Influenza in the Emergency Department: Vaccination, Diagnosis, and Treatment: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee

An educational intervention in the emergency department seeking to improve COVID-19 vaccination rates among unvaccinated patients aged 20-64

BACKGROUND

The COVID-19 vaccination rate in the US has plateaued, especially among minorities and young populations. Previous efforts within the Emergency Department (ED) setting to address this disparity have shown positive results. The ED can play a crucial role in engaging vaccine-hesitant individuals, particularly those with limited access to healthcare. By providing education, addressing concerns, and using positive framing, vaccination rates can be improved in the ED. This quality improvement project aimed to increase vaccination rates through one-on-one educational interventions and open discussions with patients.

METHODS

Between November 2021 and June 2022, unvaccinated adult patients aged 20 to 64 visiting a local ED in Kalamazoo, MI were approached for a discussion on COVID vaccines. A research team, trained in motivational interviewing techniques, provided an educational intervention, offering evidence-based information and resources to unvaccinated participants.

RESULTS

A total of 37 participants were enrolled, and their demographics were recorded. The participants expressed various concerns about the vaccine, including potential side effects, speed of testing and production, perceived ineffectiveness, mistrust, and low personal risk. At the four-week follow-up, three participants (8%) had received their first dose of the COVID-19 vaccine.

CONCLUSION

The study fell short of its desired sample size and the intervention failed to raise vaccination rates among ED patients. Factors like low perceived risk, vaccine hesitancy, and limited resources may have influenced these outcomes. Future research should focus on staffing, operational hours, repeated educational interventions, and targeted approaches for different populations. Improving participant recruitment through institutional engagement and involvement of multiple EDs should be explored. Addressing these factors can help inform effective interventions to increase COVID-19 vaccination rates in the ED.

Factors influencing recurrent emergency department visits for mild acute respiratory tract infections caused by the influenza virus

Background

Seasonal viral outbreaks, exemplified by influenza A and B viruses, lead to spikes in emergency department (ED) visits, straining healthcare facilities. Addressing ED overcrowding has become paramount due to its implications for patient care and healthcare operations. Recurrent visits among influenza patients remain an underexplored aspect, necessitating investigation into factors influencing such revisits.

Methods

Conducted within a tertiary care university hospital, this study adopts an observational retrospective cohort design. The study included adult patients with acute respiratory symptoms diagnosed with influenza using rapid antigen testing. The cohort was divided into single and recurrent ED visitors based on revisits within 10 days of initial discharge. A comparative analysis was performed, evaluating demographics, laboratory parameters, and clinical process data between recurrent visitors and single visitors.

Results

Among 218 patients, 36.2% (n = 139) experienced recurrent ED visits. Age and gender disparities were not significant. Antibiotics were prescribed for 55.5% (n = 121) and antivirals for 92.7% (n = 202) of patients, with no notable influence on recurrence. Recurrent visitors exhibited lower monocyte counts, hemoglobin levels, higher PDW and P-LCR percentages, and increased anemia prevalence (p = 0.036, p = 0.01, p = 0.004, p = 0.029, p = 0.017, respectively). C-reactive protein (CRP) levels did not significantly affect recurrence.

Conclusion

This study highlights the pressing concern of recurrent ED visits among mild influenza patients, magnifying the challenges of ED overcrowding. The observed notable prescription rates of antibiotics and antivirals underscore the intricate landscape of influenza management. Diminished monocyte counts, hemoglobin levels, and altered platelet parameters signify potential markers for identifying patients at risk of recurrent visits.

Meeting Patients Where They Are: A Nurse-Driven Quality Improvement Project to Provide Influenza Vaccinations in the Emergency Department

INTRODUCTION

Influenza is highly contagious, vaccine-preventable, and may result in significant morbidity and mortality. While vaccination is the primary protection against influenza, vaccination rates remain low. Traditionally, primary care clinics, retail pharmacies, and public health departments offer influenza vaccines. However, offering influenza vaccines in new settings may increase their availability to the public and increase community uptake. This project aimed to add emergency departments as a new influenza vaccine location to increase the number of vaccines distributed during the 2020 to 2021 influenza season.

