How long should postexposure antiviral chemoprophylaxis be given? VII. Observational studies have described the use of antiviral chemoprophylaxis of staff in addition to exposed residents [450452], and some randomized controlled trials for antiviral chemoprophylaxis of residents also offered chemoprophylaxis to staff [409, 430]. Use of antiviral chemoprophylaxis might be considered along with other control measures for influenza outbreaks in other institutional settings among persons generally not at high risk for complications from influenza, such as in dormitories at boarding schools, universities, and summer camps. The purpose of this guidelines recommendations is to provide clinicians with evidence-based recommendations for the diagnosis and treatment of seasonal influenza, including use of commercially available influenza diagnostic tests, use of approved antiviral agents for treatment and chemoprophylaxis of influenza, and use of antibiotics or other adjunctive measures for treatment of complications associated with influenza. Pediatrics. Panelists were required to disclose to the IDSA and the chairs any new activities that had the potential to be viewed as a COI prior to engaging in the activity. Finding influenza virus transmission on a second ward should prompt consideration of facility-wide antiviral chemoprophylaxis, as considerable experience by subject matter experts in this scenario has demonstrated eventual emergence of further influenza virus transmission to multiple units within the facility when implementation of facility-wide antiviral chemoprophylaxis is not implemented. Ascertainment of influenza symptoms may be challenging in residents or patients with developmental disabilities, with severe neurologic impairment or dementia, or who are nonverbal. Compared with other types of tests (eg, RT-PCR), RIDTs are significantly less sensitive than other methods (false-negative results are not uncommon). I. Feedback was obtained from external peer reviewers. Virologic testing in patients with a prolonged clinical course may help guide duration of antiviral treatment. Antiviral chemoprophylaxis can also be offered to unvaccinated staff with vaccine contraindications and to immunocompromised staff (who are expected to have poor immune response to vaccination) for the duration of an institutional outbreak. Have a body mass index above 40, which is defined as morbid obesity. The high specificity among most influenza screening tests and molecular assays indicates that the frequency of false-positive results is generally very low, especially when influenza activity is high in the patient population tested. The adamantane influenza antiviral agents, with activity only against susceptible influenza A viruses, are not recommended for treatment of influenza A given documented high levels of adamantane resistance among circulating influenza A viruses in recent years [249, 250]. A meta-analysis of data from hospitalized patients with A(H1N1)pdm09 virus infection worldwide reported that pregnant and postpartum women treated with NAIs within 2 days of admission were 20% less likely to die compared to those treated later [16]. There are no data available that provide an estimate of how often a single identified laboratory-confirmed influenza case represents the start of an influenza outbreak. People may be infected with the flu, including 2009 H1N1 and have respiratory symptoms without a fever. Several respiratory syndromes can be associated with either bacterial or viral pathogen infections or coinfections, including community-acquired pneumonia, sinusitis, pharyngitis, and acute otitis media. Zanamivir is detectable at low concentrations in breastmilk of lactating women who received inhaled zanamivir [276]. 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. Systematic reviews and meta-analyses of RCTs indicate that early initiation (within 2 days of illness onset) of antiviral treatment can reduce the duration of fever and symptoms, especially in nonasthmatic children; decrease the risk of otitis media in children; and reduce the risk of lower respiratory tract complications requiring antibiotics and of hospitalization in adults [14, 194, 200]. 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. RT-PCR is a highly sensitive and highly specific testing modality for detection of influenza A and B viral RNA in respiratory specimens, though the results may take 46 hours or more once testing is started, and RT-PCR may not be available at all clinical sites. In the same study of laboratory-confirmed influenza patients, receiving a diagnosis of bacterial infection decreased the likelihood of an influenza diagnosis by 3-fold [33]. While risk of severe morbidity and mortality from influenza occurs throughout pregnancy, these risks are higher in the second and third trimesters [225227]. Annual vaccination is the best method for preventing or mitigating the impact of influenza, but in certain situations, chemoprophylaxis with antiviral medications can be used for preexposure or postexposure prevention and can help control outbreaks in certain populations. Clinicians should start antiviral treatment as soon as possible for adults and children with documented or suspected influenza, irrespective of influenza vaccination history, who meet the following criteria: Persons of any age who are hospitalized with influenza, regardless of illness duration prior to hospitalization, Outpatients of any age with severe or progressive illness, regardless of illness duration, Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients, Children younger than 2 years and adults 65 years, Pregnant women and those within 2 weeks postpartum. Outpatients (Including Emergency Department Patients). Accessed Jan. 12, 2021. These include: Respiratory droplets and aerosols. 