Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
all patients
isolation and infection prevention and control
Infection prevention and control (IPC) is of immediate concern and local protocols should be followed. Patients who are identified as being at risk of infection as per case definitions should immediately be isolated, and personal protective equipment (PPE) should be used until the infection is either confirmed or excluded.[92]World Health Organization. Infection prevention and control guideline for Ebola and Marburg disease. Aug 2023 [internet publication]. https://www.who.int/publications/i/item/WHO-WPE-CRS-HCR-2023.1
The CDC and WHO produce detailed guidance on IPC in healthcare settings:
CDC: guidance for personal protective equipment (PPE) Opens in new window
WHO: infection prevention and control guideline for Ebola and Marburg disease Opens in new window
Specimens for laboratory investigations (e.g., Ebola RT-PCR, CBC, serum creatinine/BUN, LFTs, ABG, coagulation studies, blood cultures, and investigations for other conditions such as malaria) should be collected and sent off according to local and national protocols. Judicious selection of investigations is important in order to reduce risk of transmission to laboratory workers and other healthcare personnel.
CDC: collection, transport, and submission for Ebola virus testing in the US Opens in new window
Placement of a central line early in the patient stay (if possible) allows bloods to be taken and fluids to be given while minimizing the risk of needlestick injuries.[147]Rees PS, Lamb LE, Nicholson-Roberts TC, et al. Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit. Intensive Care Med. 2015 May;41(5):735-43. http://www.ncbi.nlm.nih.gov/pubmed/25761540?tool=bestpractice.com
A staffing ratio of at least one clinician (defined as nurses, clinical officers, or physicians) to four patients is recommended to allow patient assessment three times daily.[150]Lamontagne F, Fowler RA, Adhikari NK, et al. Evidence-based guidelines for supportive care of patients with Ebola virus disease. Lancet. 2018 Feb 17;391(10121):700-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31795-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29054555?tool=bestpractice.com
Healthcare workers should facilitate communication with family and friends (e.g., use of cell phones or the internet) in order to reduce psychologic distress without increasing the risk of infection.[150]Lamontagne F, Fowler RA, Adhikari NK, et al. Evidence-based guidelines for supportive care of patients with Ebola virus disease. Lancet. 2018 Feb 17;391(10121):700-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31795-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29054555?tool=bestpractice.com
Ebola disease is a notifiable disease.
fluid and electrolyte management
Treatment recommended for ALL patients in selected patient group
Oral rehydration solutions can be used for patients who can tolerate oral administration and who are not severely dehydrated, but the majority of patients require intravenous fluid replacement with either normal saline or lactated Ringer solution.[20]Bah EI, Lamah MC, Fletcher T, et al. Clinical presentation of patients with Ebola virus disease in Conakry, Guinea. N Engl J Med. 2015 Jan 1;372(1):40-7. https://www.nejm.org/doi/full/10.1056/NEJMoa1411249#t=article http://www.ncbi.nlm.nih.gov/pubmed/25372658?tool=bestpractice.com [94]Hunt L, Gupta-Wright A, Simms V, et al. Clinical presentation, biochemical, and haematological parameters and their association with outcome in patients with Ebola virus disease: an observational cohort study. Lancet Infect Dis. 2015 Nov;15(11):1292-9. http://www.ncbi.nlm.nih.gov/pubmed/26271406?tool=bestpractice.com Options include the peripheral or central intravenous route, or the intraosseous route[150]Lamontagne F, Fowler RA, Adhikari NK, et al. Evidence-based guidelines for supportive care of patients with Ebola virus disease. Lancet. 2018 Feb 17;391(10121):700-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31795-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29054555?tool=bestpractice.com
