Epidemiology, clinical features, and prognosis of elderly adults with severe forms of influenza A (H1N1

Treatment strategies for patients over 80 years of age with oral squamous cell carcinoma

OBJECTIVE

To analyze the clinical characteristics of patients with oral squamous cell carcinoma aged ≥80 years, focusing on surgical treatments.

STUDY DESIGN

We reviewed patients with oral squamous cell carcinoma aged ≥80 years who underwent surgery between 2005 and 2018. Basic information, comorbidities, multiple primary cancers, initial treatment, complications, and outcomes were evaluated.

RESULTS

Of 197 patients aged ≥80 years, 119 patients underwent surgery (50 males, 69 females; mean age: 83.5 years). The gingiva was the most common primary tumor site (63 patients, 52.9 %). The stage classification was stage I in 35 patients (29.4 %), stage II in 44 (37 %), stage III in 16 (13.4 %), stage IVA in 22 (18.5 %), and stage IVB in 2 (1.7 %). Comorbidities were identified in 112 patients (94.1 %). Surgery was the initial treatment in 111 patients (93.3 %). Eight (6.7 %) patients received postoperative adjuvant chemotherapy/radiotherapy; 20 patients (16.8 %) underwent free tissue transplantation. Perioperative complications were observed in 36 patients (30.3 %). The cumulative 5-year and 10-year overall survival rates were 82 % and 68.3 %, respectively; the disease-specific survival rates were 90 %.

CONCLUSION

Good treatment outcomes were obtained with radical surgery. Surgery should be the first choice if quality of life is assured and there are no issues with surgical tolerance, regardless of age.

Severe influenza A in a Tunisian ICU sentinel SARI centre: Epidemiological and clinical features

Introduction

Influenza A virus infection is a contagious acute respiratory infection which mostly evolves in an epidemic form, less frequently as pandemic outbreaks. It can take a severe clinical form that needs to be managed in intensive care unit (ICU). The aim of this study was to describe the epidemiological and clinical aspects of influenza A, then to determine independent predictive factors of ICU mortality in Abderrahmen Mami hospital, Ariana, Tunisia.

Methods

It was a single-center study, including all hospitalized patients in intensive care, between November 1^st, 2009 and October 31^st, 2019, with influenza A virus infection. We recorded demographic, clinical and biological data, evolving features; then multivariate analysis of the predictive factors of ICU mortality was realized.

Results

During the study period (10 consecutive seasons), 120 patients having severe Influenza A were admitted (Proportion = 2.5%) from all hospitalized patients, with a median age of 48 years and a gender-ratio of 1.14. Among women, 14 were pregnant. Only 7 patients (5.8%) have had seasonal flu vaccine during the year before ICU admission. The median values of the Simplified Acute Physiology Score II, Acute Physiologic and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment were respectively 26, 10 and 3. Virus strains identified with polymerase chain reaction were H₁N₁ pdm09 (84.2%) and H₃N₂ (15.8%). Antiviral therapy was prescribed in 88 (73.3%) patients. A co-infection was recorded in 19 cases: bacterial (n = 17) and aspergillaire (n = 2). An acute respiratory distress syndrome (ARDS) was diagnosed in 82 patients. Non-invasive ventilation (NIV) was conducted for 72 (60%) patients with success in 34 cases. Endotracheal intubation was performed in 59 patients with median duration of invasive mechanical ventilation 8 [3.25–13] days. The most frequent complications were acute kidney injury (n = 50, 41.7%), shock (n = 48, 40%), hospital-acquired infections (n = 46, 38.8%) and thromboembolic events (n = 19, 15.8%). The overall ICU mortality rate was of 31.7% (deceased n = 38). Independent predictive factors of ICU mortality identified were: age above 56 years (OR = 7.417; IC_95% [1.474–37.317]; p = 0.015), PaO₂/FiO₂ ≤ 95 mmHg (OR = 9.078; IC_95% [1.636–50.363]; p = 0.012) and lymphocytes count ≤ 1.325 10⁹/L (OR = 10.199; IC_95% [1.550–67.101]; p = 0.016).

