HA
Guidelines on Severe Acute Respiratory Syndrome |
A. Case
definition (3/4/2003) Print this section |
Box 1 Criteria for
reporting to HA SARS Registry: (03/04/2003) 1. Presence of new radiological
infiltrates (CXR or #CT) compatible with pneumonia, and 2. Fever 38¢XC, or
history of such any time in the last 2 days, and 3. At least 2 of the following: a. Chills any time in the last 2 days b. New or increased cough c. General malaise d. Typical physical signs of consolidation e. Known history of exposure If no known history of
exposure, consider exclusion if presence of any one of the following: 1. XR show lobar consolidation 2. The pathogen is already known |
B. admission criteria (3/4/2003) Print this section |
Chart
1 ¡V AED Flowchart
for patients with definite contact with Severe Acute Respiratory Syndrome
patients (within 10 days) (please click
to view chart).
c. Diagnostic Tests (3/4/2003) Print this section |
1. The Rapid diagnostic test
(RT-PCR) is still in the developmental phase. It should not be used to exclude
SARS and it is not useful as a screening test.
D. Treatment
(3/4/2003) Print this section |
1. The most efficacious treatment
regimen at present is unknown but better experience definitely considered in
this guideline.
2. An empirical approach yielding
encouraging results consists of an initial potent antibiotic cover for
presumptively known bacterial agents of severe pneumonia, followed by
simultaneous use of iv high dose methyiprednisolone and iv ribavirin. As the
disease progresses or when there is clinical deterioration, respiratory support
from high concentration oxygen to assisted ventilation might be needed.
For Adult Patient
|
3.
Community
acquired pneumonia characteristic of SARS, esp. from known exposure of outbreak
source and/or poor condition on presentation
Broad-spectrum potent antibiotics + Methylprednisolone +
Ribavirin
4.
Community
acquired pneumonia not fulfilling SARS definition and/or patient in good
general condition on presentation
Broad-spectrum antibiotic + Close observation
5.
If general condition deteriorates with signs
and symptoms of SARS (esp. increase fever, lethargy, lymphopenia &
thrombocytopenia)
Treat as in 3)
* Broad-spectrum
antibiotics
6. Majority of the cases cannot afford
to lose time, start with broad-spectrum potent antibiotics:
IV Rocephin 1g Q24H, or Tazocin
4.5g Q8H, or Maxipime 2g
Q8H plus Clarithromycin 500mg BD PO
Replace with Levofloxacin 500mg
daily plus Clarithromycin if
allergic to penicillin)
7.
Milder & less aggressive form can be
treated with Augmentin plus Clarithromycin/Azithromycin
8. The most potent regime
is to use the 2 together especially if:
¡P Extensive/bilateral CXR
involvement, OR
¡P Persistent CXR involvement AND
persistent high fever for 2 days, OR
¡P Clinical/CXR/Lab parameters
suggestive of deterioration (persistent/increasing lethargy is an important
sign), OR
¡P CXR abnormality AND SpO2<95% on
Room Air
9.
For
Steroid, the consensuses are:
¡P Use at the same time with ribavirin
to avoid cytokine storm and immune activation.
¡P High dose IV
¡P Methylprednisolone (MP) is better
than Hydrocortisone
¡P Pulse MP may improve clinical course
if use early
10. For Ribavirin, the consensuses are:
¡P IV route is preferred in severe
cases
¡P IV 400mg Q8H for 10 to 14 days
11. Typical regimen of steroid
treatment
¡P IV
MP 3mg/kg/day x 5
days, then
2mg/kg/day x 5 days, then
1mg/kg/day x 5 days, then
Oral Prednisolone to tail off
rapidly in 6 days
12. In
case of deterioration
(at least 2 of clinical/CXR/ SpO2 and persistent lymphopenia)
¡P Increase
to pulse MP 500mg bd x 2 days then back to 3mg/kg/day, total treatment period
maintained for 21 days.
¡P Monitor
blood sugar and signs of sepsis while on pulse MP.
13.
