Approach

No specific treatment exists for MERS; however, many drugs show promise and may prove to be valuable therapies in the future. Therefore, treatment is supportive and should focus on relieving symptoms and preventing or treating complications. Specific management depends on the clinical presentation, and patient factors such as age and the presence or absence of comorbidities.

Infection prevention and control measures

Isolation procedures should be initiated in all suspected or confirmed cases of MERS. An increased level of infection control precautions is recommended. Specifically, the World Health Organization (WHO) recommends standard, droplet, and contact precautions, as well as airborne precautions when performing aerosol-generating procedures.[85]

Patients with probable or confirmed infection should be placed in an adequately ventilated single room, clearly segregated from other patient care areas if possible. The number of healthcare workers and visitors should be kept to a minimum. In addition to standard precautions, all healthcare workers and visitors, when in close contact (i.e., approximately 3 feet) with a probable or confirmed case, should always use:

  • A medical mask

  • Eye protection

  • A clean, nonsterile, long-sleeved gown

  • Gloves.

Hand hygiene should always be performed before and after contact with the patient and their surroundings, and immediately after the removal of personal protective equipment. Movement of the patient outside of the barrier nursing room or area should be avoided unless medically necessary.

These precautions should be used for the duration of the symptomatic illness and continued for at least 24 hours after the resolution of symptoms.[85]Patients should be monitored for the clearance of infection using the recommended real-time reverse transcription polymerase chain reaction (RT-PCR) assays until there are 2 negative results on specimens taken at least 24 hours apart.[89][92]Infection control measures can be discontinued in nonventilated patients (e.g., those in home isolation) when the patient is asymptomatic and a single RT-PCR is negative.[89]

Detailed infection prevention and control recommendations are available from the Centers for Disease Control and Prevention (CDC) and WHO:

Specimen collection

The following specimens should be collected in all patients for diagnostic testing:[92]

  • Blood cultures: for potential bacterial pathogens that can also cause pneumonia or sepsis

  • Lower respiratory tract specimens (e.g., sputum, tracheal aspirates, bronchoalveolar lavage): for bacterial and viral testing

  • Upper respiratory tract specimens (e.g., nasopharyngeal and throat swabs): for molecular viral testing

  • Serum: for molecular and serologic testing.

Specimens should be collected according to the appropriate infection control measures. Blood cultures should be collected before antimicrobial therapy is started, if possible. Lower respiratory tract specimens are preferable to upper respiratory tract specimens, but both should be collected if possible. Upper respiratory tract specimens (e.g., nasopharyngeal swab) are sufficient in patients isolated at home.

Frequency of specimen collection depends on local circumstances. The WHO recommends that respiratory tract specimens for RT-PCR should be collected at least every 2 to 4 days in the initial 2 weeks, and continue until there are 2 negative test results to confirm clearance of the virus.[92] The Ministry of Health (Saudi Arabia) recommends repeat testing one week after diagnosis, and then every 3 days.[89]

Management of patients with pneumonia or comorbidities

Patients with pneumonia or respiratory distress should be promptly admitted to an appropriate healthcare facility and infection prevention and control measures instituted.

Any patient with the following signs should be admitted to the hospital:

  • Respiratory rate >30 breaths/minute

  • Hypoxemia (SpO2 <90% on room air)

  • Severe respiratory distress

  • Clinical and/or radiologic evidence of pneumonia.

These patients may rapidly progress to severe pneumonia or respiratory failure; therefore, it is important to pay attention to these clinical signs.[81]

Presence of comorbidities (e.g., diabetes mellitus, heart disease, chronic renal failure, obesity), smoking, and age ≥50 years increases the risk of developing severe infection, and these patients should also be admitted.

Supportive therapies should be started promptly:[92][89]

  • Oxygen: patients with signs of severe respiratory distress, shock, or hypoxemia should be started on oxygen therapy immediately. Initiate at 5 L/minute and titrate so that SpO2 ≥90%

  • Fluids: cautious fluid management is recommended in patients if necessary, provided that there is no evidence of shock (more aggressive resuscitation may be required in patients with shock)

  • Antimicrobials: empiric antimicrobial therapy (including antibiotics and antivirals) should be started in inpatients with suspected MERS pneumonia (within one hour if sepsis is suspected) to cover all likely community-acquired or hospital-acquired (if patient has been admitted for >48 hours) pathogens. Antimicrobial selection should be based on local epidemiology, susceptibility data, and guidelines until diagnosis is confirmed, and empiric therapy adjusted based on results

  • Antipyretics/analgesics: recommended for the control of fever and pain.