Conclusion

Influenza A in ICU is not uncommon, even in A(H1N1) dominant seasons; its management is highly demanding. It is responsible for considerable morbi-mortality especially in elderly patients.

Risk Factors Associated with 30-Day Mortality in Older Patients with Influenza

Background: Influenza is a common viral condition, but factors related to short-term mortality have not been fully studied in older adults. Our objective was to determine whether there is an association between geriatric factors and 30-day mortality. Methods: This was a retrospective cohort design. All patients aged 75 years and over, with a diagnosis of influenza confirmed by a positive RT-PCR, were included. The primary endpoint was death within the 30 days after diagnosis. Results: 114 patients were included; 14 (12.3%) patients died within 30 days. In multivariate analysis these patients were older (OR: 1.37 95% CI (1.05, 1.79), p = 0.021), and had a lower ADL score (OR: 0.36 95% CI (0, 17; 0.75), p = 0.006), and a higher SOFA score (OR: 2.30 95% CI (1.07, 4.94), p = 0.03). Oseltamivir treatment, initiated within the first 48 h, was independently associated with survival (OR: 0.04 95% CI (0.002, 0.78), p = 0.034). Conclusions: Identification of mortality risk factors makes it possible to consider specific secondary prevention measures such as the rapid introduction of antiviral treatment. Combined with primary prevention, these measures could help to limit the mortality associated with influenza in older patients.

Evaluation of Pregnancy, Younger Age, and Old Age as Independent Risk Factors for Poor Hospitalization Outcomes in Influenza A (H1N1)pdm09 Virus a Decade After the Pandemic

Introduction The influenza A (H1N1)pdm09 virus infection was first reported in Mexico in 2009 and quickly became the first flu pandemic of the 21st century. Statistics show that the prevalence of H1N1 infection was higher among young adults during the pandemic while the elderly were at more risk of death. However; many studies have shown a gradual change over the years, with attack rates increasing in older adults as compared to young adults. The other significant vulnerable group for this infection seems to be pregnant women. Over the years, many authors have found that pregnancy may not be a significant risk factor for increased hospitalization and poorer outcomes. This study aims to perform a comparative analysis and thereby assess pregnancy, younger age, and old age as independent risk factors for poor hospitalization outcomes. Materials and methods The hospital records of all patients with H1N1 infection admitted between January 1, 2018, to December 31, 2018, were screened. The patients included in the study were young adults (18-31 years), pregnant women, and the elderly (≥65 years). Comparative analysis was done between them. Nominal variables were compared using the chi-square test. Results A total of 379 patients were admitted to our hospital with H1N1 infection from January 1, 2018, to December 31, 2018. There were 75 elderly (19.7%), 224 (59%) middle-aged adults, 55 (14.5%) young adults, and 25 (6.5%) pregnant women. Fever (90%, 84%, and 96%) and cough with expectoration (72%, 67.3%, and 40%) were the most prevalent symptoms. The elderly reported more dyspnoea (28% vs. 5.5%, 4 %). Diabetes mellitus was found in 73.3 % of the elderly, 3.6% of the young adults, and 12% of pregnant women. Hypertension was present in 45% of the elderly, 1.8% of young adults, and 4% of pregnant women. Coronary artery disease was seen in 22.7% of the elderly and 1.8% of young adults. Chronic kidney disease (5.3%) and chronic obstructive pulmonary disease (13.3%) were seen only in the elderly group. Relative lymphopenia was prevalent in all groups and was more in pregnant women (76% vs. 61.8% and 41.8%) as compared to other groups. Serum creatinine was elevated in 38% of the elderly, 2% of young adults, and 0% of pregnant women. Abnormal chest radiograph was reported for 48% of the elderly, 30.9% of young adults, and 12% of pregnant women. Twenty-six point seven percent (26.7%) of the elderly needed more than a weeks' stay as compared to 7.3% of young adults and 20% of pregnant women. Thirty-two percent (32%) of the elderly required intensive care as compared to 1.5% of young adults and none of the pregnant women. More of the elderly (26.7%) required ventilator support than other groups (7.3% and 4%). About 25.3% of the elderly had a superinfection. Eight percent (8%) of the elderly died in the study while none died in the other groups. Conclusion Age representation and poor hospitalization outcomes due to H1N1 seem to have shifted from young adults to older age groups. The elderly are at more risk for a prolonged stay, intensive care, ventilator support, and death as compared to young adults and pregnant women. Pregnancy may not be associated with poor hospitalization outcomes for H1N1 as has been earlier thought.