Use of BIPAP/CPAP
BIPAP and CPAP may reduce the need for assisted ventilation if given early (e.g. first sign of lethargy). However, since there is a significant risk of spreading the infection, these procedures should not be used for all patients. If deemed medically really necessary, they should be performed under airborne precautions such as negative pressure isolation rooms (with 6-12 air changes/hour) and use of protective hoods (powered air purifying respirator system).
For Paediatric patients
|
14. History
of contacts,
progressive radiological infiltrates and lymphopenia are important in making
the diagnosis.
15. 3rd
generation
cephalosporin
(e.g. Cefotaxime) plus
macrolide (e.g. Erythromycin or Clarithromycin) for coverage of usual pathogens
of CAP
16. Commence
Ribavirin
40-60 mg/kg/day po div Q8H if contact history
definite and with fever (oral bioavailability of ribavirin is 20-64%. It may not be effective if virus load is high).
17. In
highly suspected
case or rapidly progressive disease,
start steroid at the same time with ribavirin. Methylprednisolone 3 mg/kg/day/IV or Hydrocortisone 1-2
mg/kg iv Q6h or Prednisolone 1-2 mg/kg/day po div BD depending on severity and
urgency.
18. If
fever persists,
or clinical deterioration or progressive CXR changes, pulse Methylprednisolone
10 mg/kg/dose iv Q24H for up to 3 doses, depending on clinical response plus Ribavirin 20-60 mg/kg/day iv
div Q8H (maximum dose used in some adult patients is 60 mg/kg/day or 1.2 g
Q8H).
19. Continue
with
prednisolone 1-2 mg/kg/day or Hydrocortisone 1-2 mg/kg iv Q6H after pulse
methylprednisolone. If condition
improves at 1-2 weeks after commencement of steroid therapy, start tapering of steroid over 1 week.
If CXR returns to normal by 2-3 weeks, may stop steroid or rapid tail off over
a few days. If CXR is still abnormal by 3 weeks, try slow tapering of the
steroid according to clinical and radiological improvement.
20. Ribavirin
will be given for a total of 10-14 days. Antibiotics may be discontinued if
afebrile for 5 days.
However patients started on pulse steroid should be carefully observed for
secondary infection.
21. The
antibiotic regimen can
be modified on clinical grounds if secondary or hospital acquired infection is suspected
after prolonged stay in ICU and course of high dose steroid.
Special precautions
|
Ventilator
22. BiPAP, CPAP, and nebulizer or nebulized
medication should not be used for
all patients.
23. If intubation and assisted mechanical ventilation is
required, a closed suction system should be incorporated into the ventilator
circuit and scavenging should be provided by the vacuum wall suction.
Steroid
24. Methylprednisolone must not be
administered via central venous catheters to avoid precipitating cardiac arrest or arrhythmia.
25. Hypokalaemia, hyperglycaemia
and hypertension are commonly seen after administration of high dose steroid. Concomitant anti-ulcer prophylaxis should
also be given.
Ribavirin
26. Ribavirin may be accumulated in patients with impaired renal function but not in
patients with decompensated liver disease.
27. Adverse events associated
with the use of Ribavirin:
Haematological |
haemolytic anaemia, reticulocytosis |
Cardiovascular |
cardiac arrest, hypotension,
bradycardia, tachycardia |
Neurological |
dizziness, asthenia, seizure |
Renal |
nephrolithiasis |
Hepatic |
elevated serum bilirubin and ammonia |
Metabolic |
increase in uric acid |
Dermatological |
pruritus, rash, skin eruptions |
Pregnancy and SARS
|
28. Admit
all pregnant
SARS patients to designated medical wards.
29. If
it is less than
13 weeks of gestation and the mother has been prescribed ribavirin, termination
of pregnancy (TOP) should be advised after she has recovered from the disease.
30. If
medically indicated,
caesarean section should be conducted in a room with negative pressure
ventilation.
31. All
patients on ribavirin
should be advised to practice contraception for 6 months.
(Please
click
for the detailed guidance)
Treatment using convalescent patient
serum
|
32. Convalescent patient plasma (CPP)
infusion is an exploratory treatment modality proposed for desperate cases following anecdotal reports of response in PWH. Clinician
must carefully balance the risks to both the donors and the recipients. The
feasibility and logistics of procuring CPP are under active review.
