Middle East respiratory syndrome coronavirus infection medical therapy: Difference between revisions
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====Septic Shock==== | ====Septic Shock==== | ||
This section targets the adequate management of [[septic shock]]. 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> | This section targets the adequate management of [[septic shock]]. 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> | ||
*Recognition of | *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]] | ||
* | *If [[shock]] persists, it is recommended use of [[vasopressors]] | ||
*If shock persists [[intravenous]] [[hydrocortisone]] (<200 mg/day) or [[prednisolone]] (<75 mg/day) are recommended | |||
* | |||
====Prevention of Complications==== | ====Prevention of Complications==== | ||
Revision as of 14:10, 18 June 2014
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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
Middle East Respiratory Syndrome (MERS) is a viral respiratory illness. It is caused by an emerging coronavirus, specifically a betacoronavirus called MERS-CoV (Middle East Respiratory Syndrome Coronavirus), first discovered in 2012. Being a relatively novel virus, there is no virus-specific prevention or treatment options for MERS patients. Outbreaks of MERS-CoV represent a great social challenge due to the fact that there is very limited time to develop and test new pharmaceutical drugs. The common clinical presentations documented so far include Acute Respiratory Distress Syndrome (ARDS), renal failure, pericarditis and disseminated intravascular coagulation. Therefore the supportive care should focus mainly in the prevention and monitoring of these conditions. Until now, supportive medical care has been the only treatment option, however, repurpose of drugs for other viruses and illnesses is presenting as an attractive alternative for MERS-CoV.[1][2]
Medical Therapy
MERS represents a great challenge in terms of treatment because it is caused by a relatively novel virus to which there is no approved therapy yet. According to the International Severe Acute Respiratory & Emerging Infection Consortium (ISARIC), supportive medical care continues to be the approved treatment for MERS. The search for broad-spectrum inhibitors aiming to minimize the impact of coronavirus infection remains the major goal. Recent studies are showing the potential use of other drugs and therapies to treat the MERS-CoV, which are based on the experience of treatment of other coronaviruses like the SARS virus. This repurposing of drugs has advantages such as: better availability, lower cost and known safety and tolerability profiles. However, lack of evidence makes these new therapies uncertain.[1]
Cell and animal studies have shown conflicting results: the combination of ribavirin with interferon α-2b in a cell study reduced viral replication[3]; another study in rhesus monkeys with combination of intramuscular ribavirin and interferon α-2b, the group that received the treatment did not develop breathing abnormalities nor radiographic evidence of pneumonia[4]; however, when tried in 5 critically ill patients in Saudi Arabia, this combination was inefficient in all cases, leading to a fatal outcome.[5]
Despite the absence of a specific therapy, some approaches are considered to be more worth of experimentation than others. These include:[6][7][8][2][9]
- Convalescent plasma - this therapy, along with others that involve antibodies for the MERS-CoV has the strongest evidence for intervention. Plasma from patients who recovered from MERS-CoV infection contains neutralizing antibodies, which represents the best therapy to neutralize the extracellular virus.
- Interferon - there is supporting evidence from in vitro (SARS virus and MERS-CoV) and in vivo (SARS virus) studies that interferon inhibits viral replication, especially when administered in the early course of the disease. Additionally it is commonly more available than plasma.
- Corticosteroids - there is no evidence of the benefit in the mortality rate and their use is only recommended in a planned treatment regimen or when the benefits of the drug outweigh the potential harms. When used, constant monitoring is mandatory and the ideal timing is the early course of the disease, during the period of maximal inflammatory response.
- Ribavirin - the most commonly used drug in the treatment of SARS. Due to the controversial results of clinical trials relating to the use of ribavirin for MERS and its high level of toxicity in humans, some experts recommend the withhold of the drug.
