Antiviral Medications in Seasonal and Pandemic Influenza

Sex differences in factors influencing hospital-acquired pneumonia in schizophrenia patients receiving modified electroconvulsive therapy

BACKGROUND

Sex differences may be presented in the clinical features or symptoms of schizophrenia patients but also affect the occurrence of hospital-acquired pneumonia (HAP). Modified electroconvulsive therapy (mECT) is a common treatment method for schizophrenia, used in combination with antipsychotics. This retrospective research explores the sex difference in HAP affecting patients with schizophrenia who have received mECT treatment during hospitalization.

METHODS

We included schizophrenia inpatients treated with mECT and antipsychotics between January 2015 and April 2022. Blood-related and demographic data collected on admission were analyzed. Influencing factors of HAP in male and female groups were assessed separately.

RESULTS

A total of 951 schizophrenia patients treated with mECT were enrolled in the study, including 375 males and 576 females, of which 62 patients experienced HAP during hospitalization. The risk period of HAP in these patients was found to be the first day after each mECT treatment and the first three sessions of mECT treatment. Statistically significant differences in the incidence of HAP were identified in male vs. female groups, with an incidence in men about 2.3 times higher than that in women (P < 0.001). Lower total cholesterol (Z = -2.147, P = 0.032) and the use of anti-parkinsonian drugs (χ² = 17.973, P < 0.001) were found to be independent risk factors of HAP in male patients, while lower lymphocyte count (Z = -2.408, P = 0.016), hypertension (χ² = 9.096, P = 0.003), and use of sedative-hypnotic drugs (χ² = 13.636, P < 0.001) were identified in female patients.

CONCLUSION

Influencing factors of HAP in schizophrenia patients treated with mECT have gender differences. The first day after each mECT treatment and the first three sessions of mECT treatment were identified to have the greatest risk for HAP development. Therefore, it would be imperative to monitor clinical management and medications during this period according to these gender differences.

Bifunctional Inhibitors of Influenza Virus Neuraminidase: Molecular Design of a Sulfonamide Linker

The growing resistance of the influenza virus to widely used competitive neuraminidase inhibitors occupying the active site of the enzyme requires the development of bifunctional compounds that can simultaneously interact with other regulatory sites on the protein surface. When developing such an inhibitor and combining structural fragments that could be located in the sialic acid cavity of the active site and the adjacent 430-cavity, it is necessary to select a suitable linker not only for connecting the fragments, but also to ensure effective interactions with the unique arginine triad Arg118-Arg292-Arg371 of neuraminidase. Using molecular modeling, we have demonstrated the usefulness of the sulfonamide group in the linker design and the potential advantage of this functional group over other isosteric analogues.

The evolution and future of influenza pandemic preparedness

The influenza virus is a global threat to human health causing unpredictable yet recurring pandemics, the last four emerging over the course of a hundred years. As our knowledge of influenza virus evolution, distribution, and transmission has increased, paths to pandemic preparedness have become apparent. In the 1950s, the World Health Organization (WHO) established a global influenza surveillance network that is now composed of institutions in 122 member states. This and other surveillance networks monitor circulating influenza strains in humans and animal reservoirs and are primed to detect influenza strains with pandemic potential. Both the United States Centers for Disease Control and Prevention and the WHO have also developed pandemic risk assessment tools that evaluate specific aspects of emerging influenza strains to develop a systematic process of determining research and funding priorities according to the risk of emergence and potential impact. Here, we review the history of influenza pandemic preparedness and the current state of preparedness, and we propose additional measures for improvement. We also comment on the intersection between the influenza pandemic preparedness network and the current SARS-CoV-2 crisis. We must continually evaluate and revise our risk assessment and pandemic preparedness plans and incorporate new information gathered from research and global crises.

Prophylaxis and treatment of influenza: options, antiviral susceptibility, and existing recommendations

Influenza viruses of types A and B attack 5-10% of adults and 20-30% of children, thereby causing millions of acute respiratory infections in Germany annually. A significant number of these infections are associated with complications such as pneumonia and bacterial superinfections that need hospitalization and might lead to death. In addition to vaccines, drugs were developed that might support influenza prevention and that can be used to treat influenza patients. The timely application of anti-influenza drugs can inhibit virus replication, help reduce and shorten the symptoms, and prevent death as well as virus transmission. This review concisely describes the mechanism of action, the potential for prophylactic and therapeutic use, and the knowledge on resistance of anti-influenza drugs approved today. However, the main aim is to give an overview on the recommendations available in Germany for the proper use of these drugs. In doing so, the recommendations published in statements and guidelines of medical societies as well as the German influenza pandemic preparedness plan are summarized with the consideration of specific circumstances and groups of patients.

Point-of-care testing for influenza in a university emergency department: A prospective study

BACKGROUND

Seasonal influenza is a burden for emergency departments (ED). The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures.

OBJECTIVES

The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures.

METHODS

Using a cross-over design, the cobas® Liat® Influenza A/B POC PCR test (Liat) was compared with standard clinical practice during the 2019/2020 influenza season. All adult patients (aged ≥ 18 years) with fever (≥38°C) and respiratory symptoms were included. Primary end points were the prevalence of influenza infections in the ED and staff sick days. Secondary end points were frequency of antiviral and antibacterial therapy, time between admission and test result or treatment initiation, patient disposition, ED length of stay (LOS), and for inpatients mortality and LOS. Nurses were interviewed about handling and integration of POC testing. The occurrence of SARS-CoV-2 infections coincided with the second half of the study.

