Oseltamivir for influenza infection in children: risks and benefits

Evaluation of Severe Acute Respiratory Syndrome surveillance caused by respiratory viruses in a pediatric unit, 2013 to 2019

OBJECTIVE

To evaluate severe acute respiratory syndrome surveillance in a pediatric unit.

METHODS

Descriptive study of reported severe acute respiratory syndrome cases with the detection of respiratory viruses in the nasopharyngeal sample of patients hospitalized between 2013 and 2019, in a reference hospital in the Federal District, Brazil.

RESULTS

A total of 269 children had one or more viruses detected, resulting in 280 viruses, of which 152 (54%) were respiratory syncytial virus. The detection of respiratory syncytial virus was higher during the autumn-winter period. Children´s median age was 6.9 months, 156 (58%) were male, 104 (39%) had comorbidity, 197 (73%) required mechanical ventilation, 241 (90%) received antibiotics, and 146 (54%) oseltamivir. There were 19 (7%) deaths. The median time from symptom onset to sample collection was 5 days and the median time from sample collection to final results was 6 days.

CONCLUSIONS

The system needs to reduce the time to deliver results so that inappropriate use of antibiotics and antivirals can be avoided. Moreover, the burden of viral pneumonia was relevant and the system must be flexible enough to include emerging viruses in order to be useful in responding to public health emergencies caused by respiratory viruses.

Iterative Optimization and Structure-Activity Relationship Studies of Oseltamivir Amino Derivatives as Potent and Selective Neuraminidase Inhibitors via Targeting 150-Cavity

With our continuous endeavors in seeking neuraminidase (NA) inhibitors, we reported herein three series of novel oseltamivir amino derivatives with the goal of exploring the druggable chemical space inside the 150-cavity of influenza virus NAs. Among them, around half of the compounds in series C were demonstrated to be better inhibitors against both wild-type and oseltamivir-resistant group-1 NAs than oseltamivir carboxylate (OSC). Notably, compounds 12d, 12e, 15e, and 15i showed more potent or equipotent antiviral activity against H1N1, H5N1, and H5N8 viruses compared to OSC in cellular assays. Furthermore, compounds 12e and 15e exhibited high metabolic stability in human liver microsomes (HLMs) and low inhibitory effect on main cytochrome P450 (CYP) enzymes, as well as low acute/subacute toxicity and certain antiviral efficacy in vivo. Also, pharmacokinetic (PK) and molecular docking studies were performed. Overall, 12e and 15e possess great potential to serve as anti-influenza candidates and are worthy of further investigation.

Association Between Baloxavir Marboxil Prescription for Children with Influenza B Infections and Short-Term Healthcare Consumption in Japan During the 2018-2019 Influenza Season

BACKGROUND

Baloxavir marboxil is an anti-influenza medication that was newly introduced into clinical practice in 2018. Baloxavir might be more beneficial than neuraminidase inhibitors (NAIs), as suggested by a subgroup analysis of a clinical trial. Although the association between baloxavir prescription and healthcare use pertains mainly to influenza A, few studies have investigated the association in influenza B.

METHODS

We evaluated the healthcare utilization of children (0-15 years old) treated with either baloxavir or NAIs between December 2018 and May 2019 using claims records in Japan. The primary endpoint was the composite of medical resource utilization, including hospitalization, antibiotic use, laboratory tests, radiological images, and fluid replacement therapy, over 1-9 days after antiviral prescription. Secondary outcomes representing each single outcome in the composite were examined. Subgroup analyses comparing baloxavir with each NAI were also performed.

RESULTS

Of 4490 patients with influenza B who received antiviral treatment, 51.6% were male, and the median age was 8 years old. Baloxavir was prescribed for 29.4% of the population, and NAIs were prescribed for 70.6%. In the total cohort, 49.3% of patients had any comorbidity related to complicated influenza infection. Concerning the composite endpoint, baloxavir prescription was not associated with a risk of subsequent medical resource use (adjusted odds ratio 1.11; 95% confidence interval 0.90-1.38; P = 0.34). Secondary outcomes and subgroup analyses showed similar results to the primary outcome.

CONCLUSIONS

In a single-year comparative study in Japan, baloxavir prescription for influenza B was not associated with less healthcare consumption than NAIs within 9 days of treatment.