Spanish Influenza Score (SIS): Usefulness of machine learning in the development of an early mortality prediction score in severe influenza

OBJECTIVE

To develop a mortality prediction score (Spanish Influenza Score [SIS]) for patients with severe influenza considering only variables at ICU admission, and compare its performance respect of Random Forest (RF).

DESIGN

Sub-analysis from the GETGAG/SEMICYUC database.

SCOPE

Intensive Care Medicine.

PATIENTS

Patients admitted to 184 Spanish ICUs (2009-2018) with influenza infection Intervention: None.

VARIABLES

Demographic data, severity of illness, times from symptoms onset until hospital admission (Gap-H), hospital to ICU (Gap-ICU) or hospital to diagnosis (Gap-Dg), antiviral vaccination, number of quadrants infiltrated, acute renal failure, invasive or noninvasive ventilation, shock and comorbidities. The study variable cut-off points and importance were obtained automatically. Logistic regression analysis with cross-validation was performed to develop the SIS score using the output coefficients. Accuracy and discrimination (AUC-ROC) were applied to evaluate SIS and RF. All analyses were performed using R (CRAN-R Project).

RESULTS

A total of 3959 patients were included. The mean age was 55 years (range 43-67), 60% were men, APACHE II 16 (12-21) and SOFA 5 (4-8), with ICU mortality 21.3%. Mechanical ventilation, shock, APACHE II, SOFA, acute renal failure and Gap-ICU were included in the SIS. The latter was generated according to the ORs obtained by logistic regression, and showed an accuracy of 83% with an AUC-ROC of 82%, similar to RF (AUC-ROC 82%).

CONCLUSIONS

The SIS score is easy to apply and shows adequate capacity to stratify the risk of ICU mortality. However, further studies are needed to validate the tool prospectively.

Corticosteroids as adjunctive therapy in the treatment of influenza

BACKGROUND

Specific treatments for influenza are limited to neuraminidase inhibitors and adamantanes. Corticosteroids show evidence of benefit in sepsis and related conditions, most likely due to their anti-inflammatory and immunomodulatory properties. Although commonly prescribed for severe influenza, there is uncertainty over their potential benefits or harms. This is an update of a review first published in 2016.

OBJECTIVES

To systematically assess the effectiveness and potential adverse effects of corticosteroids as adjunctive therapy in the treatment of influenza, taking into account differences in timing and doses of corticosteroids.

SEARCH METHODS

We searched CENTRAL (2018, Issue 9), which includes the Cochrane Acute Respiratory infections Group's Specialised Register, MEDLINE (1946 to October week 1, 2018), Embase (1980 to 3 October 2018), CINAHL (1981 to 3 October 2018), LILACS (1982 to 3 October 2018), Web of Science (1985 to 3 October 2018), abstracts from the last three years of major infectious disease and microbiology conferences, and references of included articles. We also searched the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry on 3 October 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and observational studies that compared corticosteroid treatment with no corticosteroid treatment for influenza or influenza-like illness. We did not restrict studies by language of publication, influenza subtypes, clinical setting, or age of participants. We selected eligible studies in two stages: sequential examination of title and abstract, followed by full text.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We pooled estimates of effect using a random-effects model, where appropriate. We assessed heterogeneity using the I² statistic and assessed the certainty of the evidence using the GRADE framework.