Prophylactic Treatment
|
33. Not all contacts will contract the virus or develop a severe form of the disease. The benefit of
improving an individual person¡¦s health or public health is unknown. The
duration of protection is primarily limited by the duration of treatment. In
view of the serious side effects of Ribavirin and possible development of drug
resistance, prophylactic use is normally not recommended and widespread use of
the drug may cause more harm than benefit.
Pre-emptive treatment
|
34. Whether early intervention
with antiviral drug and steroid can improve clinical outcome remains an attractive but unproven option. The difficulty lies in the lack of reliable rapid
diagnostic test for SARS. Suspected SARS patients, not fulfilling all
diagnostic criteria but with close contacts with proven SARS, should be closely
observed and not empirically treated with Ribavirin.
Suspected SARS cases by primary care
physician in outpatient setting
|
35. All
patient should have a CXR
reported by a radiologist.
36. Start
standard therapy including a beta-lactam (penicillin & cephalosporin
groups) and coverage for atypical
pneumonia (a fluoroquinolone, tetracyclines, or a macrolide) for 2 days.
37. Advise
patient to return
if symptom deteriorates or new symptom develops.
38. Follow
up all patients at day 3. Continue treatment if condition improve / stable or
refer to AED if:
Fever
> 38¢XC
and Respiratory symptoms - either shortness of breath or cough and X-ray shows
pulmonary infiltrate and (either no response to above-mentioned treatment or
patient having been exposed with pneumonia in the previous 2 weeks.)
E. Infection Control in Inpatient setting (5/4/2003) Print this section |
Box 2
Essential Infection Control Advice
1.
Be
vigilant at all times. 2.
All
staff MUST receive infection control precaution training. 3.
All
persons inside hospital settings MUST wear a mask. For N95 mask, ensure right size and check for leakage. 4.
All
persons inside hospital settings MUST practise hand hygiene. Avoid touching mask and/or face. Wash hands after touching mask,
patients or any suspicious surfaces. 5.
Minimise
traffic of personal belongings into and out of clinical areas as far as
possible. |
High index of suspicion
|
1. Practice infection control
precautions in all healthcare settings.
2. AED, admission wards, medical
wards, paediatrics wards, operation theatres, labour wards and XR departments
should be treated as high-risk areas.
Note: initial presentation
of SARS may be non-specific and only become more apparent after admission. |
Training and Enforcement
|
3. All personnel working inside an
inpatient setting (regardless of SARS risk) must receive training/instructions
on infection control precautions against SARS. This applies to our employees as well as contractor
staff. All hospitals MUST set up
an infection control enforcement team to monitor compliance and identify areas
of improvement.
Environmental Control
|
4. Cohort patients: separate "probable /
confirmed SARS" from "suspected SARS" from "other patients
without suspicion of SARS".
Note: Patients with
unexplained fever should be cohorted whenever possible |
5.
Disinfect all clinical areas
(at least once daily or more frequent if indicated) and facilities,
equipment (regularly and after used) with household bleach 1 in 49 dilution
(non-matalic items) and 70% alcohol (matalic items). Facilities contaminated with vomitus, body secretions and
excreta must be cleaned and
disinfected immediately. (Click
here for Chinese version of Guidance Notes on Disinfection and Cleansing
of Environment and Equipment.)
6. Prevent cross-contamination of
Equipment. SARS cohorting ward and ICU:
Avoid crossing over of equipment and other items between wards. If possible,
assign them (e.g. bed pan, scissors, thermometers, stethoscope,
sphygmomanometer) for designated patient use. If sharing is unavoidable, items must
be cleaned and disinfected before using on other patients, e.g. by 1 in 49
dilution household bleach (hypochlorite).
Control Access by Visitors
|
7. Do not allow visit unless under
very exceptional situations. In such circumstances, visit must be kept to
minimal (preferably no longer than 15 minutes) and documented. Educate all visitors to take full
barrier precautions (surgical mask, gown, gloves, protective eyewear) and their
responsibility for adherence to them. Visitors should wash their hands when
leaving the area.
