Pharmacologic Treatments and Supportive Care for Middle East Respiratory Syndrome

Taylor Kain; Patrick J. Lindsay; Neill K.J. Adhikari; Yaseen M. Arabi; Maria D. Van Kerkhove; Robert A. Fowler


Emerging Infectious Diseases. 2020;26(6):1102-1112. 

In This Article

Abstract and Introduction


Available animal and cell line models have suggested that specific therapeutics might be effective in treating Middle East respiratory syndrome (MERS). We conducted a systematic review of evidence for treatment with pharmacologic and supportive therapies. We developed a protocol and searched 5 databases for studies describing treatment of MERS and deaths in MERS patients. Risk of bias (RoB) was assessed by using ROBINS-I tool. We retrieved 3,660 unique citations; 20 observational studies met eligibility, and we studied 13 therapies. Most studies were at serious or critical RoB; no studies were at low RoB. One study, at moderate RoB, showed reduced mortality rates in severe MERS patients with extracorporeal membrane oxygenation; no other studies showed a significant lifesaving benefit to any treatment. The existing literature on treatments for MERS is observational and at moderate to critical RoB. Clinical trials are needed to guide treatment decisions.


Middle East respiratory syndrome (MERS), which is now known to be caused by MERS coronavirus (MERS-CoV), was first reported in September 2012 in Saudi Arabia.[1] Since then, it has spread to 26 other countries.[2] As of November 30, 2019, a total of 2,494 confirmed cases and 858 deaths had been reported to the World Health Organization (WHO); the case-fatality rate was 34.4%.[3] To date, all cases have been linked to travel or residence in the Arabian Peninsula. MERS-CoV is a human betacoronavirus that is found in humans and dromedary camels and is similar to other human coronaviruses (e.g., severe acute respiratory syndrome coronavirus [SARS-CoV] and SARS-CoV-2, the cause of coronavirus disease [COVID-19]).[4] Infected patients generally have fever, cough, dyspnea, and abnormal chest imaging.[5] Many patients have onset of respiratory failure and require noninvasive ventilation (NIV) or invasive mechanical ventilation; advanced supportive care techniques, such as extracorporeal membrane oxygenation (ECMO), have been used. Most of these patients are cared for in an intensive care unit (ICU).

No vaccination against MERS-CoV infection exists, and WHO and the US Centers for Disease Control and Prevention (CDC) recommend general infection prevention measures when caring for patients.[1,6] As with other coronaviruses, no evidence-based recommended pharmacologic therapy for the treatment of MERS-CoV infection exists; however, limited data from available animal and cell line models have led to multiple different combinations of antiviral drugs and other adjunctive therapies to be proposed and used in humans.[7,8] We conducted a systematic review to summarize the current evidence base for treatment of MERS, including specific treatments against MERS, adjunctive pharmacologic therapies, and supportive care.