The Hypothiocyanite and Amantadine Combination Treatment Prevents Lethal Influenza A Virus Infection in Mice

The influenza virus has a large clinical burden and is associated with significant mortality and morbidity. The development of effective drugs for the treatment or prevention of influenza is important in order to reduce its impact. Adamantanes and neuraminidase inhibitors are two classes of anti-influenza drugs in which resistance has developed; thus, there is an urgent need to explore new therapeutic options. Boosting antiviral innate immune mechanisms in the airways represents an attractive approach. Hypothiocyanite (OSCN-) is produced by the airway epithelium and is effective in reducing the replication of several influenza A virus strains in vitro. It remains, however, largely unexplored whether OSCN- has such an antiviral effect in vivo. Here we determined the therapeutic potential of OSCN-, alone or in combination with amantadine (AMT), in preventing lethal influenza A virus replication in mice and in vitro. Mice intranasally infected with a lethal dose of A/Puerto Rico/8/1934 (H1N1) or A/Hong Kong/8/1968 (H3N2) were cured by the combination treatment of OSCN- and AMT. Monotherapy with OSCN- or AMT alone did not substantially improve survival outcomes. However, AMT+OSCN- treatment significantly inhibited viral replication, and in vitro treatment inhibited viral entry and nuclear transport of different influenza A virus strains (H1N1 and H3N2) including the AMT-resistant strain A/WSN/33 (H1N1). A triple combination treatment consisting of AMT, oseltamivir, and OSCN- was also tested and further inhibited in vitro viral replication of the AMT-resistant A/WSN/33 strain. These results suggest that OSCN- is a promising anti-influenza treatment option when combined with other antiviral drugs.

Evaluation of the Clinical Effectiveness of Oseltamivir for Influenza Treatment in Children

Objective: To estimate the clinical effectiveness of oseltamivir in children with different subtypes of influenza virus infection.

Methods: A total of 998 children with acute respiratory infection were enrolled from January to March 2018, and were divided into influenza A, influenza B, influenza A + B, and non-influenza infection (IV-negative) groups. Influenza-like symptoms and duration of fever were evaluated and compared between oseltamivir-treated and non-treated groups.

Results: There were no significant differences in the reduction in total febrile period and duration of fever from the onset of therapy between the oseltamivir treated and non-treated children infected with influenza A (p = 0.6885 for total febrile period and 0.7904 for the duration of fever from the onset of treatment), influenza B (p = 0.1462 and 0.1966), influenza A + B (p = 0.5568 and 0.9320), and IV-negative (p = 0.7631 and 0.4655). The duration of fever in children received oseltamivir therapy within 48 h was not significantly shorter than that beyond 48 h (p > 0.05). Additionally, percentages and severities of influenza-like symptoms, including headache, myalgia, fatigue, bellyache, vomiting, diarrhea, sore throat, cough, and coryza were not decreased and alleviated after treatment of oseltamivir.

Conclusion: Oseltamivir treatment does not significantly shorten the duration of fever, nor does it significantly relieve influenza-like symptoms in children with infection of influenza.

Antiviral Drugs in Influenza

Flu is a serious health, medical, and economic problem, but no therapy is yet available that has satisfactory results and reduces the occurrence of these problems. Nearly 20 years after the registration of the previous therapy, baloxavir marboxil, a drug with a new mechanism of action, recently appeared on the market. This is a promising step in the fight against the influenza virus. This article presents the possibilities of using all available antiviral drugs specific for influenza A and B. We compare all currently recommended anti-influenza medications, considering their mechanisms of action, administration, indications, target groups, effectiveness, and safety profiles. We demonstrate that baloxavir marboxil presents a similar safety and efficacy profile to those of drugs already used in the treatment of influenza. Further research on combination therapy is highly recommended and may have promising results.

Update on Viral Infections Involving the Central Nervous System in Pediatric Patients

Infections of the central nervous system (CNS) are mainly caused by viruses, and these infections can be life-threatening in pediatric patients. Although the prognosis of CNS infections is often favorable, mortality and long-term sequelae can occur. The aims of this narrative review were to describe the specific microbiological and clinical features of the most frequent pathogens and to provide an update on the diagnostic approaches and treatment strategies for viral CNS infections in children. A literature analysis showed that the most common pathogens worldwide are enteroviruses, arboviruses, parechoviruses, and herpesviruses, with variable prevalence rates in different countries. Lumbar puncture (LP) should be performed as soon as possible when CNS infection is suspected, and cerebrospinal fluid (CSF) samples should always be sent for polymerase chain reaction (PCR) analysis. Due to the lack of specific therapies, the management of viral CNS infections is mainly based on supportive care, and empiric treatment against herpes simplex virus (HSV) infection should be started as soon as possible. Some researchers have questioned the role of acyclovir as an empiric antiviral in older children due to the low incidence of HSV infection in this population and observed that HSV encephalitis may be clinically recognizable beyond neonatal age. However, the real benefit-risk ratio of selective approaches is unclear, and further studies are needed to define appropriate indications for empiric acyclovir. Research is needed to find specific therapies for emerging pathogens. Moreover, the appropriate timing of monitoring neurological development, performing neuroimaging evaluations and investigating the effectiveness of rehabilitation during follow-up should be evaluated with long-term studies.