METHODS

Adult patients discharged from 24 emergency departments were included in this pre- post-intervention project. A nurse-driven order set was established to enhance efficiency. Education materials (scripting, fliers, etc.) were developed to help nurses feel comfortable with vaccine information.

RESULTS

Nurses indicated that education helped increase their belief that influenza vaccination was important. After completing the educational material, a higher number of nurses agreed that it was necessary to encourage others to be vaccinated (P < 0.05). Moreover, emergency department influenza vaccinations increased significantly throughout the 2020 to 2021 influenza season. Nurses across all 24 hospitals administered 2002 vaccines during this season compared to 9 during the previous year's season.

DISCUSSION

The project demonstrated that delivering influenza vaccinations in emergency departments is challenging yet achievable. Educational offerings were valuable resources to increase nurses' knowledge and positive attitudes about providing influenza vaccines to patients. Further studies regarding how vaccinations could be provided in more emergency departments and alternative care sites, such as urgent care and clinics other than primary care providers, are needed.

Evaluation of missed influenza vaccination opportunities in the emergency department

BACKGROUND

Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data.

METHODS

This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity.

RESULTS

A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions.

CONCLUSION

Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Assessment of a COVID-19 vaccination protocol for unhoused patients in the emergency department

BACKGROUND

We aimed to evaluate the feasibility of implementing an emergency department (ED)-based Coronavirus Disease of 2019 (COVID-19) vaccination protocol in a population of unhoused patients.

METHODS

On June 10, 2021, a best practice alert (BPA) was implemented that fired when an ED provider opened the charts of unhoused patients and prompted the provider to order COVID-19 vaccination for eligible patients. We downloaded electronic medical record data of patients who received a COVID-19 vaccine in the ED between June 10, 2021 and August 26, 2021. The outcomes of interest were the number of unhoused, and the total number of patients vaccinated for COVID-19 during the study period. Data were described with simple descriptive statistics.

RESULTS

There were 25,871 patient encounters in 19,992 unique patients (mean 1.3 visits/patient) in the emergency department during the study period. There were 1,474 (6% of total ED population) visits in 1,085 unique patients who were unhoused (mean 1.4 visits/patient). The BPA fired in 1,046 unhoused patient encounters (71% of PEH encounters) and was accepted in 79 (8%). Forty-three unhoused patients were vaccinated as a result of the BPA (4% of BPA fires) and 18 unhoused patients were vaccinated without BPA prompting. An additional 76 domiciled patients were vaccinated in the ED.

CONCLUSIONS

Implementing an ED-based COVID-19 vaccination program is feasible, however, only a small number of patients underwent COVID-19 vaccination. Further studies are needed to explore the utility of using the ED as a setting for COVID-19 vaccination.

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BACKGROUND

Chemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED.

METHODS

A PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: "febrile neutropenia" OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review.

RESULTS

The search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%).

CONCLUSIONS

FN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.

Influenza vaccination coverage among emergency department personnel is associated with perception of vaccination and side effects, vaccination availability on site and the COVID-19 pandemic

Introduction

Influenza is a major concern in hospitals, including the emergency department (ED), mainly because of a high risk for ED personnel to acquire and transmit the disease. Although influenza vaccination is recommended for health care workers, vaccination coverage is low.

Methods

This survey was conducted in the 2016/2017 and 2020/2021 influenza seasons. Questionnaires were sent to ED personnel in 12 hospitals in Bavaria, South-Eastern Germany. The response rates were 62% and 38% in 2016/2017 and 2020/2021, respectively. Data were compared between the two seasons as well as between vaccinated and not vaccinated respondents in 2020/2021.

Results

Significantly more ED personnel reported having been vaccinated in the 2020/2021 season. Factors associated with vaccination coverage (or the intention to get vaccinated) were profession (physician / medical student), having been vaccinated at least twice, the availability of an influenza vaccination on site (in the ED) as well as the COVID-19 pandemic. Additionally, significant differences in the assessment and evaluation of influenza, its vaccination side effects and ethical aspects were found between vaccinated and not vaccinated ED personnel in 2020/2021. Unvaccinated respondents estimated higher frequencies of almost all potential vaccination side effects, were less likely to accept lay-offs if employees would not come to work during an influenza pandemic and more likely to agree that work attendance should be an employee´s decision. Vaccinated participants instead, rather agreed that vaccination should be mandatory and were less likely to consider job changes in case of a mandatory vaccination policy.

