VCU infectious disease experts write guidelines for therapy, infection control for severe acute respiratory syndrome (SARS)

By Lorraine Cichowski, Richard Wenzel and Michael Edmond

RICHMOND, Va. – Immediate isolation of patients in private, negative pressure rooms and protection of health care workers with gloves, gowns, masks and eye coverings are important first steps in managing the spread of the SARS infection, according to a new set of guidelines developed by infectious disease experts at the Virginia Commonwealth University Medical Center. 

The recommendations, which appear in the May 15 issue of the New England Journal of Medicine, offer a checklist for clinicians who suspect that a patient may have Severe Acute Respiratory Syndrome (SARS), a virus that first was reported in China last November and since has spread to 28 countries, including the United States, where 64 cases have been identified as probable SARS by the Centers for Disease Control. The World Health Organization has attributed more than 570 deaths worldwide to SARS.

Richard P. Wenzel, M.D., M.Sc., chair of internal medicine, VCU School of Medicine, and chief epidemiologist Michael B. Edmond, M.D., MPH, wrote the therapy and infection-control guidelines, which accompany NEJM research articles that describe the molecular and genetic aspects of the virus that causes SARS.

Among their recommendations for control of the SARS infection:
·         The patient should be isolated in a private room, preferably one with negative pressure.
·         All healthcare workers should wear gloves, disposal gowns, N-95 masks and eye protection.
·         All healthcare workers should wash hands carefully or disinfect hands with an alcohol-based product after removing gloves.
·         The number of visitors and the number of healthcare workers caring for the patient should be limited.
·         Specimens should be obtained to rule out other bacterial infections that cause pneumonia, and specimens should be sent to the Centers for Disease Control for testing. 

In treating patients with SARS, Wenzel and Edmond suggest that the best approach currently is to prescribe standard antibiotics that routinely are used by clinicians to treat bacterial infections that cause pneumonia. They say clinicians should consider adding antiviral agents, such as the neuraminidase inhibitor sold under the trade name Tamiflu, to prevent and treat A and B influenza. They recommend oxygen be administered for hypoxemia. 

Although the antiviral drug, Ribavirin, is being used by some clinicians around the world to treat SARS, Wenzel and Edmond say no data exist to prove its effectiveness.  They recommend the use of steroids only for the most seriously ill patients.

“SARS has created international anxiety because of its novelty, communicability, amplification via jet travel and illnesses and death,” Wenzel says. “Unfortunately, we simply don’t know where we are on the curve for a massive epidemic. While the epidemic unfolds, there are steps that we can take to manage SARS.”

Wenzel, who is the first editor-at-large of the NEJM, also noted that the SARS mortality rate so far is somewhat higher than the usual cases seen in the United States for community-acquired pneumonia, which refers to the more than 4 million cases of pneumonia contracted annually by patients outside hospitals and nursing homes. And, he said, the number of SARS deaths worldwide still is just a fraction of the 35,000 who die annually of flu-related illness in the United States alone.