Middle East respiratory syndrome coronavirus infection medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

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.

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]

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]

• 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

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

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

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

• 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.