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 SARS

1st line – isolation procedures plus supportive care

Back
INITIAL
|
suspected SARS
1st line – 

isolation procedures plus supportive care

Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimise the risk of transmission, with immediate implementation of strict contact and airborne precautions set out by the Centers for Disease Control and Prevention (CDC).[44] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.

The CDC advises that patients with SARS-CoV disease who do not require hospitalisation for medical reasons may be isolated at home.[45] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.

Supportive care involves administration of adequate supplemental oxygen to correct hypoxaemia, replacement of fluid deficit caused by diarrhoea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.

Consider – mechanical ventilation

Back
INITIAL
|
suspected SARS
Consider – 

mechanical ventilation

Additional treatment recommended for SOME patients in selected patient group

Patients with impending or established respiratory failure should be admitted to ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO₂ above 90% with spontaneous ventilation despite maximal oxygen therapy.[49]

Non-invasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.

To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulised humidity and utilisation of Venturi masks without humidification, avoidance of bag-mask ventilation and utilisation of masks that permit filtration of exhaled gas, utilisation of adequate sedation during intubation, utilisation of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilisation of sedation or paralysis to minimise coughing, turning ventilator to standby and positive end expiratory pressure (PEEP) to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.[51]

Plus – empirical therapy for community-acquired pneumonia

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INITIAL
|
suspected SARS
Plus – 

empirical therapy for community-acquired pneumonia

Treatment recommended for ALL patients in selected patient group

Due to the initial uncertainty regarding diagnosis, empirical antimicrobial therapy against both typical (including drug-resistant strains) and atypical community-acquired respiratory pathogens is a prudent first-line therapy.

An appropriate beta-lactam combined with a macrolide or monotherapy with a respiratory fluoroquinolone is a reasonable option.

Possible examples of intravenous combinations in hospitalised patients include ceftriaxone or ceftaroline plus azithromycin or clarithromycin. Monotherapy with levofloxacin or moxifloxacin is an alternative.[52]

Antibiotic therapy should be discontinued as soon as a definite diagnosis is documented.

Primary options

ceftriaxone: 1-2 g intravenously every 24 hours

or

ceftaroline: 600 mg intravenously every 12 hours

-- AND --

azithromycin: 500 mg intravenously every 24 hours

or

clarithromycin: 500 mg intravenously every 12 hours

OR

levofloxacin: 750 mg intravenously every 24 hours

OR

moxifloxacin: 400 mg intravenously every 24 hours

Consider – empirical therapy for influenza

Back
INITIAL
|
suspected SARS
Consider – 

empirical therapy for influenza

Additional treatment recommended for SOME patients in selected patient group

When epidemiologically indicated (i.e., during a seasonal epidemic of influenza), influenza virus should also be covered with a 5-day course of either zanamivir or oseltamivir.

Primary options

zanamivir inhaled: 10 mg (2 inhalations) twice daily for 5 days

OR

oseltamivir: 75 mg orally twice daily for 5 days

ACUTE

confirmed SARS

1st line – isolation procedures plus supportive care

Back
ACUTE
|
confirmed SARS
|
mild-moderate infection
1st line – 

isolation procedures plus supportive care

Mild-moderate infection is denoted by fever (≥38°C [100.4°F]) plus one or more symptoms of lower respiratory tract illness: cough, dyspnoea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.

Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimise the risk of transmission, with immediate implementation of strict contact and airborne precautions set out by the Centers for Disease Control and Prevention (CDC).[44] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.

The CDC advises that patients with SARS-CoV disease who do not require hospitalisation for medical reasons may be isolated at home.[45] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.

Supportive care involves administration of adequate supplemental oxygen to correct hypoxaemia, replacement of fluid deficit caused by diarrhoea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.

Consider – mechanical ventilation

Back
ACUTE
|
confirmed SARS
|
mild-moderate infection
Consider – 

mechanical ventilation

Additional treatment recommended for SOME patients in selected patient group

Patients with impending or established respiratory failure should be admitted to ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO₂ >90% with spontaneous ventilation despite maximal oxygen therapy.[49]

Non-invasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.

To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulised humidity and utilisation of Venturi masks without humidification, avoidance of bag-mask ventilation and utilisation of masks that permit filtration of exhaled gas, utilisation of adequate sedation during intubation, utilisation of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilisation of sedation or paralysis to minimise coughing, turning ventilator to standby and positive end expiratory pressure (PEEP) to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.[51]

Plus – lopinavir/ritonavir upon confirmation of diagnosis

Back
ACUTE
|
confirmed SARS
|
mild-moderate infection
Plus – 

lopinavir/ritonavir upon confirmation of diagnosis

Treatment recommended for ALL patients in selected patient group

Mild-moderate infection is denoted by fever (≥38°C [100.4°F]) plus 1 or more symptoms of lower respiratory tract illness: cough, dyspnoea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.

Randomised controlled trial (RCT) data on the efficacy of antivirals in the treatment of SARS are limited, although it would appear that antiviral therapy should be given to all confirmed cases as early as possible.

The combination of lopinavir/ritonavir should be given for 14 days.[53]

Primary options

lopinavir/ritonavir: 400/100 mg orally twice daily

Consider – ribavirin

Back
ACUTE
|
confirmed SARS
|
mild-moderate infection
Consider – 

ribavirin

Additional treatment recommended for SOME patients in selected patient group

Mild-moderate infection is denoted by fever (≥38°C [100.4°F]) plus one or more symptoms of lower respiratory tract illness: cough, dyspnoea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.