Association of baloxavir marboxil prescription with subsequent medical resource utilization among school-aged children with influenza

PURPOSE

Baloxavir marboxil is a novel antiviral agent for influenza, introduced into clinical practice in 2018. A concern remains about the variant virus with reduced susceptibility after baloxavir exposure and its clinical consequences such as healthcare-seeking behavior.

METHODS

Using a healthcare database in Japan, we compared the medical resource use following baloxavir and neuraminidase inhibitors (NAIs) treatment among children aged 7-15 years. The study period was from December 2018 to March 2019. The primary endpoint was the composite of hospitalization, laboratory and radiological tests, and antibiotic use over 1-9 days of antiviral treatment. As exploratory analyses, secondary outcomes being each single component of the primary composite were assessed and subgroup analyses comparing baloxavir with each NAI were done.

RESULTS

Data from 115 867 prescriptions in 115 238 children were analyzed (median age: 10 years; severe influenza risk in 26%; baloxavir accounting for 43%). Overall, baloxavir use did not increase subsequent medical resource utilization in the composite endpoint (adjusted odds ratio [aOR]: 1.04; 95% confidence interval [CI]: 0.99-1.09; P = 0.14), as were likelihoods of other secondary outcomes. In the subgroup analysis, baloxavir use was associated with higher medical resource use than oseltamivir (aOR: 1.21; 95% CI: 1.13-1.31; P < 0.001) and lower resource use than zanamivir (aOR: 0.93; 95% CI 0.86-1.00; P = 0.040).

CONCLUSIONS

Based on a single-year experience in Japan, prescribing baloxavir rather than NAIs did not increase medical resource utilization within 9 days of treatment, except in one exploratory comparison with oseltamivir.

A large number of COVID-19 interventional clinical trials were registered soon after the pandemic onset: a descriptive analysis

BACKGROUND AND OBJECTIVE

There is a pressing need for evidence-based interventions to address the devastating clinical and public health effects of the coronavirus disease 2019 (COVID-19) pandemic. The number of registered trials related to COVID-19 is increasing by the day. The objective of this study was to describe the characteristics of the currently registered interventional clinical trials related to COVID-19.

METHODS

We searched the World Health Organization's International Clinical Trials Registry Platform on May 15th, 2020. We included any entry that is related to COVID-19. We abstracted and then descriptively analyzed the following characteristics of the registered trials: study design, status, phase, primary endpoints, experimental interventions, and geographic location among other qualifiers.

RESULTS

We identified 1,308 eligible registered trials. Most trials were registered with ClinicalTrials.gov (n = 703; 53.7%) and the Chinese Clinical Trial Registry (n = 291; 22.2%). The number of participants to be enrolled across these trials was 734,657, with a median of 110 participants per trial. The most commonly studied intervention category was pharmacologic (n = 763; 58.3%), with antiparasitic medications being the most common subcategory. Although over half of the trials were already recruiting, we identified published peer-reviewed results for only 8 of those trials.

CONCLUSION

There is a relatively large number of registered trials but with very few results published so far. Although our findings suggest an appropriate initial response by the research community, the real challenge will be to get these trials completed, published, and translated into practice and policy.

How does one choose the appropriate pharmacotherapy for children with lower respiratory tract infections?

INTRODUCTION

The definition of acute lower respiratory tract infection (LRTI) includes any infection involving the respiratory tract below the level of the larynx. In children, the most common acute LRTIs, and those with the greatest clinical relevance, are community-acquired pneumonia (CAP), bronchiolitis, bronchitis and tuberculosis (TB). The clinical relevance of LRTIs implies that they must be addressed with the most effective therapy. Antibiotics and antivirals play an essential role in this regard.

AREAS COVERED

In this paper, the most recent advances in the drug treatment of LRTIs in children are discussed.

