Medscape’s Alfred Saint Jacques spoke to Dr. Fowler MD, MS…….
Medscape’s Alfred Saint Jacques spoke to Dr. Fowler MD, MS…….Medscape’s Alfred Saint Jacques spoke to Dr. Fowler MD, MS, assistant professor at the University of Toronto and associate scientist at the Department of Critical Care Medicine and General Internal Medicine at Sunnybrook and Women’s College Health Science Centre in Toronto, Ontario, to get an update on the SARS situation. Steven Shadowitz, MD, from the Department of Medicine, Division of General Internal Medicine, Sunnybrook and Women’s College Health Sciences Centre, contributed to the information in this interview. Medscape: Can you give me an update on the two SARS patients that we discussed in our last interview two weeks ago? Dr. Fowler: The one patient who had been discharged from the ICU to a negative-pressure isolation room has now been discharged from the hospital. The other patient who was placed in the ICU is still critically ill and remains in our ICU intubated and ventilated. Another patient was recently admitted. So, currently, we have two patients in our ICU. Medscape: How has the situation with SARS changed at your institution and in the greater Toronto area since we last spoke? Dr. Fowler: As of April 1, 2003, there have been more than 150 probable or suspected cases within Canada. Ontario is reporting 56 probable and 68 suspect cases. British Columbia is reporting 2 probable and 12 suspect cases. New Brunswick is reporting 1 suspect case. Saskatchewan is reporting 1 suspect case. Alberta is reporting 7 suspect cases. Prince Edward Island is reporting 4 suspect cases. To date, there have been 6 deaths. These numbers are clearly still rising. At our hospital, we have created a ward of negative pressure rooms to accommodate the increased burden of illness. We are currently treating anywhere between 15 to 20 patients and many of our SARS patients are healthcare workers from other institutions. Medscape: You mentioned healthcare workers among those new patients. How many of the total patient load in your area are healthcare workers? How did they get infected? Are any from your institution? Dr. Fowler: Many of the infected healthcare workers cared for patients at the onset of the outbreak, before there was a true appreciation of the illness, and before full precautions were taken. There are a significant number of healthcare workers comprising the total number of patients currently being treated. Fortunately, at our center we have been able to maintain excellent compliance with infection precautions and our own healthcare workers have been less affected than at some hospitals involved in the care of the first couple of cases. Medscape: What diagnostics are being used in addition to the case definition that you mentioned in our last discussion? Dr. Fowler: As you recall from our last discussion, our suspect case definition is the presence of symptoms including fever greater than 38 degrees Celcius or respiratory symptoms including cough or shortness of breath and a compatible travel history (Hong Kong; Guangdong Province, China; Hanoi, Vietnam; or Singapore) or contact exposure, including potential contact at specific Toronto hospitals. Probable cases are those meeting the suspect case definition together with severe progressive respiratory illness suggestive of atypical pneumonia or acute respiratory distress syndrome with no known cause. Beyond the appropriate triage of patents to care areas, the investigations and laboratory tests that we have been routinely ordering include a chest x-ray, documentation of oxygen saturation, CBC and differential, PTT, INR, electrolytes, creatinine, liver function tests, LDH, CPK, calcium, albumin, two sets of blood cultures, sputum for routine C&S, a beta HCG if of child-bearing age in women, and in addition throat swab in viral transport media, nasal pharyngeal swab and aspirate, and serology to be sent to our local public health lab. Medscape: What is the current treatment protocol that you are using? How has it changed from what you were doing before? Dr. Fowler: Our treatment regimen has been simplified as we think we are learning more about SARS. The treatment protocol consists of a combination of antibacterial and antiviral medications. The antiviral medication is intravenous ribavirin at 2 g IV loading dose and 1 g IV everu 6 hours for 4 days. Then 0.5 g IV every 8 hours for 6 days with the option to change to oral ribavirin depending on the patient’s clinical condition. Antibacterials include levofloxacin 500 mg orally or IV once daily or a combination of ceftriaxone 1 g IV daily and azithromycin 500 mg orally or IV once daily. Medscape: Since we last spoke two weeks ago, how have precautions for healthcare professionals in your area changed? Dr. Fowler: The precautions have become more stringent to the point where everyone on staff is required to wear protective gowns, gloves, and masks. Nonessential personnel, volunteers, and even medical students have been sent home; and physicians, nurses, and other healthcare staff members are working longer hours because they are being assigned shifts to look after patients. In addition, interhospital travel of staff and patients is now prohibited. Medscape: I noticed that when I called you, there was a message on the phone that warned people about the SARS alert at your institution. Could you comment on that? Dr. Fowler: The local, provincial, and national coordinators have been very helpful in providing multiple daily updates, and we are attempting to do the same for the public and staff of the hospital. This is an extremely serious world outbreak and it’s clearly not over yet. However, it is important to add that the overwhelming majority of our cases are stable, not critically ill, and are going home after a one-week hospital stay. (Source: Medscape; 1 april 2003; Alfred J. Saint Jacques, MBA; Reviewed by Gary D. Vogin, MD)