Middle East respiratory syndrome coronavirus infection medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Antiviral therapy against MERS-CoV is not yet recommended. Supportive care is the mainstay of management of MERS-CoV. Monitoring for and early management of MERS-CoV-associated complications is also important. | |||
==Medical Therapy== | ==Medical Therapy== | ||
According to the ''International Severe Acute Respiratory & Emerging Infection Consortium'' from the ISARIC and the ''Interim Guidance Document'' from the [[WHO]], supportive medical care is the mainstay of management of [[MERS-CoV]].<ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref><ref name=ISARIC>{{cite web | title = | |||
the ''International Severe Acute Respiratory & Emerging Infection Consortium'' | Treatment of MERS-CoV: Decision Support Tool | url = http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317139281416 }}</ref> | ||
===Supportive Care=== | |||
The supportive medical care aims to minimize as much as possible the damages caused by [[MERS]]. It is divided into 4 categories, according to the clinical status of the patient. These categories include:<ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref> | |||
* | |||
* | ====Supportive Management of Primary Infection==== | ||
* | *Provide [[oxygen]] therapy to patients with severe acute [[respiratory infections]], presenting with [[hypoxemia]] or [[shock]] | ||
* | *Administer empiric [[antibiotics]] until the diagnosis of MERS-CoV is confirmed | ||
* | *Administer fluids carefully in patients with severe acute [[respiratory infections]], even in the absence of [[shock]], since volume overload may jeopardize [[oxygenation]] | ||
*Monitor forpossible clinical deterioration of patients with severe acute [[respiratory infections]] | |||
*Avoid high-dose systemic [[corticosteroids]] to prevent side-effects such as opportunistic [[infections]] and [[avascular necrosis]] | |||
====Management of Acute Respiratory Distress Syndrome==== | |||
{{Details|Acute respiratory distress syndrome medical therapy|the management of ARDS}} | |||
This section focuses on management of patients who deteriorate and develop [[ARDS]]. Management includes the following:<ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref> | |||
*Recognition of severe cases where [[oxygen]] therapy may not be enough and a higher flow system may be required | |||
*[[Mechanical ventilation]] in patients with [[respiratory distress]] or [[hypoxemia]] that does not resolve with high-flow [[oxygen]] therapy | |||
*Non-invasive [[ventilation]] (NIV) in cases of [[immunosuppression]] or in [[ARDS]] that does not present with lack of [[consciousness]] or [[cardiac failure]], under constant monitoring in an [[ICU]] environment. It is important not to delay [[endotracheal intubation]] if NIV is unsuccessful. | |||
*[[Endotracheal intubation]] for [[mechanical ventilation]] | |||
*In patients with [[ARDS]], use of a lung-protective [[ventilation]] with a low pressure ventilation protocol, has shown to reduce mortality in ARDS patients<ref name=ARDSnet>{{cite web | title = NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary | url = http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf }}</ref><ref name="pmid23353941">{{cite journal| author=Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM et al.| title=Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. | journal=Crit Care Med | year= 2013 | volume= 41 | issue= 2 | pages= 580-637 | pmid=23353941 | doi=10.1097/CCM.0b013e31827e83af | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23353941 }} </ref> | |||
*Adjunctive therapeutics in patients with severe [[ARDS]] particularly if [[ventilation]] targets are not achieved, such as neuromuscular blockage or repositioning the patient to a [[prone]] position<ref name="PapazianForel2010">{{cite journal|last1=Papazian|first1=Laurent|last2=Forel|first2=Jean-Marie|last3=Gacouin|first3=Arnaud|last4=Penot-Ragon|first4=Christine|last5=Perrin|first5=Gilles|last6=Loundou|first6=Anderson|last7=Jaber|first7=Samir|last8=Arnal|first8=Jean-Michel|last9=Perez|first9=Didier|last10=Seghboyan|first10=Jean-Marie|last11=Constantin|first11=Jean-Michel|last12=Courant|first12=Pierre|last13=Lefrant|first13=Jean-Yves|last14=Guérin|first14=Claude|last15=Prat|first15=Gwenaël|last16=Morange|first16=Sophie|last17=Roch|first17=Antoine|title=Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome|journal=New England Journal of Medicine|volume=363|issue=12|year=2010|pages=1107–1116|issn=0028-4793|doi=10.1056/NEJMoa1005372}}</ref><ref name="pmid12016096">{{cite journal| author=Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK| title=The pragmatics of prone positioning. | journal=Am J Respir Crit Care Med | year= 2002 | volume= 165 | issue= 10 | pages= 1359-63 | pmid=12016096 | doi=10.1164/rccm.2107005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12016096 }} </ref> | |||
*Fluid management in [[ARDS]] patients, in the absence of [[shock]], in order to decrease duration of [[mechanical ventilation]] | |||
====Management of Septic Shock==== | |||
{{Details|Sepsis medical therapy|the management of septic shock}} | |||
This section targets the adequate management of [[septic shock]]. Management includes the following:<ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref> | |||
*Recognition of [[septic shock]] in the presence of persistent [[hypotension]] after fluid administration or signs of peripheral [[hypoperfusion]], followed by [[resuscitation]] | |||
