What is the appropriate management for a patient with SARS (Severe Acute Respiratory Syndrome) presenting with fever?

Management of SARS Patient with Fever

For a patient with SARS presenting with fever, immediately isolate in a negative pressure room, initiate strict infection control measures, administer empiric antibiotics covering community-acquired pneumonia (co-amoxiclav 1.2g IV TDS or cefuroxime 1.5g IV TDS plus erythromycin 500mg IV QDS or clarithromycin 500mg IV BD), provide supplemental oxygen and fluids, and consider methylprednisolone 40-80mg daily for severe or rapidly progressive disease. 1

Immediate Infection Control Priorities

The cornerstone of SARS management is preventing transmission to healthcare workers and other patients, as this virus spreads primarily through close contact and respiratory droplets. 2, 3

• Place the patient in a negative pressure isolation room immediately; if unavailable, use a single room with the door closed 1
• Give the patient a surgical mask to wear continuously unless requiring face mask oxygen delivery 1
• Ensure all healthcare workers wear full personal protective equipment: gowns, gloves, goggles or visors, and respirators conforming to at least EN149:2001 standard 1
• Maintain a list of all staff with patient contact and monitor them for symptoms for 10 days post-exposure 1
• Restrict visitors to next of kin/legal guardian only 1

Clinical Assessment and Risk Stratification

Fever in SARS typically appears 5 days (range 2-10 days) after exposure and is accompanied by chills, rigors, myalgia, and flu-like symptoms. 1 Respiratory symptoms (cough, dyspnea) develop approximately 3 days after fever onset. 1

• Confirm travel history to areas with recent SARS transmission or contact with confirmed SARS cases 1
• Assess pneumonia severity using BTS community-acquired pneumonia guidelines 1
• Identify high-risk comorbidities including diabetes and cardiopulmonary disease, which predict worse outcomes 1
• Note that rash, lymphadenopathy, or CNS features make SARS less likely 1

Essential Diagnostic Workup

Before initiating specific therapy, obtain comprehensive laboratory and microbiological testing while maintaining strict infection control for all specimens. 1

• Microbiological specimens (double-bagged, labeled as biohazard): expectorated sputum if available, urine (20-30mL), stool, EDTA blood (20mL for PCR), acute serology (20mL clotted blood) 1
• Do NOT obtain nasopharyngeal aspirate as this generates aerosols 1
• Laboratory tests: chest X-ray, pulse oximetry, blood gases if oxygen saturation <92% on air, complete blood count, electrolytes, renal function, liver function tests, lactate dehydrogenase, creatinine kinase, C-reactive protein 1
• Common laboratory findings include lymphopenia, thrombocytopenia, and elevated LDH 4, 5

Empiric Antibiotic Therapy

Since SARS initially presents as pneumonia and bacterial co-infection cannot be excluded, empiric antibiotics are essential. 1

• Commence IV co-amoxiclav 1.2g TDS OR cefuroxime 1.5g TDS 1
• PLUS erythromycin 500mg IV QDS OR clarithromycin 500mg IV BD 1
• Avoid blind use of broad-spectrum antibiotics without clinical indication 1
• Monitor for secondary bacterial infections, especially in mechanically ventilated patients 6

Oxygen Therapy and Respiratory Support

Oxygen supplementation must balance patient needs with infection control considerations to minimize aerosol generation. 1

• Administer oxygen to maintain adequate saturation but avoid high-flow oxygen (>6 L/min) to reduce aerosol generation 1
• Use standard low-flow oxygen systems with air-entrainer and Ventimask to provide 30-40% oxygen 1
• Avoid aerosol-generating procedures (nebulizers, high-flow oxygen, non-invasive ventilation) whenever possible 1
• If intubation required, use experienced operators only in negative pressure room with minimal staff present 1

Corticosteroid Therapy for Severe Disease

The use of corticosteroids in SARS is controversial but may benefit patients with rapid progression or severe illness. 1

• Consider methylprednisolone 40-80mg daily for patients with rapid disease progression or severe illness, with total daily dose not exceeding 2mg/kg 1
• Pulse-dose methylprednisolone (500-1000mg IV daily for 2-3 days) can be used for patients with clinical deterioration manifest by persistent fever, worsening radiographic opacities, and hypoxemic respiratory failure 1
• Corticosteroids are NOT indicated for routine care of uncomplicated SARS 1
• Evidence suggests timely corticosteroid use may improve clinical symptoms and accelerate lung lesion absorption, though it cannot shorten hospital stay 1

Fever Management

• Use ibuprofen 0.2g orally for temperatures >38.5°C, repeatable every 4-6 hours but no more than 4 times in 24 hours 1
• Temperatures below 38°C are acceptable as lower body temperature is not conducive to antiviral treatment 1
• Acetaminophen can be used as an alternative antipyretic 7

Supportive Care Measures

• Administer IV fluids as required for hydration and hemodynamic support 1
• Provide nutritional support with protein-rich foods and consider oral nutrition supplements for patients with NRS2002 score ≥3 1
• Use stress ulcer prophylaxis (H2 receptor antagonists or proton pump inhibitors) in patients with gastrointestinal bleeding risk factors 1
• Implement deep vein thrombosis prophylaxis (pharmacologic or physical) 1
• Use sedation protocols for mechanically ventilated patients with daily interruption/lightening 1
• Position patients semi-recumbent (head of bed elevated 45 degrees) if receiving mechanical ventilation 1

Critical Care Considerations

Approximately 20% of SARS patients require ICU or high dependency care, with 13-26% developing ARDS. 6

• Monitor closely for progression to respiratory failure, septic shock, or multiple organ dysfunction syndrome 6
• Be vigilant for complications including spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema 6
• Older age consistently predicts poor prognosis 2, 6

Common Pitfalls to Avoid

• Do not delay isolation while awaiting laboratory confirmation—clinical and epidemiological criteria are sufficient to initiate management 1
• Do not use powered air purifying respirators (PAPRs) during aerosol-generating procedures due to concerns over contamination during removal 1
• Do not assume other causes of pneumonia are excluded—SARS is much less common than typical community-acquired pneumonia 1
• Do not forget to notify hospital infection control, CCDC, and designated SARS Infectious Diseases Unit immediately 1