Ebola medical therapy: Difference between revisions

Jump to navigation Jump to search
 
(24 intermediate revisions by 4 users not shown)
Line 2: Line 2:
{{Ebola}}
{{Ebola}}


{{CMG}}; {{AE}} {{GRN}}
{{CMG}}; {{AE}} {{Marjan}}
==Overview==
==Overview==
No specific [[antiviral drug]] has demonstrated effectiveness against Ebola infection. Management is primarily supportive and symptomatic. The following basic interventions, when used early, may improve the chances of survival: administration of intravenous fluids and correction of electrolyte abnormalities, maintenance of stable vital signs, and treatment against other co-infections or super-infections by antimicrobial agents. It is common practice to administer prophylactic broad-spectum antimicrobial agents, such as antibiotics and antimalarial agents, due to the high risk of co-infection or super-infection.
No specific [[antiviral drug]] has demonstrated effectiveness against Ebola infection. Management is primarily supportive and symptomatic. The following basic interventions, when used early, may improve the chances of survival: administration of intravenous fluids and correction of electrolyte abnormalities, maintenance of stable vital signs, and treatment against other co-infections or super-infections by antimicrobial agents. It is common practice to administer prophylactic broad-spectum antimicrobial agents, such as antibiotics and antimalarial agents, due to the high risk of co-infection or super-infection.


==Medical Therapy==
==Medical Therapy==
There are no targeted antiviral therapies currently in use. Supportive care is the mainstay of medical management. where hemodynamic and respiratory support are the two most important interventions.<ref name=Emergency Physicians Review>{{cite journal| author=| title=Ebola virus outbreak 2014: clinical review for emergency physicians | journal=Annals of Emergency Medicine | year= 2014| volume= | issue= | pages= | pmid= | doi= | pmc= | url=http://www.sciencedirect.com/science/article/pii/S0196064414013961 }} </ref> Administration of whole blood and plasma products from convalescent patients using standard procedures have been administered empirically with promising results and is currently recommended as empirical treatment during outbreaks by the World Health Organization (WHO).<ref name=WHO>{{cite journal| author=| title=Use of convalescent whole blood or plasma collected from patients recovered from Ebola virus disease for transfusion, as an empirical treatment during outbreaks| | year= 2014 | volume= | issue=  | pages= | | doi=| pmc= | url=http://apps.who.int/iris/bitstream/10665/135591/1/WHO_HIS_SDS_2014.8_eng.pdf }} </ref>  
:*'''Ebola virus treatment'''<ref>{{cite web|title=Ebola virus treatment|url=http://www.cdc.gov/vhf/ebola/treatment/index.html}}</ref><ref name="pmid21084112">{{cite journal| author=Feldmann H, Geisbert TW| title=Ebola haemorrhagic fever. | journal=Lancet | year= 2011 | volume= 377 | issue= 9768 | pages= 849-62 | pmid=21084112 | doi=10.1016/S0140-6736(10)60667-8 | pmc=PMC3406178 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21084112  }} </ref>
===Bleeding===
::*Preferred regimen: supportive therapy. There is no specific antiviral drug available for Ebola thus far. For information of investigational therapies including Favipiravir, Brincidofovir, ZMapp, TKM-Ebola, AVI-6002, and BCX4430, see [[Ebola future or investigational therapies|here]].
*Repletion of [[coagulation factors]] with [[fresh frozen plasma]] (FFP) if available, and [[transfusion|transfuse]] with packed red blood cells and platelets may be required. Invasive procedures should be avoided to prevent further bleeding.
:::*Isolate patient
:::*Provide intravenous fluids (IV) (patients need large volumes in some cases) and maintain electrolytes at normal levels
:::*Maintain oxygen saturation and blood pressure
:::*Administer blood products if coagulopathy or bleeding, antiemetics if vomiting , antipyretics if fever, analgesics, anti-motility if severe diarrhea, total parenteral nutrition if patient has poor oral intake and dialysis if there's renal failure
:::*Treat other infections if they occur. Provide adequate Gram-negative coverage and gram-positive if the patient has any catheter or hospital-acquired pneumonia.
:::*If there's respiratory failure, invasive mechanical ventilation may be the best option to offer respiratory support
::*Note (1): Recovery from Ebola depends on good supportive care and the patient’s immune response.
::*Note (2): While there is no proven treatment available for Ebola virus disease, human convalescent whole blood has been used as an empirical treatment with promising results in a small group of EVD cases.<ref>[http://apps.who.int/iris/bitstream/10665/135591/1/WHO_HIS_SDS_2014.8_eng.pdf interim]</ref><ref name="pmid9988160">{{cite journal| author=Mupapa K, Massamba M, Kibadi K, Kuvula K, Bwaka A, Kipasa M et al.| title=Treatment of Ebola hemorrhagic fever with blood transfusions from convalescent patients. International Scientific and Technical Committee. | journal=J Infect Dis | year= 1999 | volume= 179 Suppl 1 | issue=  | pages= S18-23 | pmid=9988160 | doi=10.1086/514298 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9988160  }} </ref>
::*Note (3): People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola.
::*Note (4): Some people who have recovered from Ebola have developed long-term complications, such as joint and vision problems.