Conclusion

The COVID-19 pandemic might have contributed to a higher influenza vaccination rate among ED workers. Vaccination on site and interventions targeting the perception of influenza vaccination and its side effects may be most promising to increase the vaccination coverage among ED personnel.

COVID-19 vaccine hesitancy among patients in two urban emergency departments

Background

Widespread vaccination is an essential component of the public health response to the COVID‐19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy.

Methods

Adult ED patients with stable clinical status (Emergency Severity Index 3–5) and without active COVID‐19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants.

Results

A total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18–93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18–24 years—OR = 4.57, 95% CI = 2.66 to 7.86; age 25–35 years—OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less—OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research.

Conclusions

Vaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations.

"Rationalization of Empiric Antibiotic Therapy" - A Move Towards Preventing Emergence of Resistant Infections

Antimicrobial resistance is a key factor leading to emerging/ re-emerging infections. Rational antimicrobial therapy or antimicrobial stewardship is one of the important interventions to prevent emergence of resistance. Choosing correct empiric therapy is crucial not only to prevent antimicrobial resistance but also to achieve good treatment outcomes. Antimicrobial therapy can be broadly classified as empiric, definitive/ targeted and preventive. It is in choice of empiric therapy that the largest margin of error exists. Paradoxically, empiric therapy is the most commonly employed therapy since microbiologic results are either not available at initiation of treatment or cannot be sent due to logistic reasons or are negative. In the Indian setting, where penetration of microbiologic diagnostic methods in small cities, towns and rural areas is still fairly low, therapy is largely empiric. Choice of empiric therapy is governed by various factors including likely pathogens, antimicrobial resistance, degree of sickness, site of infection and host co-morbidities. These principles can be applied to any clinical syndrome whether it is fever without focus, infections of the respiratory tract, gastrointestinal tract, abdomen, central nervous system, bone and joint, skin and soft tissue, urinary tract as well as neonatal sepsis and healthcare associated infections. Adherence to published guidelines for syndromic management such as that by the Indian Academy of Pediatrics and Indian Council of Medical Research is strongly recommended. One can tailor these guidelines and suggestions made in this article to an individual setting.

Hepatitis B screening in an argentine ED: Increasing vaccination in a resource-limited setting

BACKGROUND

There is limited data regarding the use of emergency departments (EDs) for infectious disease screening and vaccination in resource-limited regions. In these settings, EDs are often the only contact that patients have with the healthcare system, turning an ED visit into an opportune time to deliver preventative health services.

METHODS

In this pilot study, patients that met inclusion criteria were prospectively tested for hepatitis B surface antigen test (HBsAg). Previously unvaccinated patients who tested negative for HBsAg were offered HBV vaccination. The study setting was a public infectious disease hospital in Cordoba, Argentina. The primary outcomes were new HBV diagnoses, as well as vaccination completion between screening modalities (Point-of-Care-Testing-POCT vs. laboratory testing) and same vs. different day vaccination.

RESULTS

We screened 100 patients for HBV (75 POCT & 25 laboratory). The median age of participants was 35 years (IQR 24-52) and 55% were male. No patients tested positive for HBsAg. All patients who completed first dose vaccination were initially screened with the POCT. No patients screened with laboratory testing returned for vaccination. Patients who were scheduled for vaccination the same day were more likely to complete vaccination compared to those scheduled for another day (75% vs. 14%, p < .001).

CONCLUSION

Our study supports the use of HBV POCTs in the ED in conjunction with vaccination of HBV-negative individuals. In regions with low HBV endemicity, direct vaccination without HBsAg testing may be more cost effective. We believe that this acute-care screening model is applicable to other resource-limited settings.

