h1n1 treatment guidelines

Decisions on whether to widen antiviral chemoprophylaxis should consider the potential for influenza virus transmission between different wards and buildings of the facility and balance the risk of complications associated with additional cases of influenza in residents against the cost and adverse consequences of antiviral chemoprophylaxis. Virologic testing in patients with a prolonged clinical course may help guide duration of antiviral treatment. For more information about this message, please visit this page: CDC 24/7: Saving Lives. Novel H1N1 Influenza Practice Assessment School Nurses: On the Frontline in the Battle Against Influenza Ethical Dilemmas for Healthcare Professionals: Can We Avoid Influenza? Although no other factors have been demonstrated to be associated with the risk of outbreaks, biological plausibility and expert opinion suggest that volume and patterns of air flow, degree of crowding in rooms or public areas, the effectiveness of policies excluding ill visitors and ill staff, and the ability to reduce interresident and staff contact in response to a single identified influenza case may all influence whether introduction of a single case of influenza will result in an outbreak [430]. Facility medical directors should consider consultation from public health experts. The panel had 4 face-to-face meetings and conducted teleconferences over 5 years. Consultation should be sought with an expert on management of patients with antiviral-resistant influenza virus infection. Active daily surveillance for new influenza cases, with influenza testing for suspected cases, should be enhanced throughout the entire facility as soon as an outbreak is declared on any one ward. At annual intervals, the SPGC will determine the need for revisions to the guideline based on an examination of current literature evidence and the likelihood that any new data will have an impact on the recommendations. This may also be appropriate if >48 hours has elapsed since exposure, as the patient may already have infection established, warranting full-dose therapy. What test(s) should be used to diagnose influenza? Most of the available clinical data from patients with resistant virus infections that emerged during treatment are derived from case reports and case series in which patients on oseltamivir treatment were switched to other antivirals often late in the clinical course of their illness [285, 286, 340, 349353]. Duration of therapy with oseltamivir and zanamivir for ambulatory adults with uncomplicated influenza is 5 days. If influenza testing of high-risk outpatients with suspected influenza to confirm influenza is not feasible, or if testing will not change clinical management decisions, a clinical diagnosis of influenza without testing can support empiric antiviral treatment decisions. Which healthcare personnel should receive antiviral chemoprophylaxis during an institutional outbreak? Guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza Ref: UKHSA publication gateway number: GOV-10342 PDF, 608 KB, 42 pages This file may not be suitable. A recent modeling study estimated a range of 291243645832 seasonal influenzaassociated respiratory deaths occurring annually worldwide [10]. In the first situation, the patient will not respond to appropriate therapy, and in the second, clinical deterioration may occur following an initial response. Influenza vaccine effectiveness varies by age, host immune status, and the match between circulating and vaccine virus strains [24]. Some investigators have attributed the majority of deaths during the 1918 H1N1 pandemic to bacterial coinfection [307]. Rebound in influenza viral replication has been observed in some patients treated for 5 days, and longer duration of treatment is advisable if the disease course is severe and influenza viral RNA remains detectable. Influenza refers to symptomatic illness caused by seasonal influenza A or B virus infection. XIX. Two antiviral drugs are recommended for treating swine flu: the oral drugs oseltamivir. Brucellosis is a bacterial disease caused by various Brucella species, which mainly infect cattle, swine, goats, sheep and dogs. Other studies reported higher sensitivities for detection of influenza A(H3N2) than for A(H1N1)pdm09 and influenza B viruses compared with RT-PCR [113, 114]. The symptoms of 2009 H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Swine flu (H1N1) is a respiratory infection in humans. The disclosures were used to categorize the panelists as (i) cleared for full participation, (ii) allowed to participate with recusal from certain aspects of guidelines development, or (iii) disqualified from participation. Which asymptomatic persons exposed to influenza should be considered for postexposure antiviral chemoprophylaxis in a noninstitutional setting? Influenza viral RNA or infectious virus has rarely been detected in stool, and such detection is of unknown clinical importance [38, 173175]; therefore, testing of stool for influenza viruses is not recommended. Oseltamivir is also