'In India, viral illnesses caused by H3N2, COVID-19, and swine flu are on the rise. Because of the potential for exacerbation of reactive airway disease in influenza patients with COPD, asthma, or bronchospasm, noninhaled antiviral treatment may be safer in these individuals, although controlled studies are not available. 5. When the results of influenza molecular testing will not be available until the next day, outbreak control measures should be instituted when a single laboratory-confirmed case of influenza is accompanied by influenza activity in the community and by 2 or more other residents with symptoms compatible with influenza. Symptoms of swine flu in people are . Prolonged viral replication and shedding in the upper and lower respiratory tracts may occur in critically ill patients with influenza viral pneumonia [161, 299]. The scope of the guidelines pertains to diagnostic testing and treatment of illness caused by infection with influenza A and B viruses circulating among humans during seasonal epidemics and does not address asymptomatic infections. Greater clinical benefit was reported when NAI treatment was started very early; in both adults and children, NAI treatment started within 6 hours of illness onset reduced symptoms by about 4 days [26, 197, 207]. Content on this page was developed during the 2009-2010 H1N1 pandemic and has not been updated. Some people only get mildly ill. Others get very sick. The guidelines do not provide recommendations on diagnosis or treatment of human infections with novel influenza A viruses of animal origin following exposure to poultry or pigs (eg, avian influenza A viruses, or swine-origin [variant] viruses); current recommendations for IPC, specimen collection, diagnosis, and treatment of novel influenza A virus infections are available on the CDC website [19, 20]. If there is clinical suspicion of antiviral resistance as the cause of failure to improve or clinical deterioration, it is critical to consider a change in NAI treatment and to perform testing to confirm the presence of continued viral replication and to document resistance. Philadelphia, Pa.: Elsevier Limited; 2017. https://www.clinicalkey.com. Recommendations for prevention and control of influenza in children, 2017-2018. Antiviral treatment should be started as soon as possible for critically ill patients with suspected or laboratory-confirmed influenza. Influenza season refers to the surveillance period when influenza activity typically occurs, such as during October through May, in the United States. Supportive care such as drinking liquids, taking pain relievers for fever and headache, and resting may be helpful. 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. 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. Centers for Disease Control and Prevention. Novel influenza A virus infection should also be suspected in persons with febrile respiratory illness and a history of recent direct or close contact with pigs, such as at animal exhibits at agricultural fairs [106, 107]. Absolute risk reductions were modest. A study of extended (16 weeks) oral oseltamivir or inhaled zanamivir chemoprophylaxis vs placebo among Thai healthcare personnel reported no significant differences in adverse events and no withdrawals by drug recipients [395]. Use of a flocked nasal swab (with fibers projecting outward) may increase the detection of influenza viruses over a nonflocked swab and have a similar yield as NP aspirate [156]. Rapid antigen These guidelines provide advice to clinicians on the use of tests will be less useful once the pandemic is established. XX. Antiviral drugs are the mainstay of clinical treatment of swine influenza and can make the illness milder and enable the patient to feel better faster. 