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

INITIAL

suspected MERS

1st line – isolation procedures

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INITIAL
|
suspected MERS
1st line – 

isolation procedures

Isolation procedures should be initiated in all suspected cases of MERS.

Patients with comorbidities (e.g., diabetes mellitus, heart disease, chronic renal impairment), age ≥50 years, or with the following signs should be admitted to hospital: respiratory rate >30 breaths/minute; hypoxaemia (SpO₂ <90% on room air); severe respiratory distress; or clinical and/or radiological evidence of pneumonia.

Patients should be placed in an airborne infection isolation room, if available, or 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.

Standard, droplet, and contact precautions are recommended, as well as airborne precautions, particularly when performing aerosol-generating procedures.[68][69]​

All healthcare workers and visitors, when in close contact (i.e., approximately 1 metre) with a probable or confirmed case, should always use: respiratory protection (e.g., respirator); eye protection; a clean, non-sterile, long-sleeved gown; and 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.

Patients who do not require hospitalisation for medical reasons can be isolated at home. Infection control measures are still recommended and include using a single room, single bathroom (if possible), minimising contact with other household members, and wearing a surgical mask if contact is necessary.[68][69]​​[73][99]​​

Plus – supportive care + monitoring

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INITIAL
|
suspected MERS
Plus – 

supportive care + monitoring

Treatment recommended for ALL patients in selected patient group

Supportive therapies (e.g., oxygen, fluids, antipyretics/analgesics) should be started promptly depending on the clinical presentation.

Patients with signs of severe respiratory distress, shock, or hypoxaemia should be started on oxygen therapy immediately. Initiate at 5 L/minute and titrate so that SpO₂ ≥90%.[75] Patients with impending or established respiratory failure should be admitted to the intensive care unit. Intubation and mechanical ventilation are recommended if the patient is deteriorating and cannot maintain a SpO₂ ≥90% with oxygen therapy.[71][96]

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).[75]

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 physiological changes that occur with pregnancy.

Specimens (e.g., blood cultures, serum, lower/upper respiratory tract 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.[75] Upper respiratory tract specimens (e.g., nasopharyngeal swab) are sufficient in patients isolated at home.

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 multi-organ failure. Supportive therapy (e.g., haemodialysis, vasopressor therapy, fluid resuscitation, antimicrobials) should be initiated immediately if required.[5][8]​​[27][71][96]

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Plus – empirical antimicrobial therapy

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INITIAL
|
suspected MERS
Plus – 

empirical antimicrobial therapy

Treatment recommended for ALL patients in selected patient group

Empirical antimicrobial therapy (including antibiotics and antivirals) should be started in inpatients with suspected MERS pneumonia (within 1 hour if sepsis is suspected) to cover all likely community-acquired or hospital-acquired (if patient has been admitted for >48 hours) pathogens.[75]

Antimicrobial selection should be based on local epidemiology, susceptibility data, and guidelines until diagnosis is confirmed, and empirical therapy adjusted based on results.

Treatment can be discontinued once a diagnosis of MERS is confirmed.

ACUTE

confirmed MERS: post initial stabilisation and isolation measures

1st line – admit to hospital + isolation procedures

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ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
with pneumonia or comorbidities
1st line – 

admit to hospital + isolation procedures

Patients with comorbidities (e.g., diabetes mellitus, heart disease, chronic renal impairment), age ≥50 years, smoking history, or with the following signs should be admitted to hospital: respiratory rate >30 breaths/minute; hypoxaemia (SpO₂ <90% on room air); severe respiratory distress; or clinical and/or radiological evidence of pneumonia.

Isolation procedures should be initiated in all confirmed cases of MERS. Patients should be placed in an adequately ventilated single room, clearly segregated from other patient care areas. The number of healthcare workers and visitors should be kept to a minimum.

Standard, droplet, and contact precautions are recommended, as well as airborne precautions, particularly when performing aerosol-generating procedures.[68] All healthcare workers and visitors, when in close contact (i.e., approximately 1 metre) with a probable or confirmed case, should always use: respiratory protection (e.g., respirator); eye protection; a clean, non-sterile, long-sleeved gown; and 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. 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 two negative results on specimens taken at least 24 hours apart.[68][69][73][75]

Plus – supportive care + monitoring

Back
ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
with pneumonia or comorbidities
Plus – 

supportive care + monitoring

Treatment recommended for ALL patients in selected patient group

Supportive therapies (e.g., oxygen, fluids, antipyretics/analgesics) should be started promptly depending on the clinical presentation.

Patients with signs of severe respiratory distress, shock, or hypoxaemia should be started on oxygen therapy immediately. Initiate at 5 L/minute and titrate so that SpO₂ ≥90%.[75]

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).[75]

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 physiological changes that occur with pregnancy.

Specimens (e.g., blood cultures, serum, lower/upper respiratory tract 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.[75] 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 two negative test results to confirm clearance of the virus.[75] The Ministry of Health (Saudi Arabia) recommends repeat testing 1 week after diagnosis.[73]

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 multi-organ failure. Supportive therapy (e.g., haemodialysis, vasopressor therapy, fluid resuscitation, antimicrobials) should be initiated immediately if required.[5][8]​​[27][71][96]

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – mechanical ventilation

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ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
with pneumonia or comorbidities
Consider – 

mechanical ventilation

Additional treatment recommended for SOME patients in selected patient group

Patients with impending or established respiratory failure should be admitted to the intensive care unit.

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.[71][96] 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.[73] A small observational study found that ECMO was associated with lower mortality in MERS patients with refractory hypoxaemia.[97]

Consider – consider experimental therapies

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ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
with pneumonia or comorbidities
Consider – 

consider experimental therapies

Additional treatment recommended for SOME patients in selected patient group

There is no conclusive evidence at this time to recommend any virus-specific treatments; however, a number of treatments (e.g., interferon beta, interferon alfa, lopinavir/ritonavir, ribavirin, mycophenolate, and ciclosporin) have been studied for the treatment of MERS based on encouraging in vitro and animal studies.[5][27][100][101][102][103] 

The WHO recommends that these drugs only be used under standard research treatment protocols and occur in the context of research trials.[75]

1st line – consider home isolation

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ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
without pneumonia or comorbidities
1st line – 

consider home isolation

Young, healthy patients with no comorbidities are at a lower risk of developing complications, and can be considered for home isolation if they do not require hospitalisation for medical reasons.[73]​​[99]​These patients generally have mild, non-specific symptoms such as fever, headache, malaise, cough, sore throat, or possibly gastrointestinal symptoms.[11]​​

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.[99]

Infection control measures are still recommended and include using a single room, single bathroom (if possible), minimising contact with other household members, and wearing a surgical mask if contact is necessary.[73]​​[99]​​

Plus – supportive care + monitoring

Back
ACUTE
|
confirmed MERS: post initial stabilisation and isolation measures
|
without pneumonia or comorbidities
Plus – 

supportive care + monitoring

Treatment recommended for ALL patients in selected patient group

Supportive therapies are recommended including antipyretics/analgesics (e.g., paracetamol, 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.[75]

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 physiological changes that occur with pregnancy.

Patients should be monitored for the clearance of infection using the recommended RT-PCR assays every 2 to 4 days until there are two negative results.[73][75] Infection control measures can be discontinued in these patients when the patient is asymptomatic and a single RT-PCR is negative.[73] Upper respiratory tract specimens (e.g., nasopharyngeal swab) are sufficient in these patients.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

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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

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