preferred over IV peramivir because of the dearth of pharmacokinetic or safety data for peramivir in pregnant women [222]. Seasonal A (H1N1) refers to the human influenza A (H1N1) viruses that were circulating prior to the introduction of pandemic influenza A(H1N1) 2009 virus and which continued to circulate during 2009. These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009 [17], just prior to the recognition of the emergence of influenza A(H1N1) pdm09 virus as the cause of the 2009 H1N1 pandemic. Pada akhir Mac dan awal April tahun 2009, wabak jangkitan virus novel Influenza A H1N1 dikesan di Mexico. Based on seasonal influenza virus susceptibility patterns observed through virologic surveillance from 2009 through 2017, the use of an NAI is recommendedeither oral oseltamivir, inhaled zanamivir, or intravenous (IV) peramivir for early treatment of uncomplicated influenza in pediatric and adult patients. Pediatrics. AskMayoExpert. These factors should be considered when judging whether a single confirmed influenza case represents the beginning of an outbreak. We use cookies to ensure that we give you the best experience on our website. Guidance for the diagnosis and treatment of bacterial infection among several special populations is available, including guidance for the management of neonatal bacterial sepsis [320], sepsis among pregnant woman, infections among solid organ transplant recipients [321], and patients with human immunodeficiency virus infection (see guidelines for prevention and treatment of opportunistic infections: https://aidsinfo.nih.gov). The new guidance appears to be aimed at preventing the inadvertent prescription of oseltamivir (Tamiflu) for seasonal H1N1 infections, which have shown extensive resistance to oseltamivir in the United States and other parts of the world. The development of oseltamivir resistance during chemoprophylaxis has been reported, usually with the H275Y mutation, with limited ongoing transmission of resistant virus [96, 336, 358, 406]. A meta-analysis of RCTs of inhaled zanamivir treatment reported no evidence of an increase in reported adverse events vs placebo in children or adults [259]. The analyses were completed in parallel with drafting of updated recommendations. NAI resistance remains relatively uncommon in currently circulating influenza virus strains. One RCT reported that combination oral therapy with oseltamivir, amantadine, and ribavirin resulted in a significant but modest reduction in influenza viral shedding at treatment day 3, but was not associated with significant reduction in multiple clinical endpoints compared with oseltamivir monotherapy in adult outpatients with laboratory-confirmed influenza [253]. Molecular techniques for influenza diagnosis continue to advance; additional and updated information is available at the CDCs influenza website (http://www.cdc.gov/flu/professionals/diagnosis/index.htm). Results are available within 24 hours after specimen submission. Development of complications should also be considered in patients with clinical deterioration (Table 9). The care of specific patient populations is addressed, including children, pregnant and postpartum women, and persons who are severely immunocompromised such as hematopoietic stem cell and solid organ transplant recipients. NAI resistance can vary among influenza viruses and the specific NAI being used. There is no need to discontinue breastfeeding due to the use of oral oseltamivir. Early antiviral treatment of influenza can reduce the risk of otitis media in young children and the need for antibiotic therapy for lower respiratory tract complications [189, 191, 194]. Documented increased morbidity and mortality of influenza in newborn and very young infants should be balanced by the anticipated benefits of therapy given the available limited pharmacokinetics and safety data in this very young population [6]. Immunofluorescence assays require laboratory expertise and a fluorescent microscope, and take longer to produce results than RIDTs, rapid molecular assays, and some RT-PCR assays, but have generally better sensitivity and specificity than RIDTs [185, 186]. Antiviral drugs are sometimes prescribed within the first day or two of symptoms. An open-label multicenter RCT of convalescent or postimmunization plasma (containing variable concentrations of hemagglutinin inhibition antibodies) treatment plus standard care vs standard care alone in hospitalized children and adults with laboratory-confirmed influenza did not find significant clinical benefit or antiviral effects, but convalescent plasma was well-tolerated, and a phase 3 trial is under way [380]. Tosh PK (expert opinion). The guideline also does not provide specific recommendations for the supportive clinical management of critical illness resulting from complications of influenza virus infection. 