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. Some assays (eg, a few rapid influenza diagnostic tests) require the exact swab supplied with the test being used. Labeling of drug preparations containing salicylates. The volume of distribution of the metabolite oseltamivir carboxylate is not significantly different in nonobese and obese patients, and obese (including extremely obese) patients appear to have similar plasma levels as nonobese patients. Flu symptoms may vary from person to person. Are pregnant or within two weeks of delivery, including women who have had pregnancy loss. Studies of other drugs with immune-modulating activity, such as the hydroxy-methylglutaryl-coenzyme A reductase inhibitors (statins), have been proposed as adjunctive therapy for influenza, but no prospective data are available on which to make recommendations [381]. What specimen(s) should be collected when testing patients for influenza? Clinicians should evaluate the ability to reliably use inhaled zanamivir in children 57 years old. Hospitalized children and adults with chronic illness who develop nosocomial influenza may not initially manifest typical influenza signs and symptoms [434, 435]. 2020; doi:10.15585/mmwr.rr6908a1. Antiviral drugs are sometimes prescribed within the first day or two of symptoms. Immunosuppressed patients, especially HSCT patients, who are treated with NAIs are more likely to experience emergence of antiviral resistance during or after therapy in part due to a poor host response, with prolonged influenza virus replication [134]. Accessed Jan. 6, 2021. Management should include involvement of an infectious diseases physician competent in infectious diseases in transplant recipients, if available. Doctors are more likely to use a test to diagnose flu if: Your doctor may also use a test to determine whether a flu virus is the cause of your symptoms, or if you have or are showing signs of another problem besides the flu, such as: In some cases, your doctor may suggest that you be tested for influenza. For both the initial and the updated evidence search, the titles and abstracts of identified citations were screened, and potentially relevant citations were subjected to a full-text review, using predefined inclusion and exclusion criteria. The adopted grading system as per Table 1 ranged from the optimal category and grade for a recommendation of A-I (which meant that the panel judged that there was good evidence to support a recommendation for [should always be offered] or against [should never be offered] use, and evidence emerged from >1 properly conducted randomized controlled trial) to the lowest category and grade, which was C-III (meaning that there was poor evidence to support a recommendation and the judgment was based on evidence from opinions of respected authorities, as well as based on clinical experience, descriptive studies, or reports of expert committees). Addition of a throat swab to a nasal specimen using molecular testing has been shown to slightly increase recovery of influenza viruses in pediatric patients in some studies [159], but not in others [160]. Influenza activity is defined as the circulation of seasonal influenza A and B viruses among persons in the local community. If you have the flu, you can give it to others. Which healthcare personnel should receive antiviral chemoprophylaxis during an institutional outbreak? One study estimated that during 20102016, the seasonal incidence of symptomatic influenza among all ages in the United States was approximately 8% and varied from 3% to 11% [1]. If there are delays in obtaining aqueous zanamivir, use oseltamivir as a bridging treatment until zanamivir is available. Most people recover from uncomplicated influenza, but influenza can cause complications that result in severe illness and death, particularly among very young children, older adults, pregnant and postpartum women within 2 weeks of delivery, people with neurologic disorders, and people with certain chronic medical conditions including chronic pulmonary, cardiac, and metabolic disease, and those who are immunocompromised [28]. Types of influenza viruses. 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: Infectious Diseases. Accessed Nov. 26, 2018. In a retrospective study, rapid influenza testing led to a significant reduction in antibiotic use among hospitalized adults [12]. In 2 observational studies that utilized propensity scoring to adjust for confounding by treatment assignment, corticosteroid treatment of critically ill adults with influenza A(H1N1)pdm09 virus infection was associated with longer duration of mechanical ventilation and increased mortality [367, 368]. A large autopsy series of 100 fatal cases found no evidence of extrapulmonary influenza A(H1N1) pdm09 virus infection [167]. Systematic reviews and meta-analyses of RCTs of early NAI treatment in generally healthy outpatients with uncomplicated laboratory-confirmed influenza reported clinical benefit in reducing illness duration in children and adults, and in reducing risk of hospitalization in adults [194, 200]. A majority of H1N1 cases are reported from Tamil . It's possible to have both COVID-19 and influenza at the same time. The IDSA SPGC and the IDSA Board of Directors reviewed and approved the guidelines prior to dissemination. Mayo Clinic is a not-for-profit organization. Therefore, except for research purposes or for special patient populations, there is no diagnostic utility to routinely collect whole blood, plasma, or serum specimens for seasonal influenza virus testing by any assay. Although the benefits of