Personal Practice
|
8. All persons MUST wear a mask (Click here
for Correct Use of Mask and click
here for¡uÄY«©I§l¨t²Îºî¦X¯gÂåÅ@¤Hû·P¬V±±¨î±¹¬I¹Ï¸Ñ«ü¤Þ¡v).
9.
All persons MUST practice hand hygiene (frequent hand
washing, avoid touching the eyes, nose and mouth). (Click
here for a Chinese version of the Guidance Notes on Hand Washing).
10. Standard precautions: Hand hygiene (wash hand after
handling individual patients and removing gloves and gowns). Avoid touching the
eyes, nose and mouth. Do not eat or drink in inpatient areas or pantry adjacent
to inpatient areas.
Note: Both antiseptic use (e.g.
hibiscrub) and the physical action of washing with water are crucial for
effective hand hygiene. Hexol-rub or alcohol wipe CANNOT replace hand
washing. |
11. Droplet precautions: Surgical masks for all patient
contact. Protective eyewear (goggles or face shield) for close patient contact.
12. Contact precautions: Wash hand before nursing another
patient. Protective gowns and gloves for contact with the patient or their
environment (must wear gowns in procedures likely to generate splashes or
sprays of blood and body fluids).
13. Put on a surgical / N95 mask. (Click here for Correct Use of Mask and click
here for¡uÄY«©I§l¨t²Îºî¦X¯gÂåÅ@¤Hû·P¬V±±¨î±¹¬I¹Ï¸Ñ«ü¤Þ¡v.
Note: N95 masks are
available to staff on request. However, its perceived benefit must be
balanced against user compliance to correct usage. |
14. More stringent contact precautions:
use of cap, gown, gloves and protective eyewear; carry as few personal
belongings as possible during work and avoid bringing items into and out of clinical
areas as far as possible, e.g. patient records, pagers, stethoscopes and other
personal gears including pens and notebooks, etc.
15.
Precautions
on entering and leaving SARS cohorting areas
On
ENTERING (In sequential order)
i.
Put on a
mask
ii.
Put on protective
eyewear (especially if there is close patient contact)
iii.
Put on a
cap
iv.
Put on a
gown
v.
Rub hands
with alcoholic handrub and allow to dry
vi.
Put on
gloves
vii.
Enter the
ward / ICU
On LEAVING (in sequential
order)
i.
Remove gloves
(dispose into waste bag)
ii.
Remove cap
(dispose into waste bag)
iii.
Remove
protective eyewear, clean with 70% alcohol and store in labeled paper bag
iv.
Remove
gown (dispose into waste bag)
v.
Remove
mask; discard if contaminated, or store in labeled paper bag for reuse.
vi.
Rub hands
with alcoholic hand rub and allow to dry (if hands soiled, must wash hands
before leaving the ward)
vii.
Put on a
surgical mask whilst outside high-risk area.
Please click
here for a copy of é¤Jªù¤C¨Æ, ¥Xªù¤C¨Æû for
dissemination if necessary.
16. Continue infection control precautions at home.
Consult staff clinic or AED if fever or respiratory symptom develops.
Waste
Management of Disposable Protective Equipment |
17. Disposable masks, caps, gloves,
gowns and shoe covers exposed to SARS patients should be handled as clinical
waste, i.e., discard into Red Bags, properly packaged and labelled for delivery to incineration.
Additional
Precautions in High-risk Procedures |
Serious-risk
procedures:
18. The initial presentation of SARS
could be non-specific. A number of breakthrough infections was caused by
patients who were initially admitted for non-specific presentation but were
subsequently confirmed to have SARS.
Therefore, aerosolized medication treatments (by nebulizer) and BiPAP
and cPAP should not be used for all patients.
19. If deemed medically essential, the above procedures should only be
performed in consultation with respiratory physicians, and under high airborne
precautions such as strong negative pressure isolation rooms, and use of strict
protective gears by healthcare personnel.