1 Epidemiology of seasonal influenza [295 KB] 2 Guidelines for patient categorization [450 KB] 3 Guidelines for Providing Home Care [283 KB] 4 Guidelines on use of masks [277 KB] 5 Guidelines for clinical protocol [397 KB] 6 Guidelines for Sample Collection [606 KB] 7 Guidelines for . Antiviral resistance is discussed in the next section. These usually include hematological, microbiological, biochemical and radiologic tests. Patients with significant hypoxemia who are not receiving mechanical ventilation may not be able to reliably use the disk inhaler device needed to effectively deliver inhaled zanamivir. In a cluster randomized trial over 3 seasons in Australia comparing oseltamivir treatment of symptomatic persons and provision of oseltamivir chemoprophylaxis for elderly long-term care residents and staff, researchers found that chemoprophylaxis reduced the influenza attack rate among residents compared with treatment of symptomatic persons [407]. For example, pneumonitis has been reported with multiple immunosuppressive drugs, including in patients receiving mammalian target of rapamycin (mTOR) inhibitors such as sirolimus or everolimus [330, 331]. The searches focused on human studies and, while not an exhaustive list, included such search terms as influenza or influenza and virus, influenza and infection, influenza and treatment, influenza and prophylaxis, influenza and chemoprophylaxis, and influenza and outbreak. A subsequent literature search was developed and updated through July 2017. Flu symptoms may vary from person to person. These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009 [17]. antiviral agents for H1N1 influenza 09, drawing on studies of seasonal and H5N1 (avian) influenza, emerging data on H1N1 Recommendations for use of antiviral treatment for influenza: The Medical influenza . A self-controlled case series study in Japan could not exclude the possibility that severe abnormal behavior was induced by influenza [258]. While H3N2 is responsible for the . RT-PCR can be useful as a confirmatory test and identify influenza virus types and influenza A virus subtypes. However, the risk for developing NAI antiviral resistance is low except in severely immunocompromised persons, who can have prolonged and asymptomatic influenza virus replication [134]. Risks and benefits may differ between specific antiviral agents for various patient populations based on age, underlying medical conditions, immune function, severity of illness, and different influenza virus strains. It's called swine flu because it's similar to a flu virus that affects pigs (swine). If antiviral chemoprophylaxis is given to close contacts of high-risk persons while awaiting an immune response to influenza vaccination, it should be continued for 2 weeks after vaccination until an immune response is expected (6 weeks for children aged 6 months to <9 years not previously vaccinated and who require 2 doses). Therefore, single serum or paired sera specimens should not be collected for influenza serology except for research purposes. X. While the abrupt onset of fever with cough is a good indicator of influenza, signs and symptoms may vary for patients with different underlying conditions. Some experts have suggested consideration of higher oseltamivir dosing. The document outlines an operational approach aimed at providing health professionals working in a hospital an indication on the key measures of hygiene prophylaxis, general and influenza-specific, and the first approach to be taken in order to diagnosis and treatment of a flu syndrome (at potential pandemic spread) caused by a new virus strain, There are no data to support the safety or efficacy of antibiotic chemoprophylaxis to prevent bacterial complications in patients with influenza. In this situation, antiviral treatment dosing should be continued for a full treatment course (twice daily) for 5 days before reducing to the recommended chemoprophylaxis dosing (once daily) until the outbreak is declared over. Fever (38C), headache, cough, and absence of abnormal breathing sounds in pediatric patients had a positive predictive value of 57.1% [29]. Multiplex respiratory pathogen panels range from narrow, targeting influenza A and B viral and RSV RNA, to broad, targeting more than a dozen respiratory viruses and other pathogens in respiratory specimens. Interpretation of test results relies on the positive and negative predictive values of a test, which are influenced primarily by the prevalence of influenza viruses in the population tested and on the sensitivity and specificity of the test to detect influenza virus infection vs a gold standard test such as RT-PCR assay results [108, 109]. Effective isolation and control of outbreaks can be challenging and may require different strategies. Are immunosuppressed due to certain medications or HIV. Baloxavir significantly reduced systemic antibiotic use and influenza-related complications compared with placebo [460]. Antiviral chemoprophylaxis (once daily) rather than treatment dosing (twice daily) given to persons with asymptomatic influenza virus infection might theoretically increase the risk of selection for antiviral-resistant influenza viruses. While current evidence is limited, corticosteroid treatment of influenza patients