therapy are greatest if therapy is started within 48 hours of illness onset, there is evidence of clinical benefit with later initiation of therapy in critically ill adults [16]. Patients who responded to treatment after two to three days and become totally asymptomatic should be discharged after 5 days of treatment. The choice of an antiviral drug for treatment or chemoprophylaxis should be based on the approved and recommended ages, route of administration, whether contraindications exist for the use of a particular product, and knowledge of antiviral resistance patterns. In patients who do not demonstrate clinical improvement after at least 23 days of antiviral treatment, especially when treatment is initiated early in the clinical course, consideration should be given to potential alternative explanations. One large retrospective observational study not included in any meta-analyses reported data for 607 adults hospitalized with influenza A(H1N1)pdm09 in 51 Canadian ICUs [370]. Although laboratory testing of additional suspected cases is the most definitive means to confirm an outbreak, waiting for laboratory testing results may delay outbreak control measures. Influenza seasonal. These assays are also useful for testing individuals with suspected influenza during low influenza periods. 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]). 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. Full-dose empiric antiviral treatment should be initiated as soon as symptoms occur, if treatment is indicated, Clinicians should administer postexposure antiviral chemoprophylaxis in a nonoutbreak setting for 7 days after the most recent exposure to a close contact with influenza, Clinicians should test for influenza and switch to antiviral treatment dosing in persons receiving postexposure antiviral chemoprophylaxis who become symptomatic, preferably with an antiviral drug with a different resistance profile if not contraindicated, Clinicians should administer an NAI (inhaled zanamivir or oral oseltamivir) if postexposure chemoprophylaxis for influenza is given, rather than an adamantane antiviral, Active surveillance for additional cases should be implemented as soon as possible when one healthcare-associated laboratory-confirmed influenza case is identified in a hospital or one case of laboratory-confirmed influenza is identified in a long-term care facility, Outbreak control measures should be implemented as soon as possible, including antiviral chemoprophylaxis of residents/patients, and active surveillance for new cases, when 2 cases of healthcare-associated laboratory-confirmed influenza are identified within 72 hours of each other in residents or patients of the same ward or unit, Implementation of outbreak control measures can be considered as soon as possible if one or more residents or patients has suspected healthcare-associated influenza and results of influenza molecular testing are not available on the day of specimen collection, When an influenza outbreak has been identified in a long-term care facility or hospital, influenza testing should be done for any resident/patient with one or more acute respiratory symptoms, with or without fever, or any of the following without respiratory symptoms: temperature elevation or reduction, or behavioral change, Empiric antiviral treatment should be administered as soon as possible to any resident or patient with suspected influenza during an influenza outbreak without waiting for the results of influenza diagnostic testing, Antiviral chemoprophylaxis should be administered as soon as possible to all exposed residents or patients who do not have suspected or laboratory-confirmed influenza regardless of influenza vaccination history, in addition to implementation of all other recommended influenza outbreak control measures, when an influenza outbreak has been identified in a long-term care facility or hospital, Antiviral chemoprophylaxis should be administered to residents on outbreak-affected units, in addition to implementing active daily surveillance for new influenza cases throughout the facility, Clinicians can consider antiviral chemoprophylaxis for unvaccinated staff, including those for whom chemoprophylaxis may be indicated based upon underlying conditions of the staff or their household members (see recommendations 4143) for the duration of the outbreak, Clinicians can consider antiviral chemoprophylaxis for staff who receive inactivated influenza vaccine during an institutional influenza outbreak for 14 days postvaccination, Clinicians can consider antiviral chemoprophylaxis for staff regardless of influenza vaccination status to reduce the risk of short staffing in facilities and wards where clinical staff are limited and to reduce staff reluctance to care for patients with suspected influenza, Clinicians should administer antiviral chemoprophylaxis for 14 days and continue for at least 7 days after the onset of symptoms in the last case identified during an institutional influenza outbreak. 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