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
Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimize the risk of transmission, with immediate implementation of the strict contact and airborne precautions set out by the CDC.[29] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.
The CDC advises that patients with SARS coronavirus (CoV) disease who do not require hospitalization for medical reasons may be isolated at home.[29] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.
Supportive care involves administration of adequate supplemental oxygen to correct hypoxemia, replacement of fluid deficit caused by diarrhea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.
Treatment recommended for SOME patients in selected patient group
Patients with impending or established respiratory failure should be admitted to the ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO2 above 90% with spontaneous ventilation despite maximal oxygen therapy.
Noninvasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.
To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulized humidity and utilization of Venturi masks without humidification,[49] avoidance of bag-mask ventilation and utilization of masks that permit filtration of exhaled gas, utilization of adequate sedation during intubation, utilization of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilization of sedation or paralysis to minimize coughing, turning ventilator to standby and PEEP to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.
Treatment recommended for ALL patients in selected patient group
Primary options
ceftriaxone: 1-2 g intravenously every 24 hours
and
azithromycin: 500 mg intravenously every 24 hours
OR
ertapenem: 1 g intravenously every 24 hours
and
azithromycin: 500 mg intravenously every 24 hours
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
Due to the initial uncertainty regarding diagnosis, empiric antimicrobial therapy against both typical (including drug-resistant strains) and atypical community-acquired respiratory pathogens is a prudent first-line therapy.
Possible intravenous combinations in hospitalized patients include ceftriaxone and azithromycin, or ertapenem and azithromycin. Monotherapy with levofloxacin or moxifloxacin is an alternative[50]
Antibiotic therapy should be discontinued as soon as a definite diagnosis is documented.
Treatment recommended for SOME patients in selected patient group
Primary options
zanamivir: 10 mg (2 inhalations) twice daily for 5 days
OR
oseltamivir: 75 mg orally twice daily for 5 days
When epidemiologically indicated (i.e., during a seasonal epidemic of influenza), influenza virus should also be covered with a 5-day course of either zanamivir or oseltamivir.
mild-moderate infection
Mild-moderate infection is denoted by fever (≥100.4°F [38°C]) plus 1 or more symptoms of lower respiratory tract illness: cough, dyspnea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.
Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimize the risk of transmission, with immediate implementation of the strict contact and airborne precautions set out by the CDC.[29] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.
The CDC advises that patients with SARS coronavirus (CoV) disease who do not require hospitalization for medical reasons may be isolated at home.[29] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.
Supportive care involves administration of adequate supplemental oxygen to correct hypoxemia, replacement of fluid deficit caused by diarrhea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.
Treatment recommended for SOME patients in selected patient group
Patients with impending or established respiratory failure should be admitted to the ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO2 above 90% with spontaneous ventilation despite maximal oxygen therapy.
Noninvasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.
To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulized humidity and utilization of Venturi masks without humidification,[49] avoidance of bag-mask ventilation and utilization of masks that permit filtration of exhaled gas, utilization of adequate sedation during intubation, utilization of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilization of sedation or paralysis to minimize coughing, turning ventilator to standby and PEEP to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.
Treatment recommended for ALL patients in selected patient group
Primary options
lopinavir/ritonavir: 400/100 mg orally twice daily
Mild-moderate infection is denoted by fever (≥100.4°F [38°C]) plus 1 or more symptoms of lower respiratory tract illness: cough, dyspnea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.
RCT data on the efficacy of antivirals in the treatment of SARS are limited, although it would appear that antiviral therapy should be given to all confirmed cases as early as possible.
The combination of lopinavir/ritonavir should be given for 14 days.[51]
Treatment recommended for SOME patients in selected patient group
Primary options
ribavirin: consult specialist for guidance on dose
Mild-moderate infection is denoted by fever (≥100.4°F [38°C]) plus 1 or more symptoms of lower respiratory tract illness: cough, dyspnea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.
Although not effective as a monotherapy, ribavirin can be given with lopinavir/ritonavir.[16]
Treatment recommended for SOME patients in selected patient group
Mild-moderate infection is denoted by fever (≥100.4°F [38°C]) plus 1 or more symptoms of lower respiratory tract illness: cough, dyspnea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.
Patients, as well as their relatives, may require consultation with a specialist in psychological therapy and counseling for specialized treatment.
severe infection
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimize the risk of transmission, with immediate implementation of the strict contact and airborne precautions set out by the CDC.[29] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.
The CDC advises that patients with SARS coronavirus (CoV) disease who do not require hospitalization for medical reasons may be isolated at home.[29] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.
Supportive care involves administration of adequate supplemental oxygen to correct hypoxemia, replacement of fluid deficit caused by diarrhea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.
Treatment recommended for SOME patients in selected patient group
Patients with impending or established respiratory failure should be admitted to the ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO2 >90% with spontaneous ventilation despite maximal oxygen therapy.
Noninvasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.
To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulized humidity and utilization of Venturi masks without humidification,[49] avoidance of bag-mask ventilation and utilization of masks that permit filtration of exhaled gas, utilization of adequate sedation during intubation, utilization of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilization of sedation or paralysis to minimize coughing, turning ventilator to standby and PEEP to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.
Treatment recommended for ALL patients in selected patient group
Primary options
lopinavir/ritonavir: 400/100 mg orally twice daily
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
RCT data on the efficacy of antivirals in the treatment of SARS are limited, although it would appear that antiviral therapy should be given to all confirmed cases as early as possible.
The combination of lopinavir/ritonavir should be given for 14 days.[51]
Treatment recommended for ALL patients in selected patient group
Primary options
methylprednisolone: 250-500 mg intravenously once daily for 3-6 days
Reported to have some efficacy in severe cases (critical SARS) presenting with deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.[52]
Although various regimens have been tried, the most commonly used is 3 to 6 days of pulsed methylprednisolone.
Corticosteroids added to lopinavir/ritonavir and/or ribavirin early in the course of the infection have been shown to reduce the progression to ARDS as well as the death rate.[16]
Treatment recommended for SOME patients in selected patient group
Primary options
ribavirin: consult specialist for guidance on dose
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
Although not effective as a monotherapy, ribavirin can be given with lopinavir/ritonavir.[16]
Treatment recommended for SOME patients in selected patient group
Primary options
interferon alfa 2b: consult specialist for guidance on dose
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
Can be given to patients who do not show a favorable response to treatment with pulsed methylprednisolone and ribavirin.
Interferon alfa-2b has been shown to inhibit growth of SARS in vitro.[54]
Treatment recommended for SOME patients in selected patient group
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
Can be given to patients who do not show a favorable response to treatment with pulsed methylprednisolone and ribavirin.
The efficacy of convalescent plasma administration as a treatment of SARS has not been documented.[55][56]
Treatment recommended for SOME patients in selected patient group
Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (SpO2 <90%/Oxygenation Index <300 mmHg/PaO2 <10 kpa), and a respiratory rate of 30 or more.
Patients, as well as their relatives, may require consultation with a specialist in psychological therapy and counseling for specialized treatment.
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