should be avoided unless clinically indicated for other reasons (eg, exacerbation of asthma, COPD, low-dose hydrocortisone for adrenal insufficiency or refractory septic shock), as the risks of corticosteroid treatment are not balanced by a documented clinical benefit in the treatment of influenza [361]. However, an individual patient data meta-analysis of >3000 outpatients at high risk for complications with laboratory-confirmed influenza reported that NAI treatment significantly reduced the likelihood of hospital admission [201]. The decision to use antiviral chemoprophylaxis must balance the knowledge of the prevalence of antiviral resistance among circulating influenza viruses (see http://www.cdc.gov/flu/professionals/index.htm), risk of emergence of resistance, risk of severe complications of influenza, the potential for side effects, and the ability to initiate early therapy for influenza. Accessed Nov. 26, 2018. There are no published randomized controlled clinical trials of antiviral treatment of influenza in geriatric populations. Use of an analyzer device for rapid influenza diagnostic tests to detect influenza viral antigens (immunoassay or immunofluorescence assay) had moderately high pooled sensitivity (80% and 77%) compared with RT-PCR [111]. Severe influenza treatment guidelines for Korea also indicate that systemic corticosteroid administration should not be performed for the treatment of severe influenza patients unless the therapeutic effect has already been proven . The guidelines consider the care of children, pregnant and postpartum women, and nonpregnant adults and include special considerations for patients who are severely immunocompromised such as hematopoietic stem cell and solid organ transplant recipients. Reaffirmed July 2016. Background information about signs and symptoms of influenza, complications, groups considered to be at high risk of complications, and influenza tests are included in the next section. A wide range of influenza tests is available for diagnostic purposes: Additional tests are available and may have utility under certain circumstances (eg, institutional outbreaks), but are generally not useful for clinical diagnostic purposes. Several RCTs of antiviral chemoprophylaxis have been conducted among long-term care residents. 5. Clinicians should maintain familiarity with local patterns of influenza activity in their communities throughout influenza season. Since some elderly individuals may not be able to correctly use the inhaler device to effectively deliver zanamivir, caution should be used in prescribing inhaled zanamivir in patients with cognitive or physical limitations [267]. Accessed Nov. 27, 2018. One older randomized trial conducted during 19911995 reported that antiviral chemoprophylaxis with amantadine or rimantadine for 14 days (and for 7 days after the last confirmed influenza case) was sufficient to control influenza A outbreaks compared to 21 days (and for 7 days after the last confirmed influenza case) [454]. INTRODUCTION. Currently, only testing for the H275Y marker in A(H1N1)pdm09 viruses is available commercially. However, any hospitalized patient may be in the incubation period for influenza virus infection when admitted and become symptomatic during the first few days of hospitalization for other illnesses or injuries. Cookies facilitate the functioning of this site including a member login and personalized experience. Following infection, influenza virus strain-specific antiviral activity is present in convalescent plasma of immunocompetent persons. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Clinicians should consider novel influenza A virus infection in the differential diagnosis in travelers who have recently returned from countries affected by poultry outbreaks of avian influenza and who have febrile respiratory symptoms and a recent history of direct or close exposure to poultry (well-appearing, sick or dead birds, or visiting a live poultry market [103, 104]). One pertinent difference to note is the challenge associated with identifying whether cases of influenza with onset within 7296 hours of hospital admission are acquired in the hospital vs community acquired with onset after admission, because the incubation period for influenza ranges from 1 to 4 days. Pediatrics. V. For patients who are recommended to receive antiviral treatment for suspected or confirmed influenza, which antiviral should be prescribed, at what dosing, and for what duration? A large autopsy series of 100 fatal cases found no evidence of extrapulmonary influenza A(H1N1) pdm09 virus infection [167]. Based on pharmacokinetic modeling, a 30% dose increase of oseltamivir phosphate was estimated to be needed to attain comparable systemic exposure of oseltamivir carboxylate to nonpregnant women (105 mg once daily for prophylaxis and 105 mg twice daily for treatment) [270]. The guidelines also address diagnostic testing and use of antivirals for management of institutional influenza outbreaks. Centers for Disease Control and Prevention. Currently, circulation