Outpatient treatment and prophylaxis (mAb, antiviral) screening form

If, after reviewing the guidelines, you have a patient you believe meets the criteria for monoclonal antibody (mAb) therapy, please complete our COVID-19 resources mAb screening form. For children under consideration for mAb therapy, they should receive their infusion within the first 10 days of symptoms. It is the goal of Children’s Wisconsin to have children who are approved to receive their infusions within 72 hours of the referring provider making contact.

If you do not need a same day non-urgent, response, you may complete our screening form and your information will be reviewed by the mAb liaison within 1 business day. You will be called for further assessment. If you need a same day non-urgent response, please complete our screening form and call 414-266-2460 and request a NON URGENT consult with infectious disease.

Providers are encouraged to review the “CW guidelines for community Paxlovid use” as not all Paxlovid requests need to be routed to liaison and review team. View using this url: https://childrenswi.org/-/media/chwlibrary/files/medical-professionals/tools-and-resources/CW-Guidelines-for-community-Paxlovid-use

See the following site for guidance: https://www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/ritonavir-boosted-nirmatrelvir--paxlovid-/

In the clinical trial for Evusheld, an increased rate of cardiac events occurred for patients with risk factors for cardiac disease or history of pre-existing CV disease. See page 8 in the Fact Sheet for Healthcare Providers for description of the cardiac issues. https://www.fda.gov/media/154701/download

Baseline labs

Severity of illness

If no and the specialist is from oncology/BMT, cardiology, pulmonary, gastroenterology, rheumatology, hematology, immunology, endocrine or nephrology, please contact that specialist to discuss the child’s potential need for mAb prior to completing the form.

Please note: It may take up to 10 seconds for the form to be submitted. It is not necessary to press the Submit button below more than once.