Hospital-acquired influenza infections detected by a surveillance system over six seasons, from 2010/2011 to 2015/2016

Background

In addition to outbreaks of nosocomial influenza, sporadic nosocomial influenza infections also occur but are generally not reported in the literature.

This study aimed to determine the epidemiologic characteristics of cases of nosocomial influenza compared with the remaining severe cases of severe influenza in acute hospitals in Catalonia (Spain) which were identified by surveillance.

Methods

An observational case-case epidemiological study was carried out in patients aged ≥18 years from Catalan 12 hospitals between 2010 and 2016. For each laboratory-confirmed influenza case (nosocomial or not) we collected demographic, virological and clinical characteristics. We defined patients with nosocomial influenza as those admitted to a hospital for a reason other than acute respiratory infection in whom ILI symptoms developed ≥48 h after admission and influenza virus infection was confirmed using RT-PCR. Mixed-effects regression was used to estimate the crude and adjusted OR.

Results

One thousand seven hundred twenty-two hospitalized patients with severe laboratory-confirmed influenza virus infection were included: 96 (5.6%) were classified as nosocomial influenza and more frequently had > 14 days of hospital stay (42.7% vs. 27.7%, P < .001) and higher mortality (18.8% vs. 12.6%, P < .02). The variables associated with nosocomial influenza cases in acute-care hospital settings were chronic renal disease (aOR 2.44 95% CI 1.44–4.15) and immunodeficiency (aOR 1.79 95% CI 1.04–3.06).

Conclusions

Nosocomial infections are a recurring problem associated with high rates of chronic diseases and death. These findings underline the need for adherence to infection control guidelines.

Diagnostic accuracy of a rapid RT-PCR assay for point-of-care detection of influenza A/B virus at emergency department admission: A prospective evaluation during the 2017/2018 influenza season

STUDY OBJECTIVE

To investigate the performance of a rapid RT-PCR assay to detect influenza A/B at emergency department admission.

METHODS

This single-center prospective study recruited adult patients attending the emergency department for influenza-like illness. Triage nurses performed nasopharyngeal swab samples and ran rapid RT-PCR assays using a dedicated device (cobas Liat, Roche Diagnostics, Meylan, France) located at triage. The same swab sample was also analyzed in the department of virology using conventional RT-PCR techniques. Patients were included 24 hours-a-day, 7 days-a-week. The primary outcome was the diagnostic accuracy of the rapid RT-PCR assay performed at triage.

RESULTS

A total of 187 patients were included over 11 days in January 2018. Median age was 70 years (interquartile range 44 to 84) and 95 (51%) were male. Nine (5%) assays had to be repeated due to failure of the first assay. The sensitivity of the rapid RT-PCR assay performed at triage was 0.98 (95% confidence interval (CI): 0.91-1.00) and the specificity was 0.99 (95% CI: 0.94-1.00). A total of 92 (49%) assays were performed at night-time or during the weekend. The median time from patient entry to rapid RT-PCR assay results was 46 [interquartile range 36-55] minutes.

CONCLUSION

Rapid RT-PCR assay performed by nurses at triage to detect influenza A/B is feasible and highly accurate.

Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections

Respiratory viral infections are associated with a wide range of acute syndromes and infectious disease processes in children and adults worldwide. Many viruses are implicated in these infections, and these viruses are spread largely via respiratory means between humans but also occasionally from animals to humans. This article is an American Society for Microbiology (ASM)-sponsored Practical Guidance for Clinical Microbiology (PGCM) document identifying best practices for diagnosis and characterization of viruses that cause acute respiratory infections and replaces the most recent prior version of the ASM-sponsored Cumitech 21 document, Laboratory Diagnosis of Viral Respiratory Disease, published in 1986. The scope of the original document was quite broad, with an emphasis on clinical diagnosis of a wide variety of infectious agents and laboratory focus on antigen detection and viral culture. The new PGCM document is designed to be used by laboratorians in a wide variety of diagnostic and public health microbiology/virology laboratory settings worldwide. The article provides guidance to a rapidly changing field of diagnostics and outlines the epidemiology and clinical impact of acute respiratory viral infections, including preferred methods of specimen collection and current methods for diagnosis and characterization of viral pathogens causing acute respiratory tract infections. Compared to the case in 1986, molecular techniques are now the preferred diagnostic approaches for the detection of acute respiratory viruses, and they allow for automation, high-throughput workflows, and near-patient testing. These changes require quality assurance programs to prevent laboratory contamination as well as strong preanalytical screening approaches to utilize laboratory resources appropriately. Appropriate guidance from laboratorians to stakeholders will allow for appropriate specimen collection, as well as correct test ordering that will quickly identify highly transmissible emerging pathogens.