The volume of intravenous fluids required should be assessed based on clinical exam (i.e., level of dehydration, signs of shock) and fluid losses (i.e., volume of diarrhea and/or vomitus). Large volumes of fluid replacement (up to 10 L/day) may be required in febrile patients with diarrhea.[45]Kreuels B, Wichmann D, Emmerich P, et al. A case of severe Ebola virus infection complicated by gram-negative septicemia. N Engl J Med. 2014 Dec 18;371(25):2394-401. https://www.nejm.org/doi/full/10.1056/NEJMoa1411677#t=article http://www.ncbi.nlm.nih.gov/pubmed/25337633?tool=bestpractice.com
Close supervision and frequent monitoring are required as it is important to assess response and prevent fluid overload. Patients should be checked frequently for signs of shock, dehydration, or overhydration, and the fluid rate adjusted accordingly. Systematic monitoring of vital signs (e.g., heart rate, blood pressure, urine output, gastrointestinal fluid loss) and volume status at least three times daily is required to detect hypovolemia.[150]Lamontagne F, Fowler RA, Adhikari NK, et al. Evidence-based guidelines for supportive care of patients with Ebola virus disease. Lancet. 2018 Feb 17;391(10121):700-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31795-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29054555?tool=bestpractice.com
The availability of point-of-care tests within the isolation facility makes monitoring the patient's biochemical status more efficient and reduces the risks associated with specimen transport.[115]Fowler RA, Fletcher T, Fischer WA 2nd, et al. Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa. Am J Respir Crit Care Med. 2014 Oct 1;190(7):733-7. https://www.atsjournals.org/doi/full/10.1164/rccm.201408-1514CP#.VEe1OvldWnA http://www.ncbi.nlm.nih.gov/pubmed/25166884?tool=bestpractice.com Electrolyte monitoring should be performed daily, and repletion given as necessary.[20]Bah EI, Lamah MC, Fletcher T, et al. Clinical presentation of patients with Ebola virus disease in Conakry, Guinea. N Engl J Med. 2015 Jan 1;372(1):40-7. https://www.nejm.org/doi/full/10.1056/NEJMoa1411249#t=article http://www.ncbi.nlm.nih.gov/pubmed/25372658?tool=bestpractice.com More frequent monitoring can be considered if large volumes of intravenous fluids are being administered or if there are severe biochemical abnormalities present.
Large amounts of potassium replacement (e.g., 5-10 mmol potassium chloride per hour) may be required.[22]Schieffelin JS, Shaffer JG, Goba A, et al; KGH Lassa Fever Program; Viral Hemorrhagic Fever Consortium; WHO Clinical Response Team. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med. 2014 Nov 27;371(22):2092-100. https://www.nejm.org/doi/full/10.1056/NEJMoa1411680#t=article http://www.ncbi.nlm.nih.gov/pubmed/25353969?tool=bestpractice.com [139]Wolf T, Kann G, Becker S, et al. Severe Ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care. Lancet. 2015 Apr 11;385(9976):1428-35. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2962384-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/25534190?tool=bestpractice.com [153]Clay KA, Johnston AM, Moore A, et al. Targeted electrolyte replacement in patients with Ebola virus disease. Clin Infect Dis. 2015 Sep 15;61(6):1030-1. http://www.ncbi.nlm.nih.gov/pubmed/26056238?tool=bestpractice.com
High blood lactate levels can be a reliable measure of hypoperfusion and can help guide fluid resuscitation.[115]Fowler RA, Fletcher T, Fischer WA 2nd, et al. Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa. Am J Respir Crit Care Med. 2014 Oct 1;190(7):733-7. https://www.atsjournals.org/doi/full/10.1164/rccm.201408-1514CP#.VEe1OvldWnA http://www.ncbi.nlm.nih.gov/pubmed/25166884?tool=bestpractice.com
WHO guidelines should be consulted for specific recommendations on fluid and electrolyte management as well as on maintaining adequate nutrition during acute illness and the convalescent phase.