*Administration of [[intravenous]] crystalloids in [[septic shock]] | |||
*In persistent [[shock]] it is recommended the use of: | |||
:*[[vasopressors]], such as [[norepinephrine]], [[epinephrine]] and [[dopamine]], preferably through a [[central venous catheter]] and at minimal [[dosage]] to insure an [[SBP]] >90 mmHg | |||
:*need for concomitant [[IV]] [[hydrocortisone]] (<200 mg/day) or [[prednisolone]] (<75 mg/day) administration should be assessed | |||
====Prevention of Complications==== | |||
This section is mainly based on preventing possible [[complications]]. It includes:<ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref> | |||
*Reduction of the period under invasive [[ventilation]], by daily evaluation of spontaneous [[breathing]] and [[titration]] of [[sedation]] to a specific target | |||
*Prevent ventilator-related pneumonia by: | |||
:*preferring oral [[intubation]] | |||
:*performing frequent [[antiseptic]] oral care | |||
:*adjusting the patient to a reclined position | |||
:*preferring a closed suctioning system | |||
:*changing the [[ventilator]] circuit for every patient | |||
:*monitoring the status of heat moisture exchanger | |||
:*reducing intermittent mandatory [[ventilation]] | |||
*Prevention of [[venous thromboembolism]] with [[pharmacological]] [[prophylaxis]], in the absence of [[contraindications]]. If [[contraindications]] are present, it is suggested the [[prophylactic]] use of a mechanical device for pneumatic compression | |||
*Prevention of [[infection]] through [[catheter]] manipulation<ref name="pmid17192537">{{cite journal| author=Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al.| title=An intervention to decrease catheter-related bloodstream infections in the ICU. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 26 | pages= 2725-32 | pmid=17192537 | doi=10.1056/NEJMoa061115 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17192537 }} </ref> | |||
*Avoid prolonged immobilization by turning the patient every 2 hours | |||
*Reduce formation of [[gastric ulcer]]s by administration of early [[enteric]] nutrition along with an [[Histamine H2 receptor]] blocker or a [[PPI]] | |||
*Reduce [[weakness]] by immobilization | |||
==Antimicrobial regimen== | |||
*'''Middle East Respiratory Syndrome treatment'''<ref>http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf?ua=1</ref> | |||
:* Preferred regimen: supportive care. | |||
:* Note: There is no antiviral recommended for this infection at this moment, even though experimental therapies are at research (IFNs, [[Ribavirin]], [[Lopinavir]], [[Mycophenolic acid]], [[Cyclosporine]], [[Chloroquine]], [[Chlorpromazine]], [[Loperamide]], [[6-mercaptopurine]] and [[6-thioguanine]]). Supportive care include: administer oxygen to patients with severe acute pulmonary infection with signs of respiratory distress, hypoxaemia or shock; use conservative fluids management, avoid administering high-dose systemic glucocorticoids, use non-invasive ventilation, but, if its nor effective, do not delay endotracheal intubation; use lung-protective strategy for intubated patients, recognize sepsis as early as possible and treat it accordingly. | |||
==References== | ==References== | ||
{{ | {{reflist|2}} | ||
[[Category:Disease]] | |||
[[Category:Virology]] | |||
[[Category: | |||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
[[Category:Infectious Disease Project]] | |||
Latest revision as of 18:05, 18 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
Antiviral therapy against MERS-CoV is not yet recommended. Supportive care is the mainstay of management of MERS-CoV. Monitoring for and early management of MERS-CoV-associated complications is also important.
Medical Therapy
According to the International Severe Acute Respiratory & Emerging Infection Consortium from the ISARIC and the Interim Guidance Document from the WHO, supportive medical care is the mainstay of management of MERS-CoV.[1][2]
Supportive Care
The supportive medical care aims to minimize as much as possible the damages caused by MERS. It is divided into 4 categories, according to the clinical status of the patient. These categories include:[1]
Supportive Management of Primary Infection
- Provide oxygen therapy to patients with severe acute respiratory infections, presenting with hypoxemia or shock
- Administer empiric antibiotics until the diagnosis of MERS-CoV is confirmed
- Administer fluids carefully in patients with severe acute respiratory infections, even in the absence of shock, since volume overload may jeopardize oxygenation
- Monitor forpossible clinical deterioration of patients with severe acute respiratory infections
- Avoid high-dose systemic corticosteroids to prevent side-effects such as opportunistic infections and avascular necrosis
Management of Acute Respiratory Distress Syndrome
This section focuses on management of patients who deteriorate and develop ARDS. Management includes the following:[1]
- Recognition of severe cases where oxygen therapy may not be enough and a higher flow system may be required
- Mechanical ventilation in patients with respiratory distress or hypoxemia that does not resolve with high-flow oxygen therapy
- Non-invasive ventilation (NIV) in cases of immunosuppression or in ARDS that does not present with lack of consciousness or cardiac failure, under constant monitoring in an ICU environment. It is important not to delay endotracheal intubation if NIV is unsuccessful.
