RESPIRATORY INFECTION

Severe acute respiratory syndrome: report of treatment and outcome after a major outbreak

J J Y Sung¹, A Wu¹, G M Joynt², K Y Yuen³, N Lee¹, P K S Chan⁴, C S Cockram¹, A T Ahuja⁵, L M Yu⁶, V W Wong¹, D S C Hui¹

¹ Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
² Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
³ Department of Microbiology, The University of Hong Kong, Hong Kong
⁴ Department of Microbiology, The Chinese University of Hong Kong, Hong Kong
⁵ Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, Hong Kong
⁶ Center for Clinical Trial and Epidemiological Research, The Chinese University of Hong Kong, Hong Kong

Correspondence to:
Correspondence to:
Dr D S C Hui
Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong; dschui{at}cuhk.edu.hk

Background: The outcome is reported of a prospective uncontrolled study based on a stepwise treatment protocol during an outbreak of severe acute respiratory syndrome (SARS) in Hong Kong.

Method: One hundred and thirty eight patients were treated with broad spectrum antibiotics, a combination of ribavirin and low dose corticosteroid, and then intravenous high dose methylprednisolone according to responses. Sustained response to treatment was defined as (1) defervescence for 4 consecutive days, (2) resolution of lung consolidation by >25%, and (3) oxygen independence by the fourth day without fever. Patients with defervescence who achieved either criterion 2 or 3 were classified as partial responders. Patients who fell short of criteria 2 and 3 were non-responders.

Results: Laboratory confirmation of SARS coronavirus infection was established in 132 (95.7%). None responded to antibiotics but 25 (18.1%) responded to ribavirin + low dose corticosteroid. Methylprednisolone was used in 107 patients, of whom 95 (88.8%) responded favourably. Evidence of haemolytic anaemia was observed in 49 (36%). A high level of C-reactive protein at presentation was the only independent predictor for use of methylprednisolone (odds ratio 2.18 per 10 mg/dl increase, 95% confidence interval 1.12 to 4.25, p = 0.02). Thirty seven patients (26.8%) required admission to the intensive care unit and 21 (15.2%) required invasive mechanical ventilation. There were 15 deaths (mortality rate 10.9%), most with significant co-morbidities, whereas 122 (88.4%) had been discharged home 4 months after the outbreak onset.

Conclusion: The use of high dose pulse methylprednisolone during the clinical course of a SARS outbreak was associated with clinical improvement, but randomised controlled trials are needed to ascertain its efficacy in this condition.

Keywords: severe acute respiratory syndrome (SARS); ribavirin; treatment; corticosteroid; outcome

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