WHO: optimized supportive care for Ebola virus disease Opens in new window
analgesia/antipyretic
Treatment recommended for ALL patients in selected patient group
Should be treated with acetaminophen first line (for pain and fever).[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Opioid analgesics (e.g., tramadol, morphine) are preferable for more severe pain.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Nonsteroidal anti-inflammatory drugs (including aspirin) should be avoided due to their associated increased risk of bleeding and potential for nephrotoxicity.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Analgesia may help dysphagia, if present.
Primary options
acetaminophen: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day
Secondary options
tramadol: children: consult specialist for guidance on dose; adults: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day
OR
morphine sulfate: children: 0.2 to 0.4 mg/kg orally every 4-6 hours when required, or 0.05 to 0.1 mg/kg intravenously every 4-6 hours when required; adults: 2.5 to 10 mg orally/intravenously every 4 hours when required
antiemetic
Treatment recommended for ALL patients in selected patient group
Oral or intravenous antiemetics (e.g., ondansetron, promethazine) are recommended.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Primary options
ondansetron: children: consult specialist for guidance on dose; adults: 8 mg orally every 12 hours, or 4 mg intravenously every 8 hours when required
OR
promethazine: children: consult specialist for guidance on dose; adults: 12.5 to 25 mg orally every 4-6 hours when required
antiviral monoclonal antibody
Treatment recommended for SOME patients in selected patient group
The WHO strongly recommends either atoltivimab/maftivimab/odesivimab (also known as REGN-EB3) or ansuvimab (also known as mAb114) for patients with confirmed infection with Ebola virus (species Orthoebolavirus zairense), and neonates ≤7 days of age with unconfirmed infection who are born to mothers with confirmed infection with Ebola virus (species Orthoebolavirus zairense).[167]World Health Organization. Therapeutics for Ebola virus disease - Democratic Republic of the Congo. Aug 2022 [internet publication]. https://www.who.int/publications/i/item/9789240055742 Efficacy has not been established for other species of orthoebolaviruses.
Atoltivimab/maftivimab/odesivimab and ansuvimab are approved by the Food and Drug Administration (FDA) for the treatment of infection with Ebola virus (species Orthoebolavirus zairense) in children and adults, and atoltivimab/maftivimab/odesivimab has received orphan drug designation from the European Medicines Agency.
Atoltivimab/maftivimab/odesivimab and ansuvimab probably reduce mortality compared with standard of care (moderate-certainty evidence), ZMapp, and remdesivir. However, they may have little or no effect on time to viral clearance. It is very uncertain whether they increase the risk of serious adverse events.[167]World Health Organization. Therapeutics for Ebola virus disease - Democratic Republic of the Congo. Aug 2022 [internet publication]. https://www.who.int/publications/i/item/9789240055742 [169]Gao Y, Zhao Y, Guyatt G, et al. Effects of therapies for Ebola virus disease: a systematic review and network meta-analysis. Lancet Microbe. 2022 Sep;3(9):e683-92. https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(22)00123-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35803293?tool=bestpractice.com The PALM trial found that of the patients who received atoltivimab/maftivimab/odesivimab, 33.5% died at 28 days compared to 51.0% of patients in the control group (ZMapp). Of the patients who received ansuvimab, 35.1% died at 28 days compared to 49.7% of patients in the control group.[168]Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial of Ebola virus disease therapeutics. N Engl J Med. 2019 Dec 12;381(24):2293-303. https://www.doi.org/10.1056/NEJMoa1910993 http://www.ncbi.nlm.nih.gov/pubmed/31774950?tool=bestpractice.com
Adverse effects include hypersensitivity and infusion-related reactions, fever/chills, tachycardia, tachypnea, hypotension, and elevated hepatic enzymes.
Both treatments are administered as a single dose intravenous infusion, and should be given as soon as possible after diagnosis. They may be used in older people, pregnant and breastfeeding women, and children and newborns.
Access to these therapeutics is challenging in many parts of the world, and choice depends on availability. They may need to be used under a compassionate use framework during an outbreak.
