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New flu guidelines emphasize testing, treatment of high-risk patients
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New clinical practice guidelines from the Infectious Diseases Society of America emphasize the need to test and promptly treat patients at high risk for seasonal influenza-related complications, including pregnant women, young children, patients who are extremely obese and those who have a weakened immune system.
The guidelines, which update those issued in 2009 before the H1N1 influenza pandemic, were published today in Clinical Infectious Diseases.
“Influenza can be serious, especially for the sizable group of people at high risk,” Timothy M. Uyeki, MD, MPH, MPP, co-chair of the guidelines committee and chief medical officer in the CDC’s Influenza Division, said in a statement. “Annual influenza vaccination is the best way to prevent influenza, but it is not 100% effective. Those at high risk need to be encouraged to seek medical care right away if they develop influenza symptoms during influenza season.”
The IDSA noted some of the key recommendations:
- Patients at high risk for influenza-related complications should be tested and begin antiviral treatment promptly if they are sick enough to be hospitalized with influenza symptoms.
- Any outpatients with a diagnosis of influenza who are at high risk for complications should receive antiviral treatment as soon as possible.
- Newer and highly accurate molecular tests — such as nucleic acid amplification tests — should be used instead of rapid-influenza diagnostic tests, which often produce false-negative results.
- Antivirals should be prescribed to patients at high risk for influenza-related complications even if they have been sick for more than 2 days.
- Patients at high risk for influenza-related complications who are being admitted to the hospital with suspected influenza should be started immediately on antiviral treatment without waiting for the results of molecular testing.
- Providers caring for patients at high risk for complications who have become seriously ill with influenza should consult with an infectious disease physician.
“High-risk individuals who are hospitalized with flu complications are at an increased risk for serious bacterial infections and infectious diseases physicians’ expertise is critical to ensuring they receive the best care,” Andrew T. Pavia, MD, co-chair of the guidelines committee and chief of the division of pediatric infectious diseases at the University of Utah, said in a statement. “ID doctors also can provide guidance when a patient who has the flu is not responding to antiviral treatment or is getting worse.”
The guidelines were finalized before the FDA approved baloxavir marboxil (Xofluza, Genentech) in October and do not include recommendations on its use, the authors noted.
Baloxavir marboxil is the first new antiviral influenza treatment with a novel mechanism of action approved by the FDA in almost 20 years. Phase 3 data showed that it reduces the duration of influenza symptoms by more than 1 day and is similarly effective compared with oseltamivir. It also has demonstrated efficacy against a wide range of influenza viruses, including those resistant to oseltamivir and avian influenza strains H7N9 and H5N1, in nonclinical studies.
The current influenza season has been mild in comparison to the 2017-2018 season, in which an estimated 900,000 people were hospitalized and 80,000 died from influenza.
Reference:
Uyeki TM, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy866.
Disclosures: Pavia reports receiving grants from the National Institute of Allergy and Infectious Diseases (NIAID)/NIH, NIAID/Biofire, and the CDC, other support from Antimicrobial Therapy Inc., and personal fees from WebMD and Johnson & Johnson, outside the submitted work. Ueki reports no relevant financial disclosures. Please see the guidelines for a list of all other authors’ relevant financial disclosures.
Perspective
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Amesh A. Adalja, MD
The new guidance reinforces what people have learned about flu over the last several years. I would say the biggest recommendation that should be taken into consideration by all physicians is the delineation of the benefits of antiviral therapy for those who are at risk for flu complications, including pregnant women, patients with obesity, and those with underlying medical conditions. In the past, many people really have been wedded to this 48-hour window for antiviral therapy, and that is really not extrapolatable to people who are at high risk for flu complications. We know that during the pandemic, people probably died because they did not get antiviral therapy. I think that is the most important recommendation.
The guideline authors also call out the importance of molecular diagnostic tests to diagnose influenza. Many hospitals and clinics are still using rapid antigen tests, which are not very sensitive and miss sometimes 30% to 50% of infections. People are relying on those tests to rule out flu, they are missing a lot of cases, and many people will miss out on antiviral therapy because they have a false-negative. Additionally, providers may give patients antibiotics, which are not warranted. So, using molecular tests should really be the standard of care, and I think the guidelines help to push that forward.
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