Detection of neuraminidase inhibitor-resistant influenza A (H1N1)pdm09 viruses obtained from influenza surveillance in Indonesia

Background:

Influenza antiviral resistance has been shown to occur in many countries and is commonly found in influenza A(H1N1)pdm09 and A(H3N2). In this study, we monitored and investigated the neuraminidase inhibitor resistance of influenza A(H1N1)pdm09 viruses through the influenza surveillance system in Indonesia.

Methods:

A total of 4752 clinical specimens were collected from patients with influenza-like illness and severe acute respiratory infection during the year 2016. An allelic discrimination assay was conducted by a single base substitution or a single-nucleotide polymorphism that is specific to the H275 wild-type and Y275 mutant. Sequencing was performed to confirm the H275Y mutations, and we analysed the phylogenetic relationship.

Results:

The first occurrence of oseltamivir-resistant influenza A(H1N1)pdm09 was observed in the samples from the influenza-like illness surveillance. Two H275Y oseltamivir-resistant viruses (0.74%) out of 272 influenza A(H1N1)pdm09 positives were found. Both of them were collected from untreated patients.

Conclusion:

The number of oseltamivir-resistant influenza A(H1N1)pdm09 viruses in Indonesia is very low. However, it is necessary to continue with active surveillance for oseltamivir resistance in severe and mild cases.

Impact of bedside diagnosis of influenza in the paediatric emergency ward

OBJECTIVES

This prospective study performed in the paediatric emergency department of the University Hospital of Saint-Etienne aimed to measure the impact of the 24/7 bedside use of the Veritor™ System (Becton Dickinson) on the reduction of supplementary investigations, hospital stay and antimicrobial use.

METHODS

Influenza virus A and B antigens were detected with a rapid influenza digital immunoassay (DIA) on nasopharyngeal aspirates (NPAs) sampled from the children consulting at the paediatric emergency department between January and March 2016 for influenza-like illness. The same NPA was tested by immunofluorescence and/or molecular routine assays. Before performing the DIA, the clinician filled in a questionnaire listing the tests that he/she would have prescribed in the absence of the rapid testing. The prescription of complementary investigations, antimicrobial treatments and hospital stay were also compared to those of the 3 previous years.

RESULTS

A total of 514 children with flu-like symptoms were included. The use of the DIA at bedside decreased the prescription of blood puncture by 47.9% (21.2% to 6.6%), of chest X-rays by 69.0% (33.3% to 10.3%), of lumbar puncture by 77.8% (7.0% to 1.6%), of urine culture by 79.2% (23.3% to 4.9%), of antibiotic treatments by 70.1% (16.9% to 5.1%), and of hospital stay by 25.0% (27.2% to 20.4%), resulting in a reduction of medical costs estimated to more than €69 000 in a season.

CONCLUSIONS

In addition to delivering a rapid aetiological diagnosis, this strategy saves medical costs and favours an antimicrobial stewardship strategy. However, further prospective studies are needed to confirm our findings.

Are we missing respiratory viral infections in infants and children? Comparison of a hospital-based quality management system with standard of care

OBJECTIVES

Hospital-based surveillance of influenza and acute respiratory infections relies on International Classification of Diseases (ICD) codes and hospital laboratory reports (Standard-of-Care). It is unclear how many cases are missed with either method, i.e. remain undiagnosed/coded as influenza and other respiratory virus infections. Various influenza-like illness (ILI) definitions co-exist with little guidance on how to use them. We compared the diagnostic accuracy of standard surveillance methods with a prospective quality management (QM) programme at a Berlin children's hospital with the Robert Koch Institute.