Primary options
atoltivimab/maftivimab/odesivimab: children and adults: 50 mg/kg of each component as a single intravenous infusion
OR
ansuvimab: children and adults: 50 mg/kg as a single intravenous infusion
broad-spectrum antibiotics
Treatment recommended for SOME patients in selected patient group
In some settings, especially in endemic areas where there is poor access to diagnostic tests, patients are routinely given broad-spectrum antibiotics as part of the management protocol. If started, reassess after 48 hours.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease
convalescent whole blood or plasma
Treatment recommended for SOME patients in selected patient group
There is limited evidence from past outbreaks that transfusion of blood from convalescent patients could be beneficial in the acute phase of infection, and may reduce mortality.[6]Roddy P, Howard N, Van Kerkhove MD, et al. Clinical manifestations and case management of Ebola haemorrhagic fever caused by a newly identified virus strain, Bundibugyo, Uganda, 2007-2008. PLoS One. 2012 Dec 28;7(12):e52986. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0052986 http://www.ncbi.nlm.nih.gov/pubmed/23285243?tool=bestpractice.com [162]World Health Organization. Interim guidance: potential Ebola therapies and vaccines. Nov 2014 [internet publication]. https://apps.who.int/iris/bitstream/10665/137590/1/WHO_EVD_HIS_EMP_14.1_eng.pdf?ua=1 Use of convalescent plasma is likely to be more achievable and effective than use of whole blood.[163]Kreil TR. Treatment of Ebola virus infection with antibodies from reconvalescent donors. Emerg Infect Dis. 2015 Mar;21(3):521-3. https://wwwnc.cdc.gov/eid/article/21/3/14-1838_article http://www.ncbi.nlm.nih.gov/pubmed/25695274?tool=bestpractice.com [164]Gutfraind A, Myers LA. Evaluating large-scale blood transfusion therapy for the current Ebola epidemic in Liberia. J Infect Dis. 2015 Apr 15;211(8):1262-7. https://jid.oxfordjournals.org/content/211/8/1262 http://www.ncbi.nlm.nih.gov/pubmed/25635118?tool=bestpractice.com
Trials carried out in Guinea failed to show a survival benefit in patients treated with convalescent plasma, although the treatment appeared to be safe with no severe complications documented.[165]van Griensven J, Edwards T, de Lamballerie X, et al. Evaluation of convalescent plasma for Ebola virus disease in Guinea. N Engl J Med. 2016 Jan 7;374(1):33-42. https://www.nejm.org/doi/full/10.1056/NEJMoa1511812#t=article http://www.ncbi.nlm.nih.gov/pubmed/26735992?tool=bestpractice.com [166]van Griensven J, De Weiggheleire A, Delamou A, et al. The use of Ebola convalescent plasma to treat Ebola virus disease in resource-constrained settings: a perspective from the field. Clin Infect Dis. 2016 Jan 1;62(1):69-74. https://academic.oup.com/cid/article/62/1/69/2462604/The-Use-of-Ebola-Convalescent-Plasma-to-Treat http://www.ncbi.nlm.nih.gov/pubmed/26261205?tool=bestpractice.com
The WHO has issued interim guidelines on the use of convalescent blood/plasma.
antacid or proton-pump inhibitor
Treatment recommended for ALL patients in selected patient group
Patients may benefit from administration of a suitable antacid or a proton-pump inhibitor (e.g., omeprazole).[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1 Analgesia may help with dysphagia.
