for employers. These concerns can be addressed through open communication and shared decision-making.

Current Treatment Protocols

The IDSA guidelines recommend evaluating both patient- and pathogen-specific factors when considering treatment, including symptom severity, onset date, variant, and risk factors for severe illness.

Most COVID-19 cases are mild to moderate, resolving with supportive care such as over-the-counter medications and hydration. For patients at increased risk of severe illness—including those 65 or older or with conditions like diabetes or cystic fibrosis—antiviral therapy is recommended within five days of symptom onset.

Antiviral Options

• Nirmatrelvir/ritonavir (Paxlovid): Recommended by the IDSA for most outpatients aged 12 and older, a Cochrane review found it reduced hospitalization or death by 87%. However, careful screening for drug interactions is crucial. Virologic rebound has been observed in approximately one in five patients.
• Remdesivir: Effective in preventing progression to severe COVID-19 in outpatients, as demonstrated in the PINETREE trial. However, its administration requires three consecutive daily infusions, making outpatient use logistically challenging.
• Molnupiravir: Suggested by the IDSA as an alternative when nirmatrelvir/ritonavir is unavailable or contraindicated, and remdesivir is not feasible, for high-risk patients 18 and older. The American College of Physicians also recommends considering molnupiravir.

For patients with severe COVID-19—characterized by hypoxemia or COVID pneumonia—immunomodulatory treatments like corticosteroids are recommended in the emergency department. However, they are contraindicated in patients with less severe illness.

Future Directions

Ongoing clinical trials, such as the Outpatient Treatment with Anti-Coronavirus Immunoglobulin (OTAC) trial, are exploring additional treatment options. As the situation evolves, frequently updated, evidence-based treatment guidelines provide clear recommendations for managing both routine and high-risk cases.