Management der neuen Influenza A/H1N1-Virus-Pandemie im Krankenhaus: Eine Stellungnahme der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin

Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines

BACKGROUND

The COVID-19 pandemic has highlighted the importance of evidence-based clinical decision-making. Clinical management guidelines (CMGs) may help reduce morbidity and mortality by improving the quality of clinical decisions. This systematic review aims to evaluate the availability, inclusivity, and quality of pandemic influenza CMGs, to identify gaps that can be addressed to strengthen pandemic preparedness in this area.

METHODS

Ovid Medline, Ovid Embase, TRIP (Turning Research Into Practice), and Guideline Central were searched systematically from January 2008 to 23rd June 2022, complemented by a grey literature search till 16th June 2022. Pandemic influenza CMGs including supportive care or empirical treatment recommendations were included. Two reviewers independently extracted data from the included studies and assessed their quality using AGREE II (Appraisal of Guidelines for Research & Evaluation). The findings are presented narratively.

RESULTS

Forty-eight CMGs were included. They were produced in high- (42%, 20/48), upper-middle- (40%, 19/48), and lower-middle (8%, 4/48) income countries, or by international organisations (10%, 5/48). Most CMGs (81%, 39/48) were over 5 years old. Guidelines included treatment recommendations for children (75%, 36/48), pregnant women (54%, 26/48), people with immunosuppression (33%, 16/48), and older adults (29%, 14/48). Many CMGs were of low quality (median overall score: 3 out of 7 (range 1-7). All recommended oseltamivir; recommendations for other neuraminidase inhibitors and supportive care were limited and at times contradictory. Only 56% (27/48) and 27% (13/48) addressed oxygen and fluid therapy, respectively.

CONCLUSIONS

Our data highlights the limited availability of up-to-date pandemic influenza CMGs globally. Of those identified, many were limited in scope and quality and several lacked recommendations for specific at-risk populations. Recommendations on supportive care, the mainstay of treatment, were limited and heterogeneous. The most recent guideline highlighted that the evidence-base to support antiviral treatment recommendations is still limited. There is an urgent need for trials into treatment and supportive care strategies including for different risk populations. New evidence should be incorporated into globally accessible guidelines, to benefit patient outcomes. A 'living guideline' framework is recommended and further research into guideline implementation in different resourced settings, particularly low- and middle-income countries.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

[Management of seasonal influenza in 2017/2018 at a German tertiary-care hospital]

BACKGROUND

There are only few structured reports on inpatient management of a seasonal influenza epidemic.

OBJECTIVES

A systematic description of a seasonal influenza patient population at a German university hospital to improve risk stratification and clinical care.

METHODS

In this monocentric, retrospective observational study of the 2017/2018 influenza season at the University Medical Center Hamburg-Eppendorf, patients with confirmed influenza infection were included.

RESULTS

Of all influenza swabs performed in the emergency department, 24% (n = 162/676) were positive. A total of 255 patients (median age 66 years) had an influenza infection (influenza A n = 79, influenza B n = 176); 27 (15.3%) were nosocomial infections. Of the 179 (70.2%) patients that were hospitalized, 51 (20%) received intensive medical care. Patients with subsequent need for intensive care had an elevated CRP level (69.5 mg/dl [SD 62.8] vs. 141.7 [SD 127.2] mg/dl) at the time of influenza diagnosis and more frequent infiltrates in X‑ray/CT of the thorax (n = 43 [33.6%] vs. n = 43 [84.3%]). Antiviral therapy with oseltamivir was administered for 74 (29.0%) patients and 11 (6.1%) patients were treated with extracorporeal membrane oxygenation (ECMO). Of the 23 (9.0%) patients who died, only four of them had been vaccinated (trivalent). Those four had an influenza B infection.

CONCLUSION

The structured use of diagnostic tests (influenza PCR, X‑ray/CT chest and CRP) and antiviral therapy (oseltamivir) as well as targeted management of admission, intensive care capacities, and an increase in vaccination rates are important for improving patient care and optimizing the use of resources during seasonal influenza epidemics.

[Pandemic influenza A/H1N1 2009 : Challenge for intensive care medicine]

Mit dem Auftreten der Neuen Influenza A/H1N1 2009 als Pandemie hat auch in Deutschland die Zahl der Neuerkrankungen rasch zugenommen. Nach wie vor zeigen die meisten Erkrankten eine milde Ausprägung. In Einzelfällen kommt es jedoch zu schweren Verläufen, die eine stationäre oder intensivmedizinische Behandlung erfordern. Während mittlerweile für die Behandlung von Patienten mit A/H1N1v-Infektion im ambulanten und allgemeinstationären Bereich zahlreiche Empfehlungen und Stellungnahmen vorliegen, ergeben sich bei erforderlicher Intensivbehandlung teilweise vollkommen neue Fragestellungen. Nachfolgend wird daher auf dem Boden der aktuellen Literatur, eigener Erfahrungen und einschlägiger Empfehlungen von Gesundheitsbehörden das Vorgehen bei Patienten mit schwerem intensivpflichtigen Verlauf einer A/H1N1v-Infektion dargestellt. Bereits aus Anamnese und zeitlichem Verlauf der Symptome ergeben sich erste wichtige Schlussfolgerungen hinsichtlich weiterer therapeutischer und hygienischer Maßnahmen. Das Verfahren der Wahl zum diagnostischen Nachweis von A/H1N1v ist die Polymerase-Kettenreaktion (PCR). Liegen bestimmte Risikofaktoren vor (z. B. Schwangerschaft, Immunsuppression, Adipositas), steigt die Wahrscheinlichkeit eines schweren Verlaufs der Influenza A/H1N1v 2009. Noch bevor die Testergebnisse vorliegen, sollten daher bei begründetem Verdacht die antivirale Therapie eingeleitet und Isolations- bzw. Personalschutzmaßnahmen getroffen werden. Die weitere intensivmedizinische Therapie zielt auf die Beherrschung begleitender Organkomplikationen ab (z. B. nichtinvasive bzw. maschinelle Beatmung bei drohender Hypoxämie). Zur Vermeidung einer bakteriellen Sekundärinfektion ist bei schwerer respiratorischer Insuffizienz frühzeitig eine kalkulierte antiinfektive Therapie indiziert. In Anbetracht der hohen Dynamik bei der Entwicklung einer respiratorischen Insuffizienz kann eine extrakorporale Membranoxygenierung notwendig werden. In diesem Fall sollte frühzeitig mit einem entsprechenden Zentrum Kontakt aufgenommen werden.