MAIN RESULTS

This updated review includes 30 studies (one RCT with two arms and 29 observational studies) with a total of 99,224 participants. We included 19 studies in the original review (n = 3459), all of which were observational, with 13 studies included in the meta-analysis for mortality. We included 12 new studies in this update (one RCT and 11 observational studies), and excluded one study in the original review as it has been superceded by a more recent analysis. Twenty-one studies were included in the meta-analysis (9536 individuals), of which 15 studied people infected with 2009 influenza A H1N1 virus (H1N1pdm09). Data specific to mortality were of very low quality, based predominantly on observational studies, with inconsistent reporting of variables potentially associated with the outcomes of interest, differences between studies in the way in which they were conducted, and with the likelihood of potential confounding by indication. Reported doses of corticosteroids used were high, and indications for their use were not well reported. On meta-analysis, corticosteroid therapy was associated with increased mortality (odds ratio (OR) 3.90, 95% confidence interval (CI) 2.31 to 6.60; I² = 68%; 15 studies). A similar increase in risk of mortality was seen in a stratified analysis of studies reporting adjusted estimates (OR 2.23, 95% CI 1.54 to 3.24; I² = 0%; 5 studies). An association between corticosteroid therapy and increased mortality was also seen on pooled analysis of six studies which reported adjusted hazard ratios (HRs) (HR 1.49, 95% CI 1.09 to 2.02; I² = 69%). Increased odds of hospital-acquired infection related to corticosteroid therapy were found on pooled analysis of seven studies (pooled OR 2.74, 95% CI 1.51 to 4.95; I² = 90%); all were unadjusted estimates, and we graded the data as of very low certainty.

AUTHORS' CONCLUSIONS

We found one RCT of adjunctive corticosteroid therapy for treating people with community-acquired pneumonia, but the number of people with laboratory-confirmed influenza in the treatment and placebo arms was too small to draw conclusions regarding the effect of corticosteroids in this group, and we did not include it in our meta-analyses of observational studies. The certainty of the available evidence from observational studies was very low, with confounding by indication a major potential concern. Although we found that adjunctive corticosteroid therapy is associated with increased mortality, this result should be interpreted with caution. In the context of clinical trials of adjunctive corticosteroid therapy in sepsis and pneumonia that report improved outcomes, including decreased mortality, more high-quality research is needed (both RCTs and observational studies that adjust for confounding by indication). The currently available evidence is insufficient to determine the effectiveness of corticosteroids for people with influenza.

Repeated influenza vaccination for preventing severe and fatal influenza infection in older adults: a multicentre case-control study

BACKGROUND

The effectiveness of repeated vaccination for influenza to prevent severe cases remains unclear. We evaluated the effectiveness of influenza vaccination on preventing admissions to hospital for influenza and reducing disease severity.

METHODS

We conducted a case-control study in 20 hospitals in Spain during the 2013/14 and 2014/15 influenza seasons. Community-dwelling adults aged 65 years or older who were admitted to hospital for laboratory-confirmed influenza were matched with inpatient controls by sex, age, hospital and admission date. The effectiveness of vaccination in the current and 3 previous seasons in preventing influenza was estimated for inpatients with nonsevere influenza and for those with severe influenza who were admitted to intensive care units (ICUs) or who died.

