Evaluation of a direct test for seasonal influenza in outpatients

The Clinical Utility of Point-of-Care Tests for Influenza in Ambulatory Care: A Systematic Review and Meta-analysis

Background

Point-of-care tests (POCTs) for influenza are diagnostically superior to clinical diagnosis, but their impact on patient outcomes is unclear.

Methods

A systematic review of influenza POCTs versus usual care in ambulatory care settings. Studies were identified by searching six databases and assessed using the Cochrane risk of bias tool. Estimates of risk ratios (RR), standardised mean differences, 95% confidence intervals and I2 were obtained by random effects meta-analyses. We explored heterogeneity with sensitivity analyses and meta-regression.

Results

12,928 citations were screened. Seven randomized studies (n = 4,324) and six non-randomized studies (n = 4,774) were included. Most evidence came from paediatric emergency departments. Risk of bias was moderate in randomized studies and higher in non-randomized studies. In randomized trials, POCTs had no effect on admissions (RR 0.93, 95% CI 0.61–1.42, I2 = 34%), returning for care (RR 1.00 95% CI = 0.77–1.29, I2 = 7%), or antibiotic prescribing (RR 0.97, 95% CI 0.82–1.15, I2 = 70%), but increased prescribing of antivirals (RR 2.65, 95% CI 1.95–3.60; I2 = 0%). Further testing was reduced for full blood counts (FBC) (RR 0.80, 95% CI 0.69–0.92 I2 = 0%), blood cultures (RR 0.82, 95% CI 0.68–0.99; I2 = 0%) and chest radiography (RR 0.81, 95% CI 0.68–0.96; I2 = 32%), but not urinalysis (RR 0.91, 95% CI 0.78–w1.07; I2 = 20%). Time in the emergency department was not changed. Fewer non-randomized studies reported these outcomes, with some findings reversed or attenuated (fewer antibiotic prescriptions and less urinalysis in tested patients).

Conclusions

Point-of-care testing for influenza influences prescribing and testing decisions, particularly for children in emergency departments. Observational evidence shows challenges for real-world implementation.

Management of seasonal influenza by family physicians

INTRODUCTION

Seasonal influenza is responsible for approximately 2.5 million consultations with the family physician (FP) per year in France. We performed this study with FPs to assess whether their practice complied with French guidelines.

MATERIAL AND METHOD

Descriptive survey carried out from June to August 2018 using a questionnaire sent electronically to 1,140 Alsatian FPs.

RESULTS

A total of 121 FPs responded to the questionnaire (10.6%). The main clinical symptoms that FPs believed to be the most reliable to diagnose influenza were fever (95%) and arthromyalgia (76.9%), well ahead of cough (27.3%). Overall, 23.1% of FPs declared that they occasionally used microbiological confirmation; 80.2% of FPs performed hand hygiene once per consultation but 95.9% did not wear surgical masks when managing patients with influenza and only 53.7% wore them when they themselves presented with influenza-like symptoms. Hand sanitizers, masks, or tissues were made available to patients in 35.5%, 19.8%, and 30.6%, respectively. Overall, 77.7% of participating physicians were vaccinated against influenza. Influenza vaccination was widely offered to high-risk patients, but some groups were insufficiently vaccinated: obese patients (32.2%) and pregnant women (47.9%). Overall, 48.8% of physicians never prescribed oseltamivir at a curative dose and 72.7% never prescribed it at a preventive dose; 86.8% of physicians prescribed at least one non-recommended symptomatic treatment including an NSAID (24.8%) or aspirin (12.4%).

CONCLUSION

This study revealed several mismatches with guidelines and suggested potential corrective actions.

Systematic review of the impact of point-of-care testing for influenza on the outcomes of patients with acute respiratory tract infection

Acute respiratory tract infections are a major cause of morbidity and mortality and represent a significant burden on the health care system. Laboratory testing is required to definitively distinguish infecting influenza virus from other pathogens, resulting in prolonged emergency department (ED) visits and unnecessary antibiotic use. Recently available rapid point-of-care tests (POCT) may allow for appropriate use of antiviral and antibiotic treatments and decrease patient lengths of stay. We undertook a systematic review to assess the effect of POCT for influenza on three outcomes: (1) antiviral prescription, (2) antibiotic prescription, and (3) patient length of stay in the ED. The databases Medline and Embase were searched using MeSH terms and keywords for influenza, POCT, antivirals, antibiotics, and length of stay. Amongst 245 studies screened, 30 were included. The majority of papers reporting on antiviral prescription found that a positive POCT result significantly increased use of antivirals for influenza compared with negative POCT results and standard supportive care. A positive POCT result also led to decreased antibiotic use. The results of studies assessing the effect of POCT on ED length of stay were not definitive. The studies assessed in this systematic review support the use of POCT for diagnosis of influenza in patients suffering an acute respiratory infection. Diagnosis using POCT may lead to more appropriate prescription of treatments for infectious agents. Further studies are needed to assess the effect of POCT on the length of stay in ED.