EXPERT OPINION

Although LRTIs are extremely common and one of the most important causes of hospitalization and death in children, anti-infective therapy for these diseases remains unsatisfactory. For CAP and BR, the most important problem is the overuse and misuse of antibiotics; for BCL, the lack of drugs with demonstrated efficacy, safety and tolerability; for TB, the poor knowledge on the true efficacy and safety of the new drugs specifically planned to overcome the problem of MDR M. tuberculosis strains. There is still a long way to go for the therapy of pediatric LRTIs to be considered satisfactory.

Preparation of 1,6-di-deoxy-d-galacto and 1,6-di-deoxy-l-altro nojirimycin derivatives by aminocyclization of a 1,5-dicarbonyl derivative

Iminosugars are known glycosidase inhibitors which are the subject of drug development efforts against several diseases. The access to structurally-related families of iminosugars is of primary importance for running structure-activity relationship studies. In this work, the double reductive amination (aminocyclization) reaction of a dicarbonyl derivative of the l-arabino series, in turn obtained from lactose, is reported. Different ratios of 1,6-di-deoxy-d-galacto and 1,6-di-deoxy-l-altro nojirimycin derivatives were obtained depending on the amine employed in this transformation which provided an insight into the effects of their structure on the outcome of the reaction. Of particular interest were the results obtained when two enantiomeric amino acids (d-Phe-OMe and l-Phe-OMe) were used, which resulted in the inversion of the reaction stereoselectivity.

Drugs for Influenza Treatment: Is There Significant News?

Vaccines remain the best measure to reduce total influenza burden. However, presently available influenza vaccines have some limitations that cause a reduced efficacy compared to immunization practices with other respiratory pathogens. This paper shows the clinical roles of antiviral drugs against influenza that have been licensed in at least one country and the potential roles of compounds that are in development. Several attempts have been made to develop new agents against influenza viruses to overcome the supposed or demonstrated limitations of neuraminidase inhibitors (NAIs). Antibodies against the highly conserved stem region of the haemagglutinin molecule of influenza A viruses and drugs that target different stages of the influenza virus life cycle than NAIs in human cells have been developed and tested. Among these preparations, baloxavir marboxil (BAM), and favipiravir (FP) (i.e., polymerase inhibitors) are the only drugs that have reached the market (the first in Japan and the USA, and the second only in Japan). Other antiviral compounds and monoclonal antibodies are in advanced stage of development, but none of these new drugs and monoclonal antibodies in development have adequate characteristics to substitute for NAIs at present. However, although NAIs remain the drug of choice for influenza treatment, their overuse has to be avoided. Accurate selection of patients for whom treatment is truly needed is required.

Chirality sensing of bioactive compounds with amino alcohol unit via circular dichroism

The aim of the present work was to test various chiroptical techniques, including in particular the in situ dirhodium methodology, to assign the absolute configuration of 1,2- and 1,3-amino alcohols. As models, we selected mainly compounds that have both an additional strongly absorbing and interfering chromophoric system and application in medicinal chemistry. Determination of the absolute configuration (AC) of the tested molecules such as cinchona alkaloids, Tamiflu, and others was carried out using a combination of electronic and vibrational circular dichroism (ECD, VCD) spectroscopy. It has been demonstrated that both 1,2- and 1,3-aminol moieties are subject to the same sector rule correlating stereostructure of formed Rh₂ -complex with chiroptical properties, and that the changes in the position of the stereogenic center do not affect its proper use.

The role of the NxTAG® respiratory pathogen panel assay and other multiplex platforms in clinical practice

INTRODUCTION

The advent of nucleic acid amplification tests has significantly improved the aetiologic diagnosis of respiratory infections. However, multiplex real-time polymerase chain reaction (PCR) can be technologically challenging. Areas covered: This paper reports the results of the main published studies on the NxTAG Respiratory Pathogen Panel (RPP) and discusses the advantages and disadvantages of extensive use of multiplex assays in clinical practice. Expert commentary: Currently available data seem to indicate that routine use of multiplex assays, including NxTAG RPP Assay, should be recommended only when epidemiological data concerning circulation of viruses and bacteria have to be collected. Their use in clinical practice seems debatable. They have limited sensitivity and specificity at least in the identification of some infectious agents or, as in the case of NxTAG RPP, they have not been evaluated in a sufficient number of patients to allow definitive conclusions. In the future, the clinical relevance of multiplex assays, including NxTAG RPP, could significantly increase, mainly because a number of new antiviral agents effective against several respiratory viruses for which no drug is presently available will be marketed. In addition, it is highly likely that the efficiency of multiplex assays will be significantly improved.