RESULTS

We enrolled 130 inpatients with severe and 598 with nonsevere influenza who were matched to 333 and 1493 controls, respectively. Compared with patients who were unvaccinated in the current and 3 previous seasons, adjusted effectiveness of influenza vaccination in the current and any previous season was 31% (95% confidence interval [CI] 13%-46%) in preventing admission to hospital for nonsevere influenza, 74% (95% CI 42%-88%) in preventing admissions to ICU and 70% (95% CI 34%-87%) in preventing death. Vaccination in the current season only had no significant effect on cases of severe influenza. Among inpatients with influenza, vaccination in the current and any previous season reduced the risk of severe outcomes (adjusted odds ratio 0.45, 95% CI 0.26-0.76).

INTERPRETATION

Among older adults, repeated vaccination for influenza was twice as effective in preventing severe influenza compared with nonsevere influenza in patients who were admitted to hospital, which is attributable to the combination of the number of admissions to hospital for influenza that were prevented and reduced disease severity. These results reinforce recommendations for annual vaccination for influenza in older adults.

Clinical characteristics, evolution, and treatment-related risk factors for mortality among immunosuppressed patients with influenza A (H1N1) virus admitted to the intensive care unit

PURPOSE

Information about immunocompromised patients infected with influenza A (H1N1) virus and requiring admission to the ICU is lacking. Our objective was to know the clinical characteristics of these patients and to identify treatment-related variables associated with mortality.

MATERIAL AND METHODS

A prospective multicenter observational cohort study was based on data from a Spanish registry (2009-2015) collected by 148 Spanish ICUs. All patients admitted to the ICU with the diagnosis of influenza A (H1N1) virus infection were included. Immunosuppression was clearly defined. Factors associated with mortality in immunocompromised patients were assessed by conventional logistic regression analysis and by a propensity score (PS) adjusted-multivariable analysis.

RESULTS

Of 1899 patients with influenza A (H1N1) infection, 238 (12.5%) were classified as immunocompromised. Mortality was significantly higher in immunosuppressed patients. Four variables independently associated with mortality were identified: SOFA score, need of vasopressor, use of corticosteroids, and acute renal failure, AKIN 3 stage. In the PS-adjusted model, corticosteroid therapy remained as an independent factor associated with increased mortality (OR 2.25;95%CI, 1.15-4.38;p = 0.017). In the subgroup of hematological patients (n = 141), corticosteroid therapy was also associated with increased mortality (OR 3.12; 95%CI, 1.32-7.41; p = 0.010).

CONCLUSION

Immunocompromised individuals with influenza A (H1N1) admitted to the ICU have a poor outcome. In this population, the use of corticosteroids is strongly discouraged.

Risk factors for serious outcomes associated with influenza illness in high- versus low- and middle-income countries: Systematic literature review and meta-analysis

Aim

To determine factors associated with a serious outcome (hospital admission or severe outcome: critical care or death) and associated with illness caused by laboratory‐confirmed influenza, with a specific interest in low‐ and middle‐income countries (LMIC).

Method

Databases were searched on 11 March 2016 for reports of influenza and factors associated with mortality or morbidity in humans, with no language restrictions. Pooled risks were estimated using random‐effects models.

Results

Despite the heterogeneity of results across studies, known risk factors for serious disease were associated with both hospital admission and severe outcomes (critical care and/or death). In LMIC, but not in high income countries (HIC), pregnant women, people with HIV/AIDS and children < 5 years old (compared with older children) were at increased risk of a severe outcome. Also, although all patients with neurological conditions were at higher risk of severe outcomes than those without, children were at higher risk than adults and children who lived in a LMIC were at significantly higher risk than those living in HIC. Adults were more likely than children to suffer a severe outcome if they had diabetes or a hematologic condition, were obese or had liver disease. Asthma is a risk factor for hospital admission but not for severe outcomes.

Conclusion

Known risk factors for serious disease remain important predictors of hospital admission and severe outcomes with few differences between HIC and LMIC countries. These differences likely reflect differences in health‐seeking behaviours and health services, but high heterogeneity between studies limits conclusions about the effect size.