====Dehydration and Shock====
==Pregnant Women with Ebola Virus Disease==
*Patients with Ebola virus disease should be considered high-risk for development of shock.
*Healthcare providers caring for pregnant women in U.S. hospitals should be prepared to screen patients for EVD and have a plan in place to triage these patients.
*Intravenous fluids should be aggressively administered with careful consideration of electrolyte imbalances.
*Obstetric management of pregnant women with EVD, particularly decisions about mode of delivery for women in labor, needs to consider risks to the woman, risks of exposure for healthcare providers, and potential benefits to the neonate.
*Hypokalemia and hypocalcemia are common and repletion of potassium levels and calcium may be necessary.
*Healthcare workers who are pregnant should not care for patients with EVD.
*A combination of intravenous fluids, vasopressors, and blood products may be necessary as needed.
*Pregnant PUIs or patients with confirmed EVD should be hospitalized, and CDC guidance for hospitalized PUIs or patients with confirmed EVD should be followed.
===Hypoxia===
*There is no evidence currently exists to suggest that pregnant women are more susceptible to infection from Ebola virus (EBOV) than the general population.
Supplemental oxygen, including intubation and mechanical ventilation, may be necessary for patients with severe dyspnea, pulmonary edema, severe hemorrhage, and acute respiratory distress syndrome (ARDS).
*limited evidence does suggest that pregnant women are likely to be at increased risk of severe illness and death when infected with EBOV.
===Superimposed Infections===
*Pregnant women with EVD also appear to be at an increased risk of fetal loss and pregnancy-associated hemorrhage.
Close monitoring for possible superimposed infections is necessary given the high association between Ebola virus disease and overwhelming sepsis. Aggressive empirical administration of antimicrobial agents is necessary to treat infectious complications of Ebola virus disease.<ref name="pmid25337633">{{cite journal| author=Kreuels B, Wichmann D, Emmerich P, Schmidt-Chanasit J, de Heer G, Kluge S et al.| title=A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia. | journal=N Engl J Med | year= 2014 | volume=  | issue=  | pages=  | pmid=25337633 | doi=10.1056/NEJMoa1411677 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25337633  }} </ref> Infectious agents should be isolated and cultured for appropriate continuation of targeted antimicrobial therapy.
*EBOV can cross the placenta, and pregnant woman infected with the virus will likely transmit it to the fetus.


==Prophylaxis Against Co-infections or Super-infections==
==Prophylaxis Against Co-infections or Super-infections==
Line 25: Line 34:


==Nutritional Support==
==Nutritional Support==
*Although preferred, enteral nutrition may not be tolerated due to vomiting or paralytic ileus.
*When both the lactating woman and child are positive for EVD, and where replacement feeding with liquid ready-to-use infant formula (RUIF) is acceptable, feasible, and provision is guaranteed, suspend breastfeeding until breast milk tests are negative.
*Parental nutrition should be administered to patients who cannot tolerate oral food intake.
*When the lactating woman is positive for EVD and child negative for EVD suspend breastfeeding.
*Enteral nutrition should be resumed as soon as it is tolerated.
*When the lactating woman is negative for EVD and child positive for EVD suspend breastfeeding.
*The nutritional needs and approach to nutritional care in any individual will be determined by the patient’s preceding nutritional status, severity of illness and age.
*Intake of high nutrient-dense foods may be important in patients in the early phase of the disease who still have appetite and no eating difficulties.
*In patients who are ill for longer time period in the convalescence phase; and following discharge.


==References==
==References==
Line 37: Line 49:
[[Category:Zoonoses]]
[[Category:Zoonoses]]
[[Category:Hemorrhagic fevers]]
[[Category:Hemorrhagic fevers]]
[[Category:Needs content]]
 
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]



Latest revision as of 00:55, 7 May 2019

Ebola Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Ebola from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Algorithm for the Evaluation of the Returned Traveler

Emergency Department Evaluation

Case Definition

History and Symptoms

Physical Examination

Laboratory Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Hospital Preparedness

Checklists

Air Medical Transport

Monitoring and Movement Following Exposure

Primary Prevention

Future or Investigational Therapies

Postmortem Care

Postmortem Care

Case Studies

Case #1

Ebola medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Ebola medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Ebola medical therapy

CDC on Ebola medical therapy

Ebola medical therapy in the news

Blogs on Ebola medical therapy

Directions to Hospitals Treating ebola

Risk calculators and risk factors for Ebola medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Marjan Khan M.B.B.S.[2]

Overview

No specific antiviral drug has demonstrated effectiveness against Ebola infection. Management is primarily supportive and symptomatic. The following basic interventions, when used early, may improve the chances of survival: administration of intravenous fluids and correction of electrolyte abnormalities, maintenance of stable vital signs, and treatment against other co-infections or super-infections by antimicrobial agents. It is common practice to administer prophylactic broad-spectum antimicrobial agents, such as antibiotics and antimalarial agents, due to the high risk of co-infection or super-infection.

