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

ACUTE

symptomatic patients

1st line – isolation and infection control

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ACUTE
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symptomatic patients
1st line – 

isolation and infection control

This is a biosafety level 4 pathogen. Appropriate infection control procedures need to be initiated as soon as a case is suspected.

Isolation and infection control precautions are the same as for other level 4 pathogens, such as viral haemorrhagic fevers. Patients who are identified as being at risk of infection should immediately be isolated in a room with private bathroom facilities.

All healthcare personnel attending to the patient must wear appropriate personal protective equipment (PPE) that conforms to published protocols. All contaminated materials (e.g., clothes, bed linens) should be treated as potentially infectious. The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), as well as national bodies (e.g., UK Department of Health), produce detailed guidance on PPE for Ebola virus, which may be helpful to use in managing suspected cases of henipavirus infection:

Specimens for laboratory investigations (e.g., blood, cerebrospinal fluid, urine) should be collected and sent off according to local, national, and international protocols. Judicious selection of investigations is important in order to reduce risk of transmission to laboratory workers and other healthcare personnel. Careful and clear communication with laboratory staff is required in order to highlight the possibility of Nipah virus (NiV) or Hendra virus (HeV) prior to transport of samples to ensure that appropriate safety precautions are carried out. The WHO produces detailed guidance on specimen collection and transport:

Plus – supportive care

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ACUTE
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symptomatic patients
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

With special attention to airway support for those patients with decreased level of consciousness, and respiratory support (non-invasive ventilation and/or intubation and mechanical ventilation) for those patients with acute respiratory distress or failure. Many patients require intensive monitoring in a critical care environment. Additional considerations include prophylaxis for venous thromboembolism and prevention/treatment of nosocomial infection.

Plus – neurological evaluation ± intracranial pressure-lowering regimen

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ACUTE
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symptomatic patients
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with neurological symptoms
Plus – 

neurological evaluation ± intracranial pressure-lowering regimen

Treatment recommended for ALL patients in selected patient group

Cranial nerve examination, fundoscopy, and brain imaging (CT or MRI) should be performed to evaluate for cerebral oedema and elevated intracranial pressure.

If intracranial pressure is elevated, conservative and/or surgical measures may be required to reduce the pressure. In such instances, the placement of an external ventricular device should be considered.

The efficacy of mannitol has not been evaluated in the context of HeV or NiV, and therefore it is not recommended.

Plus – anticonvulsants

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ACUTE
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symptomatic patients
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with neurological symptoms
Plus – 

anticonvulsants

Treatment recommended for ALL patients in selected patient group

Patients with seizure activity should be treated with anticonvulsants in accordance with local protocols.

In general, benzodiazepines are preferred for the initial management of seizures, with lorazepam being most effective due to its long half-life.

Phenytoin is recommended if a second drug is needed to terminate seizures, although in pregnant women it should only be used in life-threatening cases as it is considered to be a teratogen.

Serum drug levels should be monitored to ensure that therapeutic levels are achieved.

Primary options

lorazepam: children: 0.05 to 0.1 mg/kg (maximum 4 mg/dose) intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary; adults: 4 mg intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary

Secondary options

phenytoin: children and adults: 15-20 mg/kg intravenously as a loading dose, followed by 5-10 mg/kg as a single dose if necessary; consult specialist for guidance on maintenance dose

Plus – intravenous aciclovir

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ACUTE
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symptomatic patients
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with neurological symptoms
Plus – 

intravenous aciclovir

Treatment recommended for ALL patients in selected patient group

Treatment with aciclovir is recommended until herpes simplex virus/varicella zoster virus encephalitis has been ruled out.[49]

Primary options

aciclovir: children: 10-20 mg/kg intravenously every 8 hours; adults: 10 mg/kg intravenously every 8 hours

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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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