of NAI-resistant influenza viruses is rare, although limited community circulation of oseltamivir-resistant A(H1N1)pdm09 viruses has been reported in several countries [358360]. Mortality at 60 days was higher in patients who received corticosteroids compared with those who did not (aHR, 1.98; 95% CI, 1.033.79; P = .04). Also, a surface test method, which involved drying an amount of virus on a surface and then applying the inactivation methods for 1 minute of contact time, was used to determine the virucidal activity. While most of the cases are due to H3N2, data shows that swine flu and covid cases are also rising in the country. There are multiple assays approved by the FDA. One meta-analysis of data from patients with acute respiratory infections enrolled in 26 RCTs reported that procalcitonin-guided antibiotic treatment reduced 30-day mortality, antibiotic exposures, and antibiotic-related adverse effects [327]. The risk of influenza-associated complications is not identical among all high-risk persons, and antiviral chemoprophylaxis is likely to have the greatest benefit among those at highest risk of influenza complications and death, particularly if influenza vaccination is contraindicated or not expected to be effective (eg, severely immunocompromised persons). The decision to test is related to the level of suspicion for influenza, local influenza activity, and the sensitivity and specificity of available influenza tests. Once placed in rooms, patients with suspected or confirmed 2009 H1N1 influenza should be encouraged to practice respiratory hygiene and cough etiquette when they are coughing or sneezing throughout their duration of stay. RT-PCR assays, whether real-time or multiplex, are highly sensitive and highly specific nucleic acid amplification tests for detection of influenza viral RNA. Treatment of hospitalized patients and patients at higher risk for influenza. Respiratory viral infection, including influenza virus infection, can be difficult to distinguish from bacterial infection. Supportive care such as drinking liquids, taking pain relievers for fever and headache, and resting may be helpful. The lower systemic exposure might also compromise the effectiveness of once-daily oseltamivir chemoprophylaxis. He or she may use various tests to diagnose influenza. The relevant study population to assess clinical benefit of NAI treatment is patients with laboratory-confirmed influenza (intention-to-treat-infected). Use of a respiratory viral panel test for children admitted to the hospital with an acute respiratory tract illness resulted in shorter time to diagnosis, duration of antibiotic use, and length of inpatient stay [141]. Seasonal influenza is characterized by a sudden onset of fever, cough (usually dry), headache, muscle and joint pain, severe malaise (feeling unwell), sore throat and a runny nose. Where necessary, screening of retrieved articles was conducted in duplicate and independently. During 20102018, seasonal influenza epidemics were associated with an estimated 4.323 million medical visits, 140 000960 000 hospitalizations, and 1200079 000 respiratory and circulatory deaths each year in the United States [9]. Comparative prospective, controlled data on outcomes with different antiviral agents do not exist for most of these risk groups and conditions. Higher sensitivity to detect influenza viruses in respiratory specimens has been reported for one rapid molecular assay (isothermal nucleic acid amplification) than for rapid antigen detection tests [117119], and a meta-analysis of rapid molecular assays reported pooled sensitivities of 92% and 95% for detection of influenza A and B viruses, respectively, and pooled specificities of 99% [111]. Data from a prospective surveillance study indicated that in patients aged 65 years hospitalized with acute cardiopulmonary illnesses, the clinical symptoms of cough and/or sore throat combined with a lowered oral temperature threshold (37.3C or 99.0F) increased sensitivity and specificity of influenza diagnosis [76]. Influenza vaccination is the primary tool to prevent influenza. Antiviral treatment of influenza with any licensed, recommended, age-appropriate influenza antiviral medication is recommended for children with suspected or confirmed influenza who are hospitalized, have severe or progressive disease, or have underlying conditions that increase their risk of complications of influenza. Mayo Clinic is a not-for-profit organization. To reduce the risk of subtherapeutic dosing if influenza virus infection has occurred following exposure, antiviral treatment (twice-daily dosing) rather than once-daily chemoprophylaxis dosing has been recommended by some experts, particularly in immunocompromised patients, when postexposure antiviral chemoprophylaxis is indicated. Another study reported that while the proportion of hospitalized influenza patients who received antiviral treatment increased during 20102011 to 20142015, the percentage was higher in adults than children, and only 56% were treated on the day of admission [214]. This