- Endotracheal intubation for mechanical ventilation
- In patients with ARDS, use of a lung-protective ventilation with a low pressure ventilation protocol, has shown to reduce mortality in ARDS patients[3][4]
- Adjunctive therapeutics in patients with severe ARDS particularly if ventilation targets are not achieved, such as neuromuscular blockage or repositioning the patient to a prone position[5][6]
- Fluid management in ARDS patients, in the absence of shock, in order to decrease duration of mechanical ventilation
Management of Septic Shock
This section targets the adequate management of septic shock. Management includes the following:[1]
- Recognition of septic shock in the presence of persistent hypotension after fluid administration or signs of peripheral hypoperfusion, followed by resuscitation
- Administration of intravenous crystalloids in septic shock
- In persistent shock it is recommended the use of:
- vasopressors, such as norepinephrine, epinephrine and dopamine, preferably through a central venous catheter and at minimal dosage to insure an SBP >90 mmHg
- need for concomitant IV hydrocortisone (<200 mg/day) or prednisolone (<75 mg/day) administration should be assessed
Prevention of Complications
This section is mainly based on preventing possible complications. It includes:[1]
- Reduction of the period under invasive ventilation, by daily evaluation of spontaneous breathing and titration of sedation to a specific target
- Prevent ventilator-related pneumonia by:
- preferring oral intubation
- performing frequent antiseptic oral care
- adjusting the patient to a reclined position
- preferring a closed suctioning system
- changing the ventilator circuit for every patient
- monitoring the status of heat moisture exchanger
- reducing intermittent mandatory ventilation
- Prevention of venous thromboembolism with pharmacological prophylaxis, in the absence of contraindications. If contraindications are present, it is suggested the prophylactic use of a mechanical device for pneumatic compression
- Prevention of infection through catheter manipulation[7]
- Avoid prolonged immobilization by turning the patient every 2 hours
- Reduce formation of gastric ulcers by administration of early enteric nutrition along with an Histamine H2 receptor blocker or a PPI
- Reduce weakness by immobilization
Antimicrobial regimen
- Middle East Respiratory Syndrome treatment[8]
- Preferred regimen: supportive care.
- Note: There is no antiviral recommended for this infection at this moment, even though experimental therapies are at research (IFNs, Ribavirin, Lopinavir, Mycophenolic acid, Cyclosporine, Chloroquine, Chlorpromazine, Loperamide, 6-mercaptopurine and 6-thioguanine). Supportive care include: administer oxygen to patients with severe acute pulmonary infection with signs of respiratory distress, hypoxaemia or shock; use conservative fluids management, avoid administering high-dose systemic glucocorticoids, use non-invasive ventilation, but, if its nor effective, do not delay endotracheal intubation; use lung-protective strategy for intubated patients, recognize sepsis as early as possible and treat it accordingly.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 "Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do" (PDF).
- ↑ "Treatment of MERS-CoV: Decision Support Tool".
- ↑ "NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary" (PDF).
- ↑ Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM; et al. (2013). "Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012". Crit Care Med. 41 (2): 580–637. doi:10.1097/CCM.0b013e31827e83af. PMID 23353941.
- ↑ Papazian, Laurent; Forel, Jean-Marie; Gacouin, Arnaud; Penot-Ragon, Christine; Perrin, Gilles; Loundou, Anderson; Jaber, Samir; Arnal, Jean-Michel; Perez, Didier; Seghboyan, Jean-Marie; Constantin, Jean-Michel; Courant, Pierre; Lefrant, Jean-Yves; Guérin, Claude; Prat, Gwenaël; Morange, Sophie; Roch, Antoine (2010). "Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome". New England Journal of Medicine. 363 (12): 1107–1116. doi:10.1056/NEJMoa1005372. ISSN 0028-4793.
- ↑ Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK (2002). "The pragmatics of prone positioning". Am J Respir Crit Care Med. 165 (10): 1359–63. doi:10.1164/rccm.2107005. PMID 12016096.
- ↑ Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S; et al. (2006). "An intervention to decrease catheter-related bloodstream infections in the ICU". N Engl J Med. 355 (26): 2725–32. doi:10.1056/NEJMoa061115. PMID 17192537.
- ↑ http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf?ua=1