Primary options
omeprazole: children ≥10 years of age and adults: 20 mg orally once daily
supportive therapies
Treatment recommended for ALL patients in selected patient group
Zinc is recommended in children with diarrhea.[157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Patients should be evaluated for gastrointestinal infections and managed accordingly.[157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Fecal management systems were used successfully in the 2014 outbreak in West Africa in patients with severe diarrhea. They were well tolerated and provided infection prevention and control benefits for healthcare workers.[117]Dickson SJ, Clay KA, Adam M, et al. Enhanced case management can be delivered for patients with EVD in Africa: experience from a UK military Ebola treatment centre in Sierra Leone. J Infect. 2018 Apr;76(4):383-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903873 http://www.ncbi.nlm.nih.gov/pubmed/29248587?tool=bestpractice.com
Diarrhea should be managed conservatively; the use of antimotility agents is not generally recommended.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease
Primary options
zinc: children <6 months of age: 10 mg orally once daily for 10-14 days; children ≥6 months of age: 20 mg orally once daily for 10-14 days
benzodiazepine or anticonvulsant
Treatment recommended for ALL patients in selected patient group
Although uncommon, seizures are a feature of advanced disease and pose a risk to healthcare workers because they increase the risk of contact with the patient's body fluids.
Recognition and correction of contributing factors (e.g., high temperature, hypoperfusion, electrolyte disturbances, hypoglycemia) is essential.
A benzodiazepine (e.g., intravenous/intramuscular or rectal diazepam) can be used to abort the seizure while an anticonvulsant (e.g., phenobarbital) can be given for repeated seizures.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Primary options
diazepam: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously/intramuscularly initially, repeat every 10-15 minutes if required, maximum 30 mg/total dose
OR
diazepam rectal: children: consult specialist for guidance on dose; adults: 0.2 mg/kg rectally as a single dose, a second dose can be given in 4-12 hours if necessary
Secondary options
phenobarbital: children: consult specialist for guidance on dose; adults: 10 mg/kg intravenously initially, followed by 5 mg/kg every 30-60 minutes until seizures under control, maximum total loading dose 30 mg/kg
sedative
Treatment recommended for ALL patients in selected patient group
Although uncommon, agitation may be associated with encephalopathy or possibly a direct effect of the virus on the brain, and can occur in advanced disease.
Judicious use of a sedative (e.g., haloperidol or a benzodiazepine) is imperative for keeping the patient calm and preventing needlestick injuries in healthcare workers.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Repeat doses are based on clinical response.
Primary options
diazepam: children: consult specialist for guidance on dose; adults: 5 mg orally/intravenously as a single dose
OR
haloperidol: children: consult specialist for guidance on dose; adults: 5 mg intramuscularly as a single dose
oxygen
Treatment recommended for ALL patients in selected patient group
Oxygen should be titrated to maintain SpO2 >94%. Patients should be evaluated for pneumonia, fluid overload, wheezing, and congestive heart failure and managed accordingly.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
sepsis management protocol
Treatment recommended for ALL patients in selected patient group
Identification of sepsis or septic shock should be done rapidly using established criteria. Management follows the same principles as for bacterial sepsis. Local guidance should be followed, but should include: broad-spectrum empiric antibiotic therapy, ideally given within one hour of recognition; rapid intravenous fluid resuscitation with assessment of response; and appropriate airway management and oxygen administration.[158]Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11): e1063-e1143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
Blood lactate levels are a useful tool to help assess perfusion and response to resuscitation.
In the absence of a response to initial management, inotropic support should be considered, preferably via a central venous catheter in an intensive care unit where invasive monitoring enables more aggressive fluid, electrolyte, and acid-base balance correction.[115]Fowler RA, Fletcher T, Fischer WA 2nd, et al. Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa. Am J Respir Crit Care Med. 2014 Oct 1;190(7):733-7. https://www.atsjournals.org/doi/full/10.1164/rccm.201408-1514CP#.VEe1OvldWnA http://www.ncbi.nlm.nih.gov/pubmed/25166884?tool=bestpractice.com [146]Canadian Critical Care Society; Canadian Association of Emergency Physicians; Association of Medical Microbiology and Infectious Diseases of Canada. Ebola clinical care guidelines: a guide for clinicians in Canada. October 2014 [internet publication]. https://www.canadiancriticalcare.org/resources/Pictures/Ebola%20Clinical%20Care%20Guidelines_ENG.pdf
Possibility of hemorrhage should be considered, particularly in patients with skin or mucosal bleeding.