The impact of commercial rapid respiratory virus diagnostic tests on patient outcomes and health system utilization

INTRODUCTION

Acute respiratory tract infections due to influenza A/B and respiratory syncytial virus (RSV) are major causes of morbidity and mortality globally. Rapid tests for detection of these pathogens include antigen detection point of care tests (POC) and newer easy to use molecular tests. From experience, these assays improve both laboratory workflow and assay interpretation issues. However, the question of the benefits of using rapid test technology compared to routine laboratory testing for respiratory viral pathogens is still often asked. Areas covered: Specifically, this review aims to; 1) identify clinical/patient indicators that can be measured prior to and following the implementation of rapid diagnostic test for influenza and RSV, 2) provide multiple perspectives on the extent of impact of a rapid diagnostic test, including direct and indirect outcomes, and 3) identify the technological advancements in the development of rapid testing, demonstrating a timeline that transitions from antigen-based assays to molecular assays. Expert commentary: Key benefits to the use of either antigen-based or molecular rapid tests for patient care, patient flow within institutions, as well as laboratory utilization are identified. Due to improved test characteristics, the authors feel that rapid molecular tests have greater benefits than antigen-based detection methods.

Impact of oseltamivir use on the reduction of complications in patients with influenza: a prospective study

To evaluate the factors associated with oseltamivir prescription and to study the effectiveness of oseltamivir in reducing influenza-related complications. A prospective cohort study using the SOS Doctors (a network of physicians who perform house-call visits in Attica, Greece). Patients with confirmed or clinically suspected influenza were followed up to 14 days during the 2011-2012 influenza period. 410 patients with confirmed or suspected influenza were included. Healthy adults were mainly enrolled, with a median age of 44 years. Influenza diagnosis was mainly based on clinical criteria (65.8 % of patients). Oseltamivir was prescribed for 45.4 % of them. In a multivariate analysis, prescription of oseltamivir was associated with the attending physician (p < 0.001), positive influenza test (p < 0.001) and diabetes (p = 0.027). Data on complications were available for 351 patients, and 50 (15.8 %) of them reported at least one. Seven patients required hospitalization. Types of complications (pneumonia, bronchitis, etc.) were not significantly different between patients receiving and those not receiving oseltamivir. In the multivariate analysis, higher oseltamivir prescription rate was associated with fewer complications (p < 0.001). Bearing in mind the limitations of a non-randomized study, in a real-life setting, oseltamivir prescription and the rate of complications in patients with influenza were associated with the attending physician, underlying diseases and diagnostic tests. Overall, when the frequency of oseltamivir prescription increased, the influenza-related complications decreased.

Comparison of characteristics of outpatients with 2009 H1N1 pandemic and seasonal influenza

BACKGROUND

The latest influenza pandemic intensified the interest in this infection.

OBJECTIVE

We aimed to compare the characteristics of outpatients with seasonal and pandemic influenza.

METHODS

We retrospectively reviewed data regarding outpatients who sought medical advice from a network of physicians performing house-call visits at the area of Attica, Greece, and who underwent a direct influenza test during the period of seasonal influenza (1/1/2009-1/5/2009) and 2009 H1N1 pandemic influenza period (17/5/2009-15/4/2010).

RESULTS

A total of 195 and 1317 patients had a direct influenza test during the seasonal and pandemic influenza period, respectively; 50.7% and 32% of these patients had a positive test result for influenza, respectively. Viral culture or polymerase chain reaction (PCR) were not implemented. Patients found positive for influenza during the pandemic period, compared with those evaluated during the seasonal period, were younger (mean age ± SD: 33 ± 17.2 vs. 38.2 ± 19.2, p = 0.008), more likely to have no comorbidity (62.9% vs. 45.5%, p = 0.002), had milder clinical manifestations, and were treated with more antibiotics (38.3% vs. 9.9%, p < 0.001). However, patients found positive during the seasonal period were treated with more antivirals (oseltamivir: 69.1% vs. 85.7%, p = 0.006). No difference was observed regarding the need for immediate hospitalisation. These findings were consistent in the complementary analysis involving patients tested for influenza during the compared periods.

CONCLUSION

Despite the methodological limitations, our findings suggest that patients with pandemic influenza were younger, had milder clinical manifestations and were less likely to have any kind of comorbidity compared with patients with seasonal influenza.