content does not have an English version. Renaud DL (expert opinion). Influenza NAI resistance testing can be considered for: Patients who develop laboratory-confirmed influenza while on or immediately after NAI chemoprophylaxis, Patients with an immunocompromising condition and evidence of persistent influenza viral replication (eg, after 710 days, demonstrated by persistently positive RT-PCR or viral culture results) and remain ill during or after NAI treatment, Patients with laboratory-confirmed influenza who inadvertently received subtherapeutic NAI dosing, Patients with severe influenza who do not improve with NAI treatment and have evidence of persistent influenza viral replication (eg, after 710 days), Clinicians should remain informed on current CDC and World Health Organization surveillance data on the frequency and geographic distribution of NAI-resistant influenza viruses during influenza season, and with the latest CDC antiviral treatment recommendations, Clinicians should not administer corticosteroid adjunctive therapy for the treatment of adults or children with suspected or confirmed seasonal influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons, Clinicians should not routinely administer immunomodulation using immunoglobulin preparations such as intravenous immunoglobulin for treatment of adults or children with suspected or confirmed seasonal influenza, Clinicians can consider antiviral chemoprophylaxis for the duration of the influenza season for adults and children aged 3 months who are at very high risk of developing complications from influenza and for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness (eg, persons who are severely immunocompromised), Clinicians can consider antiviral chemoprophylaxis for the duration of the influenza season for adults and children aged 3 months who have the highest risk of influenza-associated complications, such as recipients of hematopoietic stem cell transplant in the first 612 months posttransplant and lung transplant recipients, Clinicians can consider short-term antiviral chemoprophylaxis in conjunction with prompt administration of inactivated influenza vaccine for unvaccinated adults and children aged 3 months who are at high risk of developing complications from influenza in whom influenza vaccination is expected to be effective (but not yet administered) when influenza activity has been detected in the community, Clinicians can consider short-term antiviral chemoprophylaxis for unvaccinated adults, including healthcare personnel, and for children aged 3 months who are in close contact with persons at high risk of developing influenza complications during periods of influenza activity when influenza vaccination is contraindicated or unavailable and these high-risk persons are unable to take antiviral chemoprophylaxis, Clinicians can consider educating patients and parents of patients to arrange for early empiric initiation of antiviral treatment as an alternative to antiviral chemoprophylaxis, Clinicians should use an NAI (oral oseltamivir or inhaled zanamivir) if preexposure chemoprophylaxis for influenza is administered rather than an adamantane antiviral, Clinicians should administer preexposure antiviral chemoprophylaxis for adults and children aged 3 months who are at very high risk of developing complications from influenza (eg, severely immunocompromised persons such as hematopoietic stem cell transplant recipients) for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness, as soon as influenza activity is detected in the community and continued for the duration of community influenza activity, Clinicians should test for influenza and switch to antiviral treatment dosing in persons receiving preexposure antiviral chemoprophylaxis who become symptomatic, preferably with an antiviral drug with a different resistance profile if not contraindicated, Clinicians can consider postexposure antiviral chemoprophylaxis for asymptomatic adults and children aged 3 months who are at very high risk of developing complications from influenza (eg, severely immunocompromised persons) and for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness, after household exposure to influenza, Clinicians can consider postexposure antiviral chemoprophylaxis (in conjunction with influenza vaccination) for adults and children aged 3 months who are unvaccinated and are household contacts of a person at very high risk of complications from influenza (eg, severely immunocompromised persons), after exposure to influenza, Clinicians can consider educating patients and arranging for early empiric initiation of antiviral treatment as an alternative to postexposure antiviral chemoprophylaxis, If chemoprophylaxis is given, clinicians should administer postexposure antiviral chemoprophylaxis as soon as possible after exposure, ideally no later than 48 hours after exposure, Clinicians should not administer once-daily postexposure antiviral chemoprophylaxis if >48 hours has elapsed since exposure. 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