METHODS

Independent from routine care, all patients fulfilling pre-defined ILI-criteria (QM-ILI) participated in the QM programme. A separate QM team conducted standardized clinical assessments and collected nasopharyngeal specimens for blinded real-time quantitative PCR for influenza A/B viruses, respiratory syncytial virus, adenovirus, rhinovirus and human metapneumovirus.

RESULTS

Among 6073 individuals with ILI qualifying for the QM programme, only 8.7% (528/6073) would have undergone virus diagnostics during Standard-of-Care. Surveillance based on ICD codes would have missed 61% (359/587) of influenza diagnoses. Of baseline ICD codes, 53.2% (2811/5282) were non-specific, most commonly J06 ('acute upper respiratory infection'). Comparison of stakeholder case definitions revealed that QM-ILI and the WHO ILI case definition showed the highest overall sensitivities (84%-97% and 45%-68%, respectively) and the CDC ILI definition had the highest sensitivity for influenza infections (36%, 95% CI 31.4-40.8 for influenza A and 48%, 95% CI 40.5-54.7 for influenza B).

CONCLUSIONS

Disease-burden estimates and surveillance should account for the underreporting of cases in routine care. Future studies should explore the effect of ILI screening and surveillance in various age groups and settings. Diagnostic algorithms should be based on the WHO ILI case definition combined with targeted testing.

Diagnostic performance of the Sofia® influenza A+B fluorescent immunoassay in adult outpatients in Northern Taiwan

To evaluate the diagnostic performance of the Sofia influenza A+B fluorescent immunoassay (Sofia FIA), we performed a prospective study at the Chang Gung Memorial Hospital in Taiwan from January 2012 to December 2013. Patients who presented at out-patient clinics or the emergency department with influenza-like illness were included. Upper respiratory tract specimens were collected from oropharynx or nasopharynx. Performance of the Sofia FIA was compared to that of the Formosa One Sure Flu A/B Rapid Test. A Real-time reverse transcriptase-polymerase chain reaction assay (RT-PCR) and/or virus culture were used as reference standards. Of the 109 enrolled patients, the sensitivity, specificity, positive, and negative predictive values of the Sofia FIA to detect influenza A virus were 82%, 89%, 77%, and 89%, respectively. These parameters were 100% when the samples were from nasopharynx. The positive predictive value for influenza B virus detection was 29%. The sensitivity of the Sofia FIA for detection of influenza A virus was 93% between days 2 and 4 after onset of symptoms. For specimens with low viral loads (RT-PCR cycle threshold between 30 and 34.9), the sensitivity of The Sofia FIA was 83% (10/12). The Sofia FIA performed effectively in detecting influenza A virus infection. With nasopharyngeal samples, the performance was comparable to RT-PCR. Although influenza viral load typically decreases with time, the Sofia FIA was sensitive enough to identify influenza infecting patients presenting after several days of illness. However, a high false positive rate limits the assay's usefulness to identify influenza B virus infection.

Towards the electrochemical diagnostic of influenza virus: development of a graphene–Au hybrid nanocomposite modified influenza virus biosensor based on neuraminidase activity

An effective electrochemical influenza A biosensor based on a graphene–gold (Au) hybrid nanocomposite modified Au-screen printed electrode has been developed.

Anti-influenza Activity of a Bacillus subtilis Probiotic Strain

Among Bacillus bacteria, B. subtilis is the species that produces the most antimicrobial compounds. In this study, we analyzed the activity of probiotic strain B. subtilis 3 against the influenza virus. The antiviral effect of this strain has been demonstrated in vitro and in vivo A new peptide, P18, produced by the probiotic strain was isolated, purified, chemically synthesized, and characterized. Cytotoxicity studies demonstrated no toxic effect of P18 on Madin-Darby canine kidney (MDCK) cells, even at the highest concentration tested (100 μg/ml). Complete inhibition of the influenza virus in vitro was observed at concentrations of 12.5 to 100 μg/ml. The protective effect of P18 in mice was comparable to that of oseltamivir phosphate (Tamiflu). Further study will assess the potential of peptide P18 as an antiviral compound and as a promising candidate for the development of new antiviral vaccines.