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:[2]
Early recognition
This section focuses on the early recognition of symptoms and management of patients with severe acute respiratory infections. This includes:[2]
- Recognition of severe manifestations of acute respiratory infections
- Prevention of infection and control measures
- Providing oxygen therapy to patients with severe acute respiratory infections
- Specimen collection for laboratory testing
- Antibiotics
- Fluid administration in patients with severe acute respiratory infections, even in the absence of shock
- Monitoring of possible clinical deterioration of patients with severe acute respiratory infections
- Avoidance of high-dose systemic corticosteroids
ARDS
This section focuses on management of patients who deteriorate and develop ARDS. It includes:[2]
- Recognition of severe cases where oxygen therapy may not be enough
- Mechanical ventilation in patients with respiratory distress or hypoxemia that does not resolve with high-flow oxygen therapy
- Non-invasive ventilation in cases of immunosuppression or in ARDS that does not present with lack of consciousness or cardiac failure
- Endotracheal intubation for mechanical ventilation
- In patients with ARDS, use of a lung-protective ventilation strategy
- Adjunctive therapeutics in patients with severe ARDS particularly if ventilation targets are not achieved
- Fluid management in ARDS patients, in the absence of shock, in order to decrease duration of mechanical ventilation
Septic Shock
This section targets the adequate management of septic shock. It includes:[2]
- 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
- If shock persists, it is recommended use of vasopressors
- If shock persists intravenous hydrocortisone (<200 mg/day) or prednisolone (<75 mg/day) are recommended
Prevention of Complications
This section is mainly based on prevention of complications. It includes:[2]
- Weaning protocols that include daily assessment for readiness to breathe spontaneously
- Sedation protocols to titrate administration of sedation to a specific target, with or without daily interruption of continuous sedative infusions
- Oral intubation is preferable to nasal intubation
- Perform regular antiseptic oral care
- Keep patient in semi-recumbent position
- Use a closed suctioning system; periodically drain and discard condensate in tubing
- Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged but not routinely
- Change heat moisture exchanger when it malfunctions, when soiled or every 5–7 days
- Reduce days of IMV
- Use pharmacological prophylaxis (for example, heparin 5000 units subcutaneously twice daily) in patients without contraindications. For those with contraindications, use mechanical prophylactic device such as intermittent pneumatic compression devices.
- Use a simple checklist during insertion as reminder of each step needed for sterile insertion and daily reminder to remove catheter if no longer needed[10]
- Turn patient every two hours
- Give early enteral nutrition (within 24–48 hours of admission), administer histamine-2 receptor blockers or proton-pump inhibitors
- Early mobility
References
- ↑ 1.0 1.1 Dyall J, Coleman CM, Hart BJ, Venkataraman T, Holbrook MR, Kindrachuk J; et al. (2014). "Repurposing of clinically developed drugs for treatment of Middle East Respiratory Coronavirus Infection". Antimicrob Agents Chemother. doi:10.1128/AAC.03036-14. PMID 24841273.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 "Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do" (PDF).
- ↑ Falzarano D, de Wit E, Martellaro C, Callison J, Munster VJ, Feldmann H (2013). "Inhibition of novel β coronavirus replication by a combination of interferon-α2b and ribavirin". Sci Rep. 3: 1686. doi:10.1038/srep01686. PMC 3629412. PMID 23594967.
- ↑ Falzarano D, de Wit E, Rasmussen AL, Feldmann F, Okumura A, Scott DP; et al. (2013). "Treatment with interferon-α2b and ribavirin improves outcome in MERS-CoV-infected rhesus macaques". Nat Med. 19 (10): 1313–7. doi:10.1038/nm.3362. PMID 24013700.
- ↑ Al-Tawfiq JA, Momattin H, Dib J, Memish ZA (2014). "Ribavirin and interferon therapy in patients infected with the Middle East respiratory syndrome coronavirus: an observational study". Int J Infect Dis. 20: 42–6. doi:10.1016/j.ijid.2013.12.003. PMID 24406736.
- ↑ "Treatment of MERS-CoV: Decision Support Tool".
- ↑ Guery B, van der Werf S (2013). "Coronavirus: need for a therapeutic approach". Lancet Infect Dis. 13 (9): 726–7. doi:10.1016/S1473-3099(13)70153-1. PMID 23782860.
- ↑ Ren Z, Yan L, Zhang N, Guo Y, Yang C, Lou Z; et al. (2013). "The newly emerged SARS-like coronavirus HCoV-EMC also has an "Achilles' heel": current effective inhibitor targeting a 3C-like protease". Protein Cell. 4 (4): 248–50. doi:10.1007/s13238-013-2841-3. PMID 23549610.
- ↑ Momattin H, Mohammed K, Zumla A, Memish ZA, Al-Tawfiq JA (2013). "Therapeutic options for Middle East respiratory syndrome coronavirus (MERS-CoV)--possible lessons from a systematic review of SARS-CoV therapy". Int J Infect Dis. 17 (10): e792–8. doi:10.1016/j.ijid.2013.07.002. PMID 23993766.
- ↑ 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.