Potential Cost-Effectiveness of an Influenza Vaccination Program Offering Microneedle Patch for Vaccine Delivery in Children

Objective

The influenza vaccine coverage rate of children is low in Hong Kong. Microneedle patches (MNPs) is a technology under development for painless delivery of vaccines. This study aimed to examine the potential clinical outcomes and direct medical costs of an influenza program offering MNP vaccine to children who have declined intramuscular (IM) vaccine in Hong Kong.

Methods

A decision model was designed to compare potential outcomes between IM vaccine program and a program offering MNP vaccine to those declined IM vaccine (IM/MNP program) in a hypothetical cohort of children over one-year time horizon. The model outcomes included direct medical cost, influenza infection rate, mortality rate, and quality-adjusted life-years (QALYs) loss. Model inputs were retrieved from published literature. Sensitivity analyses were performed to examine the robustness of model results.

Results

In base-case analysis, IM/MNP program was more costly per child (USD19.13 versus USD13.69; USD1 = HKD7.8) with lower influenza infection rate (98.9 versus 124.8 per 1,000 children), hospitalization rate (0.83 versus 1.05 per 1,000 children) and influenza-related mortality rate (0.00042 versus 0.00052 per 1,000 children) when compared to IM program. The incremental cost per QALY saved (ICER) of IM/MNP program versus IM program was 27,200 USD/QALY. Using gross domestic product (GDP) per capita of Hong Kong (USD40,594) as threshold of willingness-to-pay (WTP) per QALY, one-way sensitivity analysis found ICER of IM/MNP to exceed WTP when duration of illness in outpatient setting was <5.7 days or cost per MNP vaccine was >1.39-time of IM vaccine cost. In 10,000 Monte Carlo simulations, IM/MNP program was the preferred option in 57.28% and 91.68% of the time, using 1x and 3x GDP per capita as WTP threshold, respectively.

Conclusion

Acceptance of IM/MNP program as the preferred program was subject to the WTP threshold, duration of illness in outpatient settings, and cost of MNP vaccine.

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.

Cost-effectiveness of an influenza vaccination program offering intramuscular and intradermal vaccines versus intramuscular vaccine alone for elderly

BACKGROUND

Intradermal (ID) injection is an alternative route for influenza vaccine administration in elderly with potential improvement of vaccine coverage. This study aimed to investigate the cost-effectiveness of an influenza vaccination program offering ID vaccine to elderly who had declined intramuscular (IM) vaccine from the perspective of Hong Kong public healthcare provider.

METHODS

A decision analytic model was used to simulate outcomes of two programs: IM vaccine alone (IM program), and IM or ID vaccine (IM/ID program) in a hypothetic cohort of elderly aged 65 years. Outcome measures included influenza-related direct medical cost, infection rate, mortality rate, quality-adjusted life years (QALYs) loss, and incremental cost per QALY saved (ICER). Model inputs were derived from literature. Sensitivity analyses evaluated the impact of uncertainty of model variables.

RESULTS

In base-case analysis, the IM/ID program was more costly (USD52.82 versus USD47.59 per individual to whom vaccine was offered) with lower influenza infection rate (8.71% versus 9.65%), mortality rate (0.021% versus 0.024%) and QALYs loss (0.00336 versus 0.00372) than the IM program. ICER of IM/ID program was USD14,528 per QALY saved. One-way sensitivity analysis found ICER of IM/ID program to exceed willingness-to-pay threshold (USD39,933) when probability of influenza infection in unvaccinated elderly decreased from 10.6% to 5.4%. In 10,000 Monte Carlo simulations of elderly populations of Hong Kong, the IM/ID program was the preferred option in 94.7% of time.

CONCLUSIONS

An influenza vaccination program offering ID vaccine to elderly who had declined IM vaccine appears to be a highly cost-effective option.

Corticosteroids as adjunctive therapy in the treatment of influenza

BACKGROUND

Specific treatments for influenza are limited to neuraminidase inhibitors and adamantanes. Corticosteroids show evidence of benefit in sepsis and related conditions, most likely due to their anti-inflammatory and immunomodulatory properties. Although commonly prescribed for severe influenza, there is uncertainty over their potential benefit or harm.

