Treatment with antivirals, antibiotics reduces respiratory hospitalization risk in patients with flu
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Patients prescribed antivirals and antibiotics during treatment for influenza have a lower risk for 30-day hospitalization compared with patients given antivirals alone, according to findings published in Clinical Infectious Diseases.
In addition, patients with influenza who received both an antiviral and an antibiotic had a decreased risk for respiratory hospitalizations within 30 days compared with those patients who only received an antiviral.
“Morbidity and mortality associated with influenza have increased in the last 2 decades, in part because of the aging population, underscoring the need for enhanced treatment,” S. Scott Sutton, PharmD, professor and chair of the department of clinical pharmacy and outcome sciences at the University of South Carolina College of Pharmacy, and colleagues wrote. “Although the use of antivirals is associated with fewer hospitalizations and complications, clinicians may prescribe an antibiotic to patients they perceive as high risk for bacterial complications. In the absence of an evident superinfection, antibiotics are not recommended for the management of influenza. However, a significant portion of influenza morbidity and mortality is related to bacterial coinfections.”
Sutton and colleagues performed a retrospective cohort study of patients with confirmed influenza who had health care encounters between January 2011 and January 2019 using data from the VA Informatics and Computing Infrastructure. Inpatient hospitalizations (all-cause and respiratory) within 30 days of influenza diagnosis were compared between four cohorts — no treatment, antibiotics only, antivirals only and antibiotics and antivirals together.
Sutton and colleagues examined data from 12,806 patients with influenza. Most patients received either only an antiviral (n = 6,492) or no treatment (n = 4,228); the remaining patients received either an antibiotic and an antiviral (n = 1,415) or only an antibiotic (n = 671).
Patients who were treated with antivirals only, antibiotics and antivirals together and antibiotics only all had a statistically significant lower risk of all-cause and respiratory hospitalization compared with those who were not treated. When comparing the antibiotic and antiviral cohort with those who were prescribed an antiviral alone, there was a 47% lower risk for respiratory hospitalization (RR = 0.53, 95% CI, 0.31-0.94). No other statistical differences were identified.
“The results of our primary and sub-analysis demonstrate that there is a role for combination antibiotic and antiviral therapy in select patients with confirmed influenza. We are not recommending systematic use of combination treatment and the results should not drive a change in practice for influenza at this time,” Sutton and colleagues wrote. “However, we feel that the results demonstrate a potential role for combination therapy in select patients with documented influenza.”
They added: “We hope our data can guide the needed future studies that will identify the patients that would benefit the most from this intervention.”
In an accompanying commentary, Michael G. Ison, MD, MS, professor of medicine (infectious disease) and surgery (organ transplantation) at Northwestern University Feinberg School of Medicine, and Jeffrey A Linder, MD, MPH, FACP, associate physician in the department of medicine – general medicine at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, proposed a question about whether or not, based on the results of the study by Sutton and colleagues, patients with influenza should be given early antibiotics and said that, for now, the answer is “no.” They added, however, that further studies are needed.
“Antibiotics only appeared beneficial for a subset of hospitalizations and the absolute differences were very small,” they wrote. “Of course, this was an observational study and unmeasured confounding, including confounding by indication, is always a possibility.”
According to Ison and Linder, patient behavior could also impact the findings if, for example, patients who received antibiotics and antivirals already thought they received maximal treatment and they therefore did not seek further care.
“Clinicians are comfortable prescribing antibiotics, but not antivirals, for patients likely to have influenza,” they concluded. “Approaches that result in the ‘right’ [patients with influenza] getting antivirals should decrease antibiotic use, which should improve outcomes and minimize harms, such as antimicrobial resistance and Clostridioides difficile colitis.” – by Caitlyn Stulpin
Disclosures: Ison reports serving as a paid member of a data and safety monitoring board for Janssen, Merck and Vitaeris; receiving personal consulting fees from AlloVir, Celltrion, Genentech/Roche, Janssen, Shionogi, Viracor Eurofins and VirBio; and receiving payments to Northwestern University by AiCuris, Emergent BioScience, Genentech/Roche, Hologic, Janssen and Shire for research. Linder and Sutton report no relevant financial disclosures.
(Editor’s note: This story was updated on Feb. 4, 2020, to include information from the accompanying commentary.)
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