20. Potentially aerosol-generating
procedures (diagnostic sputum induction, bronchoscopy, airway suctioning,
endotracheal intubation), laboratory handling and processing of fresh specimens
associated with SARS, post-mortem examination of human remains of SARS
patients.
i
Performed
only if deemed medically necessary.
ii
Limit the
extent of procedure to the minimum necessary.
iii
Limit the
number of personnel to the minimum necessary.
21. Laboratory processing of fresh SARS
specimen should be performed in a biological safety cabinet. If centrifugation
is required, it should be carried out using sealed centrifuge cups or rotors that are
loaded and unloaded in a biological safety cabinet.
22. Contact precautions should vary
with the risk of exposure. For post-mortem examination, for example, protective
garments should include surgical scrub suit, surgical cap, impervious gown or
apron with full sleeve coverage, eye protection (goggles or face shield), shoe
covers and double surgical gloves with an interposed layer of cut-proof
synthetic mesh gloves. Make sure that the protective outer garments are removed
when leaving the immediate autopsy area and discarded in appropriate laundry or
waste receptacles.
F. Infection
Control measures at home (3/4/2003) Print this section |
1. All staff caring for SARS patients
/ contacts of SARS patients or SARS
patients discharged from hospital should adopt the following infection
control measures at home:
i.
Frequent handwashing
with liquid soap rather than bar soap, especially after contact with nose,
mouth and respiratory secretions, e.g. after sneezing.
ii.
Family
members should practise handwashing frequently, and avoid touching the eyes,
nose and mouth with their hands.
iii.
Put on a
surgical mask.
iv.
Avoid
close contact with family members (e.g. mucosal contact).
v.
Avoid
sharing food and utensils with family members.
vi.
Shower
immediately after work (for staff caring for patients with Severe Respiratory
Syndrome).
vii.
Cleanse
and disinfect the facilities (including furniture and toilet facilities)
regularly (at least once a day), using diluted household bleach (i.e. adding 1 part of household bleach
to 99 parts of water), rinse with water and then mop dry.
viii.
If the
facilities are contaminated with vomitus or body secretions, wash / wipe with
diluted domestic bleach (mixing 1 part of bleach with 49 parts of water) immediately.
ix.
These
precautionary measures should be adopted for 10 days from the latest contact
with patient with Severe Respiratory Syndrome, and for 3 weeks for discharged
patients with Severe Respiratory Syndrome.
2. Please click
here for Å@²z¡u«D¨å«¬ªÍª¢¡v¯f¤Hªºû¤uÀ³¿í¦uªº·P¬V±±¨î±¹¬I and
click
here for ¡u«D¨å«¬ªÍª¢¡v¯f¤H¥X°|¶·ª¾
for
dissemination.
G. CONVALESCENCE
(3/4/2003) Print this section |
1. The potential for continued viral shedding during convalescence is under investigation. A cautious approach is to cohort convalescence cases in [hospital /
convalescence facilities / home] for up to 3 weeks from onset of illness, or at
least 7 days since convalescence, whichever is longer.
2.
Definition
of Convalescent Cases
Clinical
symptoms/findings:
Afebrile
for 48 hours
Resolving
cough
AND Laboratory
tests: if previously abnormal are improving
White
cell count returning to normal
Platelet
count returning to normal
Creatine
phosphokinase / LDH returning to normal
Liver
function tests returning to normal
Plasma
sodium returning to normal
C
reactive protein returning to normal
AND
Radiological findings:
Improving
chest x-ray changes
Home care
|
3.
Upon discharge, advise patients to self-quarantine
and take enteric precaution at home for 10 days (may be longer, studies not
available). During which they
should:
¡P
Stay indoors and keep contact with others to a minimum.
¡P
Wear mask and practice other personal hygiene measures, e.g.
avoid mucosal contact, frequent hand washing, do not share eating utensils.
¡P
Check temperature twice daily and report to AED (of the
hospital from which they were discharged) if temperature ³38¢XC on 2 consecutive occasions.
¡P
Report to AED if condition deteriorates and any further
symptoms develop.
4.
Follow up weekly
until the chest x-ray and patient¡¦s health return to normal.