OBJECTIVES

To systematically assess the effectiveness and potential adverse effects of corticosteroids as adjunctive therapy in the treatment of influenza, taking into account differences in timing and doses of corticosteroids.

SEARCH METHODS

We searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June week 1, 2015), EMBASE (1974 to June 2015), CINAHL (1981 to June 2015), LILACS (1982 to June 2015), Web of Science (1985 to June 2015), abstracts from the last three years of major infectious disease and microbiology conferences, and references of included articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and observational studies that compared corticosteroid treatment with no corticosteroid treatment for influenza or influenza-like illness. We did not restrict studies by language of publication, influenza subtypes, clinical setting or age of participants. We selected eligible studies in two stages: sequential examination of title and abstract, followed by full text.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently extracted data and assessed risk of bias. We pooled estimates of effect using random-effects meta-analysis models, where appropriate. We assessed heterogeneity using the I(2) statistic and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

MAIN RESULTS

We identified 19 eligible studies (3459 individuals), all observational; 13 studies (1917 individuals) were suitable for inclusion in the meta-analysis of mortality. Of these, 12 studied patients infected with 2009 influenza A H1N1 virus (H1N1pdm09). Risk of bias was greatest in the 'comparability domain' of the Newcastle-Ottawa scale, consistent with potential confounding by indication. Data specific to mortality were of very low quality. Reported doses of corticosteroids used were high and indications for their use were not well reported. On meta-analysis, corticosteroid therapy was associated with increased mortality (odds ratio (OR) 3.06, 95% confidence interval (CI) 1.58 to 5.92). Pooled subgroup analysis of adjusted estimates of mortality from four studies found a similar association (OR 2.82, 95% CI 1.61 to 4.92). Three studies reported greater odds of hospital-acquired infection related to corticosteroid therapy; all were unadjusted estimates and we graded the data as very low quality.

AUTHORS' CONCLUSIONS

We did not identify any completed RCTs of adjunctive corticosteroid therapy for treating influenza. The available evidence from observational studies is of very low quality with confounding by indication a major potential concern. Although we found that adjunctive corticosteroid therapy was associated with increased mortality, this result should be interpreted with caution. In the context of clinical trials of adjunctive corticosteroid therapy in sepsis and pneumonia that report improved outcomes, including decreased mortality, more high-quality research is needed (both RCTs and observational studies). Currently, we do not have sufficient evidence in this review to determine the effectiveness of corticosteroids for patients with influenza.

The PAndemic INfluenza Triage in the Emergency Department (PAINTED) pilot cohort study

BACKGROUND

Research needs to be undertaken rapidly in the event of an influenza pandemic to develop and evaluate triage methods for people presenting to the emergency department with suspected pandemic influenza.

OBJECTIVES

We aimed to pilot a research study to be undertaken in a pandemic to identify the most accurate triage method for patients presenting to the emergency department with suspected pandemic influenza. The objectives of the pilot study were to develop a standardised clinical assessment form and secure online database; test both using data from patients with seasonal influenza; seek clinician views on the usability of the form; and obtain all regulatory approvals required for the main study.

DESIGN

Study methods were piloted using an observational cohort study and clinician views were sought using qualitative, semistructured interviews.

SETTING

Six acute hospital emergency departments.

PARTICIPANTS

Patients attending the emergency department with suspected seasonal influenza during winter 2012-13 and clinicians working in the emergency departments.

MAIN OUTCOME MEASURES

Adverse events up to 30 days were identified, but analysis of the pilot data was limited to descriptive reporting of patient flow, data completeness and patient characteristics.

