Approach

There are no specific treatments available for hantavirus cardiopulmonary syndrome (HCPS), and treatment is supportive. If HCPS is suspected, emergency medical care is required, even before the diagnosis is confirmed. Early intensive medical care is critical to improve the chances of recovery. Key components of management include cardiac function monitoring, fluid therapy, supplemental oxygen, platelet transfusion, and mechanical ventilation if needed. Without adequate treatment, most deaths occur within 24 to 48 hours.[60]

Infection prevention and control (IPC)

Standard precautions are recommended when managing all patients with hantavirus infection.[49][50]

Human-to-human transmission has been reported rarely with Andes virus (ANDV). If ANDV infection is suspected or confirmed, the patient should be placed in an isolation room, and contact and airborne precautions are recommended including use of a gown, eye protection, and a N95 (or higher-level) respirator when entering the patient’s room. Duration of precautions should be determined on a case-by-case basis in conjunction with local public health authorities.[6][51]​​

Empiric antimicrobial therapy

Empiric broad-spectrum antimicrobial therapy for the treatment of sepsis is appropriate until a diagnosis of HCPS is confirmed.[47][60]​​​ See Sepsis in adults and Sepsis in children.

Analgesia and antipyretics may be given while awaiting confirmation of the diagnosis. Antibiotics are discontinued once the diagnosis is made.

Intensive care unit (ICU) management

Patients in the cardiopulmonary phase of the disease can rapidly deteriorate. Approximately two-thirds of patients experience cardiopulmonary failure within the first 8 to 24 hours.[69]

HCPS can progress rapidly to cardiogenic shock and death. Therefore, close monitoring in an ICU is warranted.[47][60]​​[69]

  • Supplemental oxygen may be required, with intubation and initiation of mechanical ventilation as needed to treat respiratory failure.

  • Fluids should be given along with vasopressors to maintain blood pressure. Fluid management should be careful to avoid volume overload. Inotropic therapy may be required for cardiogenic shock.

  • Platelet transfusion may be required according to local protocols.

About 40% of patients admitted to the hospital will not require intubation and can be managed with supplemental oxygen and careful fluid administration.[10]

Extracorporeal membrane oxygenation (ECMO)

Early consideration of transfer to a center with ECMO access is key. A falling cardiac index with evidence of cardiovascular collapse is an indication for ECMO support.[58][60]​​[69]

Findings associated with a 100% mortality in the absence of ECMO include:[68]

  • Cardiac index <2.5 L/minute/m²

  • Serum lactate >4 mmol/L

  • Ventricular fibrillation, tachycardia, or pulseless electrical dissociation

  • Shock refractory to fluids and vasoactive therapy.

Published experience suggests that up to 72% of HCPS patients with high mortality risk supported with ECMO have survived to hospital discharge.[58][78]

In a single case report ECMO was successful in supporting a pregnant patient with severe HCPS.[79]

Experimental therapies

Experimental therapies (e.g., favipiravir) may be used off-label during outbreaks. Consult your local public health authority for guidance.

Favipiravir is an experimental, broad-spectrum, oral antiviral drug that inhibits viral RNA-dependent RNA polymerase.[7]

  • Favipiravir has shown activity against hantaviruses in vitro in laboratory studies and in vivo in animal models. In the hamster-adapted Sin Nombre virus (SNV)/ANDV-infection model, favipiravir reduced tissue viral antigen levels.[80]​ Other studies have shown that the ANDV-hamster model did not offer protection once viremia has started.[81]​ There are no human data available. 

  • Favipiravir may be recommended as an off-label investigational therapy by local public health authorities during outbreaks. However, there are currently no guidelines that recommend favipiravir for the treatment of hantavirus infection.

​Ribavirin is a broad-spectrum, oral antiviral drug that inhibits viral RNA-dependent RNA polymerase.

  • Intravenous ribavirin does not seem effective against HCPS when given during the cardiopulmonary phase. Once the cardiopulmonary phase begins, the rate of disease progression and death are too rapid for ribavirin to be of benefit. Administration of ribavirin during the prodrome phase has not been studied, mainly due to difficulty enrolling participants during this phase.[82]

  • An analysis of open-label ribavirin use for HCPS did not find that it was effective and also noted that 71% of ribavirin recipients became anemic, with 19% requiring transfusion.[83]

  • Thus, treatment with intravenous ribavirin is probably not effective.

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