WHO guidelines should be consulted for specific recommendations on the management of sepsis/septic shock.
WHO: optimized supportive care for Ebola virus disease Opens in new window
supportive care
Treatment recommended for ALL patients in selected patient group
Multi-organ dysfunction is a common feature of advanced infection and includes acute kidney injury, pancreatitis, adrenal failure, and liver damage.
Liver damage (e.g., hepatitis) is common; however, jaundice is not a common feature.[69]Fletcher T, Fowler RA, Beeching NJ. Understanding organ dysfunction in Ebola virus disease. Intensive Care Med. 2014 Dec;40(12):1936-9. http://www.ncbi.nlm.nih.gov/pubmed/25366120?tool=bestpractice.com
Renal dysfunction is common in the advanced stages, but can be reversed with adequate fluid resuscitation in the initial stages.[69]Fletcher T, Fowler RA, Beeching NJ. Understanding organ dysfunction in Ebola virus disease. Intensive Care Med. 2014 Dec;40(12):1936-9. http://www.ncbi.nlm.nih.gov/pubmed/25366120?tool=bestpractice.com In patients with anuria who do not respond to fluid resuscitation, renal replacement therapy has been used, although there are no trial data to support the efficacy of this intervention. Of the 5 critically ill patients in Europe and North America with multi-organ failure who were managed with both invasive mechanical ventilation and renal replacement therapy, 3 died.[45]Kreuels B, Wichmann D, Emmerich P, et al. A case of severe Ebola virus infection complicated by gram-negative septicemia. N Engl J Med. 2014 Dec 18;371(25):2394-401. https://www.nejm.org/doi/full/10.1056/NEJMoa1411677#t=article http://www.ncbi.nlm.nih.gov/pubmed/25337633?tool=bestpractice.com [107]Lyon GM, Mehta AK, Varkey JB, et al; Emory Serious Communicable Diseases Unit. Clinical care of two patients with Ebola virus disease in the United States. N Engl J Med. 2014 Dec 18;371(25):2402-9. https://www.nejm.org/doi/full/10.1056/NEJMoa1409838#t=article http://www.ncbi.nlm.nih.gov/pubmed/25390460?tool=bestpractice.com [139]Wolf T, Kann G, Becker S, et al. Severe Ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care. Lancet. 2015 Apr 11;385(9976):1428-35. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2962384-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/25534190?tool=bestpractice.com [141]Uyeki TM, Mehta AK, Davey RT Jr, et al. Clinical management of Ebola virus disease in the United States and Europe. N Engl J Med. 2016 Feb 18;374(7):636-46. https://www.nejm.org/doi/full/10.1056/NEJMoa1504874#t=article http://www.ncbi.nlm.nih.gov/pubmed/26886522?tool=bestpractice.com [161]Connor MJ Jr, Kraft C, Mehta AK, et al. Successful delivery of RRT in Ebola virus disease. J Am Soc Nephrol. 2015 Jan;26(1):31-7. http://www.ncbi.nlm.nih.gov/pubmed/25398785?tool=bestpractice.com
transfusion, vitamin K, tranexamic acid, or proton-pump inhibitor
Treatment recommended for ALL patients in selected patient group
Major bleeding occurs infrequently, but is a manifestation of advanced infection that is usually, but not always, fatal.