Influenza and other respiratory viruses: standardizing disease severity in surveillance and clinical trials

INTRODUCTION

Influenza-Like Illness is a leading cause of hospitalization in children. Disease burden due to influenza and other respiratory viral infections is reported on a population level, but clinical scores measuring individual changes in disease severity are urgently needed. Areas covered: We present a composite clinical score allowing individual patient data analyses of disease severity based on systematic literature review and WHO-criteria for uncomplicated and complicated disease. The 22-item ViVI Disease Severity Score showed a normal distribution in a pediatric cohort of 6073 children aged 0-18 years (mean age 3.13; S.D. 3.89; range: 0 to 18.79). Expert commentary: The ViVI Score was correlated with risk of antibiotic use as well as need for hospitalization and intensive care. The ViVI Score was used to track children with influenza, respiratory syncytial virus, human metapneumovirus, human rhinovirus, and adenovirus infections and is fully compliant with regulatory data standards. The ViVI Disease Severity Score mobile application allows physicians to measure disease severity at the point-of care thereby taking clinical trials to the next level.

Delay in diagnosis of influenza A (H1N1)pdm09 virus infection in critically ill patients and impact on clinical outcome

BACKGROUND

Patients infected with influenza A (H1N1)pdm09 virus requiring admission to the ICU remain an important source of mortality during the influenza season. The objective of the study was to assess the impact of a delay in diagnosis of community-acquired influenza A (H1N1)pdm09 virus infection on clinical outcome in critically ill patients admitted to the ICU.

METHODS

A prospective multicenter observational cohort study was based on data from the GETGAG/SEMICYUC registry (2009-2015) collected by 148 Spanish ICUs. All patients admitted to the ICU in which diagnosis of influenza A (H1N1)pdm09 virus infection had been established within the first week of hospitalization were included. Patients were classified into two groups according to the time at which the diagnosis was made: early (within the first 2 days of hospital admission) and late (between the 3rd and 7th day of hospital admission). Factors associated with a delay in diagnosis were assessed by logistic regression analysis.

RESULTS

In 2059 ICU patients diagnosed with influenza A (H1N1)pdm09 virus infection within the first 7 days of hospitalization, the diagnosis was established early in 1314 (63.8 %) patients and late in the remaining 745 (36.2 %). Independent variables related to a late diagnosis were: age (odds ratio (OR) = 1.02, 95 % confidence interval (CI) 1.01-1.03, P < 0.001); first seasonal period (2009-2012) (OR = 2.08, 95 % CI 1.64-2.63, P < 0.001); days of hospital stay before ICU admission (OR = 1.26, 95 % CI 1.17-1.35, P < 0.001); mechanical ventilation (OR = 1.58, 95 % CI 1.17-2.13, P = 0.002); and continuous venovenous hemofiltration (OR = 1.54, 95 % CI 1.08-2.18, P = 0.016). The intra-ICU mortality was significantly higher among patients with late diagnosis as compared with early diagnosis (26.9 % vs 17.1 %, P < 0.001). Diagnostic delay was one independent risk factor for mortality (OR = 1.36, 95 % CI 1.03-1.81, P < 0.001).

CONCLUSIONS

Late diagnosis of community-acquired influenza A (H1N1)pdm09 virus infection is associated with a delay in ICU admission, greater possibilities of respiratory and renal failure, and higher mortality rate. Delay in diagnosis of flu is an independent variable related to death.

Fabrication of Electrochemical Model Influenza A Virus Biosensor Based on the Measurements of Neuroaminidase Enzyme Activity

Neuroaminidase (NA) enzyme is a kind of glycoprotein that is found on the influenza A virus. During infection, NA is important for the release of influenza virions from the host cell surface together with viral aggregates. It may also be involved in targeting the virus to respiratory epithelial cells. In this study, a model electrochemical influenza A viral biosensor in which receptor-binding properties have been based on NA was developed for the first time. The biosensor's working principle is based on monitoring the interactions between fetuin A and NA enzyme. The assay was monitored step by step by using electrochemical impedance spectroscopy.