Medical Therapy

  • Preferred regimen: supportive therapy. There is no specific antiviral drug available for Ebola thus far. For information of investigational therapies including Favipiravir, Brincidofovir, ZMapp, TKM-Ebola, AVI-6002, and BCX4430, see here.
  • Isolate patient
  • Provide intravenous fluids (IV) (patients need large volumes in some cases) and maintain electrolytes at normal levels
  • Maintain oxygen saturation and blood pressure
  • Administer blood products if coagulopathy or bleeding, antiemetics if vomiting , antipyretics if fever, analgesics, anti-motility if severe diarrhea, total parenteral nutrition if patient has poor oral intake and dialysis if there's renal failure
  • Treat other infections if they occur. Provide adequate Gram-negative coverage and gram-positive if the patient has any catheter or hospital-acquired pneumonia.
  • If there's respiratory failure, invasive mechanical ventilation may be the best option to offer respiratory support
  • Note (1): Recovery from Ebola depends on good supportive care and the patient’s immune response.
  • Note (2): While there is no proven treatment available for Ebola virus disease, human convalescent whole blood has been used as an empirical treatment with promising results in a small group of EVD cases.[3][4]
  • Note (3): People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola.
  • Note (4): Some people who have recovered from Ebola have developed long-term complications, such as joint and vision problems.

Pregnant Women with Ebola Virus Disease

  • Healthcare providers caring for pregnant women in U.S. hospitals should be prepared to screen patients for EVD and have a plan in place to triage these patients.
  • Obstetric management of pregnant women with EVD, particularly decisions about mode of delivery for women in labor, needs to consider risks to the woman, risks of exposure for healthcare providers, and potential benefits to the neonate.
  • Healthcare workers who are pregnant should not care for patients with EVD.
  • Pregnant PUIs or patients with confirmed EVD should be hospitalized, and CDC guidance for hospitalized PUIs or patients with confirmed EVD should be followed.
  • There is no evidence currently exists to suggest that pregnant women are more susceptible to infection from Ebola virus (EBOV) than the general population.
  • limited evidence does suggest that pregnant women are likely to be at increased risk of severe illness and death when infected with EBOV.
  • Pregnant women with EVD also appear to be at an increased risk of fetal loss and pregnancy-associated hemorrhage.
  • EBOV can cross the placenta, and pregnant woman infected with the virus will likely transmit it to the fetus.

Prophylaxis Against Co-infections or Super-infections

Overwhelming sepsis is associated with the majority of deaths due to Ebola virus disease.[5] Thus, it is common practice to administer antibiotics and antimalarial agents for patients with Ebola virus disease due to the high risk of co-infection or super-infection with Malaria and bacterial organisms.[6] In contrast, the administration of antiviral agents, such as acyclovir or ribavirin, has not demonstrated efficacy.[5]

Nutritional Support

  • When both the lactating woman and child are positive for EVD, and where replacement feeding with liquid ready-to-use infant formula (RUIF) is acceptable, feasible, and provision is guaranteed, suspend breastfeeding until breast milk tests are negative.
  • When the lactating woman is positive for EVD and child negative for EVD suspend breastfeeding.
  • When the lactating woman is negative for EVD and child positive for EVD suspend breastfeeding.
  • The nutritional needs and approach to nutritional care in any individual will be determined by the patient’s preceding nutritional status, severity of illness and age.
  • Intake of high nutrient-dense foods may be important in patients in the early phase of the disease who still have appetite and no eating difficulties.
  • In patients who are ill for longer time period in the convalescence phase; and following discharge.

References

  1. "Ebola virus treatment".
  2. Feldmann H, Geisbert TW (2011). "Ebola haemorrhagic fever". Lancet. 377 (9768): 849–62. doi:10.1016/S0140-6736(10)60667-8. PMC 3406178. PMID 21084112.
  3. interim
  4. Mupapa K, Massamba M, Kibadi K, Kuvula K, Bwaka A, Kipasa M; et al. (1999). "Treatment of Ebola hemorrhagic fever with blood transfusions from convalescent patients. International Scientific and Technical Committee". J Infect Dis. 179 Suppl 1: S18–23. doi:10.1086/514298. PMID 9988160.
  5. 5.0 5.1 Parkes-Ratanshi R, Ssekabira U, Crozier I (2014). "Ebola in West Africa: be aware and prepare". Intensive Care Med. 40 (11): 1742–5. doi:10.1007/s00134-014-3497-z. PMID 25253023.
  6. Kreuels B, Wichmann D, Emmerich P, Schmidt-Chanasit J, de Heer G, Kluge S; et al. (2014). "A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia". N Engl J Med. doi:10.1056/NEJMoa1411677. PMID 25337633.


Template:WH Template:WS