¡P
At each follow up, repeat chest x-ray and full blood count
(and other blood tests that were previously abnormal).
¡P
Further confinement and longer follow up could be
recommended for those who are immunosuppressed.
¡P
Obtain convalescent serology at 7 and 14 days after the
acute sample taken on or soon after the date of disease onset.
5. SARS patients on discharge must be advised to strictly follow
INFECTION CONTROL MEASURES AT HOME (click
here for a copy for a copy of¡u«D¨å«¬ªÍª¢¡v¯f¤H¥X°|¶·ª¾ for dissemination).
H. post mortem examination
(5/4/2003) Print
this section |
Case Definition |
1.
Please see latest definition in use in HA..
Precautions for Mortuary Personnel |
2.
Indications for autopsy
i.
SARS cases confirmed by PCR or serology of the newly
identified Coronavirus: Unless otherwise indicated, an autopsy is not
necessary. A waiver should be
recommended to the Coroner for Coroner's autopsy cases.
ii. Clinically
suspected or probable but unconfirmed SARS case: To minimize dissemination of
virus, limit procedure to taking post mortem lung biopsies for culture,
molecular and histology studies.
3.
Limit the number of personnel
to the minimum necessary, viz., 1
pathologist plus 1 mortuary technician/attendant if practical.
4.
Handle body as per category
2 of guidelines on Precautions for handling and disposal of dead bodies,
issued jointly by DH, HA and Food & Environmental Hygiene Department in
January 2002 (4th edition). (Click
here to retrieve the guidelines).
The deceased must be put in double plastic bag in the ward
with the yellow tag tied prominently on the outside of bag to alert the ward
and mortuary staff to take due precautions.
5.
Protective garments:
Surgical scrub suit, surgical cap, impervious gown or apron with full sleeve
coverage, eye protection (e.g., goggles or face shield), shoe covers and double
surgical gloves with an interposed layer of cut-proof synthetic mesh gloves.
Note: Protective
outer garments should be removed when leaving the immediate autopsy area and
discarded in appropriate laundry or waste receptacles. |
6.
Respiratory protection:
N-95 mask or powered air-purifying respirators (PAPR) equipped with a high
efficiency particulate air (HEPA) filter. PAPR is recommended for any
procedures that result in mechanical generation of aerosols, e.g., use of
oscillating saws. Autopsy personnel who cannot wear N-95 respirators because of
facial hair or other fit-limitations should wear PAPR.
7.
Avoid splashing and aerosols as far as possible. Perform minimal dissection of organs in
the fresh state.
8.
After sampling for fresh tissue, the remaining tissue
should be adequately fixed in formalin at least overnight before cutting for
tissue processing.
9.
Despatch of specimen
Recommendation to persons collecting body |
10. The
mortuary officer or duty attendant should inform such persons of precautions
recommended for handling dead bodies with infectious diseases listed under
category 2. (please click
here for details stated in Section D2 of the guidelines on Precautions of
handling and disposal of dead bodies). It is advisable to provide those persons
with printed copies of the Chinese version (please click
here).
Appendix:
Correct use of N95 masks Print this section |
The
mask provides an effective barrier to prevent healthcare workers from inhaling
airborne pathogens such as Mycobacterium tuberculosis. The level of protection
is determined by the efficiency of the filter material and how well the
facepiece fits or seals to the health care worker's face. N95 mask should not
be worn when conditions prevent a good face seal, e.g. a growth of beard,
sideburns, etc.
Fit check: Perform fit check before each use. Put on the mask and
press the metal strip to fit contour of face. Place both hands gently over the
mask and exhale vigorously to check for air leakage around the nosepiece or
edge. Reposition and recheck as needed.
Reuse:
N95 masks may be reused. Since it cannot be disinfected, use must be restricted
to a single person. Discard if it is physically damaged or soiled.
Handling and storage: The external surface may be contaminated. Do not touch with fingers. Label (or identify by other means) your
mask to avoid mixing-up. For temporary storage, use a paper bag or box but not
sealable plastic bag. Sealing
maintain dampness and encourages microbial growth.