Patients with impending or established respiratory failure should be admitted to the ICU. Intubation and mechanical ventilation are recommended if the patient is deteriorating and cannot maintain a SpO2 ≥90% with oxygen therapy. Noninvasive mechanical ventilation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) have been used in patients with MERS.[81][125] However, noninvasive ventilation should be avoided due to the high risk of generating aerosols, and because it lacks evidence of efficacy compared to endotracheal intubation and mechanical ventilation.[89] A small observational study found that ECMO was associated with lower mortality in MERS patients with refractory hypoxemia.[126]

Corticosteroids are generally not recommended; however, stress doses may be given if needed (e.g., patient with adrenal suppression). High doses should not be used for prolonged periods of time due to a high risk of adverse effects, the risk of developing opportunistic infections, and a lack of proven efficacy in treating MERS.[92][127] 

Patients should be monitored closely for signs of deterioration and the development of complications including respiratory failure, acute respiratory distress syndrome, acute renal failure, septic shock, and multiorgan failure. Supportive therapy (e.g., hemodialysis, vasopressor therapy, fluid resuscitation, antimicrobials) should be initiated immediately if required.[5][8][26][81][125]

Data on pregnant women are limited. Pregnant women can be treated with the supportive therapies detailed above (except ibuprofen, which is not recommended in pregnant women especially in the third trimester), taking into account the physiologic changes that occur with pregnancy.

Management of patients without pneumonia or comorbidities

Patients who are young and healthy with no comorbidities are at a lower risk of developing complications, and may be considered for home isolation, if appropriate.[89][86][128]These patients generally have mild, nonspecific symptoms such as fever, headache, malaise, cough, sore throat, or possibly gastrointestinal symptoms. Chest x-ray is normal.[10]

The CDC recommend this is appropriate only once a healthcare professional, in consultation with their local or state health department, deems that the residential setting is suitable and that the patient is capable of adhering to recommended infection control precautions.[129]The WHO recommend that confirmed symptomatic cases should be isolated and monitored in a hospital setting whenever possible; however, home isolation may be considered in certain patients with mild symptoms and no underlying conditions (e.g., heart disease, renal failure) or immunocompromising conditions if inpatient care is not available or is unsafe. The decision requires careful clinical judgement and should be informed by assessing the safety of the patient's home environment.[128]

Infection control measures are still recommended for these patients and include using a single room, single bathroom (if possible), minimizing contact with other household members, and wearing a surgical mask if contact is necessary.[89][86]

Supportive therapies are recommended including antipyretic and analgesics (e.g., acetaminophen, ibuprofen) for the relief of pain and fever. Patients should keep hydrated, but should not take in too much fluid as this can worsen oxygenation.[92]

Detailed guidelines for home isolation are available from the CDC and WHO:

Experimental therapies

There is no conclusive evidence at this time to recommend any virus-specific treatments for patients with suspected or confirmed infection. However, a number of treatments (e.g., interferon beta, interferon alfa, lopinavir, ribavirin, mycophenolate, and cyclosporine) have been studied for the treatment of MERS based on encouraging in vitro and animal studies.[130][131] So far, none of these treatments have proven to be effective. This is partly due to a lack of randomized controlled trials and the limited number of patients that are included in retrospective studies.

Some countries, such as Republic of Korea (South Korea), have issued guidance that permits physicians to cautiously use some of the studied therapies.[132]

These therapies are generally only used in unstable patients with extensive pneumonia. If investigational agents are used, the WHO recommends that these drugs only be used under standard research treatment protocols and occur in the context of research trials.[92] Further studies are needed to evaluate the safety and efficacy of these agents in people with MERS.

See Emerging Therapies for more detailed information about specific experimental drugs.

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