When available, fresh whole blood or platelet and plasma transfusions should be given according to local protocols and guided by clinical and laboratory (if available) indicators (e.g., hemoglobin, hematocrit, INR).[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1 [159]Wada H, Thachil J, Di Nisio M, et al. Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from three guidelines. J Thromb Haemost. 2013 Feb 4;11(4):761-7. https://onlinelibrary.wiley.com/doi/10.1111/jth.12155/full http://www.ncbi.nlm.nih.gov/pubmed/23379279?tool=bestpractice.com
Vitamin K, tranexamic acid, or a proton-pump inhibitor (for gastrointestinal bleeding) are reasonable treatment options in patients who are bleeding.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease [157]World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. Feb 2016 [internet publication]. https://apps.who.int/iris/bitstream/10665/205570/1/9789241549608_eng.pdf?ua=1
Primary options
phytonadione (vitamin K1): consult specialist for guidance on dose
OR
tranexamic acid: consult specialist for guidance on dose
OR
omeprazole: children ≥10 years of age and adults: 20 mg orally once daily
antimalarial therapy
Treatment recommended for ALL patients in selected patient group
Malaria should be tested for and treated with appropriate antimalarial therapy if present while keeping in mind the patient's risk for Ebola disease and the possibility of a dual infection. In endemic settings, malaria treatment is usually given as part of the routine management protocol, with or without confirmation of the infection.
Give empiric antimalarial therapy until the malaria testing is negative or the treatment course is finished.[148]World Health Organization. Optimized supportive care for Ebola virus disease. July 2019 [internet publication]. https://www.who.int/publications-detail/optimized-supportive-care-for-ebola-virus-disease
monitoring and early treatment of complications
Treatment recommended for ALL patients in selected patient group
The WHO recommends the following key management principles in pregnant women: use both standard precautions and Ebola-specific infection prevention and control measures; include optimized supportive care in the clinical management of all pregnant women; atoltivimab/maftivimab/odesivimab and ansuvimab may be offered to pregnant women in the context of rigorous research, or in accordance with local protocols; do not induce labor or perform invasive procedures for fetal indications in pregnant women with acute infection; advise women with suspected or confirmed acute infection not to breast-feed until after two negative breast milk tests (by RT-PCR) separated by 24 hours (in the meantime, infants should be separated from the mother and given a suitable breast milk substitute).[84]World Health Organization. Guidelines for the management of pregnant and breastfeeding women in the context of Ebola virus disease. 2020 [internet publication]. https://www.who.int/publications/i/item/9789240001381
Intrapartum hemorrhage and spontaneous abortion appear to be common in infected women; therefore, obstetric management should focus on monitoring for, and early treatment of, hemorrhagic complications.[21]Chertow DS, Kleine C, Edwards JK, et al. Ebola virus disease in West Africa - clinical manifestations and management. N Engl J Med. 2014 Nov 27;371(22):2054-7. https://www.nejm.org/doi/full/10.1056/NEJMp1413084 http://www.ncbi.nlm.nih.gov/pubmed/25372854?tool=bestpractice.com [171]Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis. 1999 Feb;179 Suppl 1:S11-2. https://jid.oxfordjournals.org/content/179/Supplement_1/S11.long http://www.ncbi.nlm.nih.gov/pubmed/9988157?tool=bestpractice.com [173]Jamieson DJ, Uyeki TM, Callaghan WM, et al. What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol. 2014 Nov;124(5):1005-10. http://www.ncbi.nlm.nih.gov/pubmed/25203368?tool=bestpractice.com [174]Association of Women's Health, Obstetric and Neonatal Nurses. Ebola: caring for pregnant and postpartum women and newborns in the United States: AWHONN practice brief number 3. J Obstet Gynecol Neonat Nurs. 2015 Jan-Feb;44(1):164-5. https://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12518/full http://www.ncbi.nlm.nih.gov/pubmed/25421426?tool=bestpractice.com [175]Kitching A, Walsh A, Morgan D. Ebola in pregnancy: risk and clinical outcomes. BJOG. 2015 Feb;122(3):287. http://www.ncbi.nlm.nih.gov/pubmed/25585496?tool=bestpractice.com
The CDC has produced specific guidance for caring for pregnant women and neonates:
CDC: clinical guidance for Ebola in people who are pregnant Opens in new window
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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