Although not effective as a monotherapy, ribavirin can be given with lopinavir/ritonavir.[16]

Primary options

ribavirin: consult specialist for guidance on dose

Consider – psychological therapy and counselling

Back
ACUTE
|
confirmed SARS
|
mild-moderate infection
Consider – 

psychological therapy and counselling

Additional treatment recommended for SOME patients in selected patient group

Mild-moderate infection is denoted by fever (≥38°C [100.4°F]) plus one or more symptoms of lower respiratory tract illness: cough, dyspnoea, difficulty breathing.[21] The following are absent: deteriorating radiographic consolidation, increasing oxygen requirement, and a respiratory rate of ≥30 breaths/minute.

Patients, as well as their relatives, may require consultation with a specialist in psychological therapy and counselling for specialised treatment.

1st line – isolation procedures plus supportive care

Back
ACUTE
|
confirmed SARS
|
severe infection
1st line – 

isolation procedures plus supportive care

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Once a clinical suspicion of SARS has been established, all appropriate protective measures must be initiated to minimise the risk of transmission, with immediate implementation of strict contact and airborne precautions set out by the Centers for Disease Control and Prevention (CDC).[44] These measures must be further intensified when diagnostic or therapeutic aerosol-generating procedures are carried out.

The CDC advises that patients with SARS-CoV disease who do not require hospitalisation for medical reasons may be isolated at home.[45] Stable patients should be placed in isolation and nursed in a negative pressure room where one is available. More severe cases (i.e., those presenting with or developing acute respiratory failure) should be admitted to the ICU or an intermediate care unit under airborne transmission precautions.

Supportive care involves administration of adequate supplemental oxygen to correct hypoxaemia, replacement of fluid deficit caused by diarrhoea or fever, correction of electrolyte disturbances, and antipyretics and analgesia for the control of fever and pain.

Consider – mechanical ventilation

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

mechanical ventilation

Additional treatment recommended for SOME patients in selected patient group

Patients with impending or established respiratory failure should be admitted to ICU or an intermediate care unit. Intubation and mechanical ventilation are instituted if the patient is clinically deteriorating and cannot maintain an SaO₂ >90% with spontaneous ventilation despite maximal oxygen therapy.[49]

Non-invasive positive pressure ventilation (NIPPV) is associated with the risk of viral transmission and high rates of pneumothorax as well as subcutaneous and mediastinal emphysema.

To decrease the risk of transmission during mechanical ventilation, the following precautions must be taken: avoidance of nebulised humidity and utilisation of Venturi masks without humidification, avoidance of bag-mask ventilation and utilisation of masks that permit filtration of exhaled gas, utilisation of adequate sedation during intubation, utilisation of closed suction systems and submicron filters in the exhalation outlet of mechanical ventilators, utilisation of sedation or paralysis to minimise coughing, turning ventilator to standby and positive end expiratory pressure (PEEP) to off when disconnecting the circuit, and avoidance of bronchoscopy if possible.[51]

Plus – lopinavir/ritonavir upon confirmation of diagnosis

Back
ACUTE
|
confirmed SARS
|
severe infection
Plus – 

lopinavir/ritonavir upon confirmation of diagnosis

Treatment recommended for ALL patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Randomised controlled trial (RCT) data on the efficacy of antivirals in the treatment of SARS are limited, although it would appear that antiviral therapy should be given to all confirmed cases as early as possible.

The combination of lopinavir/ritonavir should be given for 14 days.[53]

Primary options

lopinavir/ritonavir: 400/100 mg orally twice daily

Plus – corticosteroid

Back
ACUTE
|
confirmed SARS
|
severe infection
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Reported to have some efficacy in severe cases (critical SARS) presenting with deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.[54]

Although various regimens have been tried, the most commonly used is 3 to 6 days of pulsed methylprednisolone.

Corticosteroids added to lopinavir/ritonavir and/or ribavirin early in the course of the infection have been shown to reduce the progression to acute respiratory distress syndrome as well as the death rate.[16]

Primary options

methylprednisolone: 250-500 mg intravenously once daily for 3-6 days

Consider – ribavirin

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

ribavirin

Additional treatment recommended for SOME patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Although not effective as a monotherapy, ribavirin can be given with lopinavir/ritonavir.[16]

Primary options

ribavirin: consult specialist for guidance on dose

Consider – IgM-enriched immunoglobulin

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

IgM-enriched immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Although not available in some countries (including the US and UK), a 5-day course of IgM-enriched immunoglobulin (Pentaglobin®), has been found to be beneficial in the treatment of SARS.[55]

Consider – interferon alfacon-1

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

interferon alfacon-1

Additional treatment recommended for SOME patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Can be given to patients who do not show a favourable response to treatment with pulsed methylprednisolone and ribavirin.

One uncontrolled clinical trial reported that a 10-day course of a synthetic interferon alfacon-1 combined with corticosteroids resulted in oxygenation improvements and faster resolution of radiographic abnormalities.[56]

Primary options

interferon alfacon-1: consult specialist for guidance on dose

Consider – convalescent plasma

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

convalescent plasma

Additional treatment recommended for SOME patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Can be given to patients who do not show a favourable response to treatment with pulsed methylprednisolone and ribavirin.

The efficacy of convalescent plasma administration as a treatment of SARS has not been documented.[57][58]

Consider – psychological therapy and counselling

Back
ACUTE
|
confirmed SARS
|
severe infection
Consider – 

psychological therapy and counselling

Additional treatment recommended for SOME patients in selected patient group

Severe infection is denoted by deteriorating radiographic consolidation, increasing oxygen requirement (PaO₂ <10 kpa/SpO₂ <90%/Oxygenation Index <300 mmHg), and a respiratory rate of ≥30 breaths/minute.

Patients, as well as their relatives, may require consultation with a specialist in psychological therapy and counselling for specialised treatment.

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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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