RESULTS

Some 165 patients were identified, of whom 10 withdrew their data, leaving 155 (94%) for analysis. Follow-up data were available for 129 of 155 (83%), with 50 of 129 (39%) being admitted to hospital. Three cases (2%) were recorded as having suffered an adverse outcome. There appeared to be variation between the hospitals, allowing for small numbers. Three of the hospitals identified 150 of 165 (91%) of the patients, and all 10 withdrawing patients were at the same hospital. The proportion with missing follow-up data varied from 8% to 31%, and the proportion admitted varied from 4% to 85% across the three hospitals with meaningful numbers of cases. All of the deaths were at one hospital. There was less variation between hospitals in rates of missing data, and for most key variables missing rates were between 5% and 30%. Higher missing rates were recorded for blood pressure (39%), inspired oxygen (43%), capillary refill (36%) and Glasgow Coma Scale score (43%). Chest radiography was performed in 51 of 118 cases, and electrocardiography in 40 of 111 cases with details recorded. Blood test results were available for 32 of 155 cases. The qualitative interviews revealed generally positive views towards the standardised assessment form. Concerns about lack of space for free text were raised but counterbalanced by appreciation that it fitted on to one A4 page. A number of amendments were suggested but only three of these were suggested by more than one participant, and no suggestions were made by more than two participants.

CONCLUSIONS

A standardised assessment form is acceptable to clinicians and could be used to collect research data in an influenza pandemic, but analysis may be limited by missing data.

FUTURE WORK

An observational cohort study to identify the most accurate triage method for predicting severe illness in emergency department attendees with suspected pandemic influenza is set up and ready to activate if, or when, a pandemic occurs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56149622.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 3. See the NIHR Journals Library website for further project information.

Do corticosteroids reduce the mortality of influenza A (H1N1) infection? A meta-analysis

Introduction

Corticosteroids are used empirically in influenza A (H1N1) treatment despite lack of clear evidence for effective treatment. This study aims to assess the efficacy of corticosteroids treatment for H1N1 infection.

Methods

Systematic review and meta-analysis were used to estimate the efficacy of corticosteroids for the prevention of mortality in H1N1 infection. Databases searched included MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Clinical Trials and so on, and bibliographies of retrieved articles, from April 2009 to October 2014. We included both cohort studies and case-control studies reported in English or Chinese that compared treatment effects between corticosteroids and non-corticosteroids therapy in inpatients with H1N1 virus infection. Cohort studies employed mortality as outcome, and case-control studies employed deaths as cases and survivors as controls; both were assessed in this meta-analysis.

Results

In total twenty-three eligible studies were included. Both cohort studies (nine studies, n = 1,405) and case-control studies (14 studies, n = 4,700) showed a similar trend toward increased mortality (cohort studies relative risk was 1.85 with 95% confidence interval (CI) 1.46 to 2.33; case-control studies odds ratio was 4.22 with 95% CI 3.10 to 5.76). The results from both subgroup analyses and sensitive analyses were consistent with each other, showing that steroid treatment is associated with mortality. However, considering the fact that corticosteroids were tend to be used in sickest case-patients and heterogeneity was observed between studies, we cannot make a solid conclusion.

Conclusions

Available evidence did not support the use of corticosteroids as standard care for patients with severe influenza. We conclude that further research is required.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0764-5) contains supplementary material, which is available to authorized users.

Takotsubo cardiomyopathy after anti-influenza vaccination: catecholaminergic effects of immune system

Takotsubo cardiomyopathy (TTC) is a well-known condition, which leads to sudden transient regional systolic dysfunction. It mostly affects aging women and is usually precipitated by emotional or physical stress. Despite the tremendous amount of literature on TTC, cardiac sympathetic hyperactivity is the only thing known to be associated with pathogenesis. In our case, an elderly woman presented with an acute episode of TTC 24 hours after anti-influenza vaccination without any obvious stressor for sudden rise in the catecholamine level. Sudden postvaccination change in the cardiac sympathetic discharge is the most likely precipitant of TTC in this case.