RESULTS

A total of 828 patients were enrolled in the study. All 375 patients of the intervention group were tested with Liat, and 103 patients of them (27.6%) tested positive. During the intervention period, staff sick days were reduced by 34.4% (P = .023). Significantly, more patients in the intervention group received antiviral therapy with neuraminidase inhibitors (7.2% vs 3.8%, P = .028) and tested patients received antibiotics more frequently (40.0% vs 31.6%, P = .033). Patients with POC test were transferred to external hospitals significantly more often (5.6% vs 1.3%, P = .01).

CONCLUSION

We conclude that POC testing for influenza is useful in the ED, especially if it is heavily frequented by patients with respiratory symptoms.

Increasing Influenza Vaccination Rates in People With Chronic Illness

BACKGROUND

The safety and efficacy of influenza vaccination for the chronically ill are clearly supported by the evidence, yet vaccination rates in this vulnerable popu- lation remain low. This leads to many avoidable hospitalizations and deaths in Germany every year. The goal of this systematic review is to identify measures in primary care medicine that can be used to increase influenza vaccination rates among the chronically ill.

METHODS

This review was carried out as recommended in the PRISMA statement. A systematic literature search was performed. Only randomized, controlled trials were included in the analysis. Details can be found in the study protocol (PROSPERO, CRD42018114163).

RESULTS

15 trials were included in the analysis. Training sessions for medical practice teams focusing on a particular disease raised the vaccination rates by as much as 22%. A financial incentive had the greatest effect (relative risk [RR]: 2.79; 95% confidence interval: [1.18; 6.62]). Reminders via text message yielded a maximum 3.8% absolute increase in vaccination rates. Complex interventions were not found to be of any greater benefit than simple ones.

CONCLUSION

A variety of approaches can be effective. Focusing training sessions for medical practice teams on certain diseases may be of greater benefit than vacci- nation-centered training sessions. Reminder systems for doctors should be more reliably implemented. Simple strategies are perhaps the most suitable ones in the heterogeneous population of chronically ill persons. The limitations of this system- atic review include the heterogeneity of the studies that we examined and the small number of studies in each category.

[Influenza]

BACKGROUND

The influenza virus (IV)-associated mortality and morbidity remains high in Europe.

OBJECTIVE

This article gives an overview of the pathogenesis, diagnostics and treatment optimization strategies according to the currently existing guidelines and clinical trials.

MATERIAL AND METHODS

Literature search and analysis of national and international guidelines for the epidemiology, diagnostics, treatment and prevention of IV infections.

RESULTS AND CONCLUSION

Although the incidence of IV infections remains underrecognized, it is the leading infectious disease-associated cause of mortality and morbidity in Europe. Viruses are mainly transmitted by aerosol inhalation and can cause a wide spectrum of symptoms, ranging from mild signs of a cold to severe respiratory failure requiring mechanical ventilation. The clinical diagnosis should be verified through a PCR-based test in patients with indications for treatment. Neuraminidase inhibitors are currently the treatment of choice for IV infections. Seasonal influenza vaccination is an efficient preventive method. It is therefore imperative to improve vaccination rates in Germany, which have been continuously declining since the pandemic of 2009/2010.

Cost-Benefit Analysis of Real-Time Influenza Testing for Patients in German Emergency Rooms

Background: Seasonal influenza causes significant morbidity worldwide and has a substantial economic impact on the healthcare system. Objective: To assess the cost–benefit relation of implementing a real-time influenza test in emergency rooms (ER) of German hospitals. Methods: A deterministic decision-analytic model was developed simulating the incremental costs of using the Solana^® Influenza A+B test, compared to those of using conventional clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients, in German ER, prior to hospitalization. Direct costs were evaluated from the hospital perspective, considering resource use directly related to influenza testing and treatment, as well as indirect costs incurred by nosocomial influenza transmission. Results: Through base-case analysis and assuming an influenza prevalence of 42.6%, real-time testing with Solana^® reduced average costs of hospitalized ILI patients by €132.61, per tested patient. Moreover, the Solana^® saved €6.9 per tested patient in favor of the hospital. In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Solana^® saved on average €144.13 as compared to applying the clinical-judgement-only strategy, thus, it was found to be constantly less expensive. Conclusions: Using highly sensitive and specific real-time influenza tests in ILI patients at German ER might significantly reduce hospital expenditures

Impact of Obesity on Influenza A Virus Pathogenesis, Immune Response, and Evolution

With the rising prevalence of obesity has come an increasing awareness of its impact on communicable disease. As a consequence of the 2009 H1N1 influenza A virus pandemic, obesity was identified for the first time as a risk factor for increased disease severity and mortality in infected individuals. Over-nutrition that results in obesity causes a chronic state of meta-inflammation with systemic implications for immunity. Obese hosts exhibit delayed and blunted antiviral responses to influenza virus infection, and they experience poor recovery from the disease. Furthermore, the efficacy of antivirals and vaccines is reduced in this population and obesity may also play a role in altering the viral life cycle, thus complementing the already weakened immune response and leading to severe pathogenesis. Case studies and basic research in human cohorts and animal models have highlighted the prolonged viral shed in the obese host, as well as a microenvironment that permits the emergence of virulent minor variants. This review focuses on influenza A virus pathogenesis in the obese host, and on the impact of obesity on the antiviral response, viral shed, and viral evolution. We comprehensively analyze the recent literature on how and why viral pathogenesis is altered in the obese host along with the impact of the altered host and pathogenic state on viral evolutionary dynamics in multiple models. Finally, we summarized the effectiveness of current vaccines and antivirals in this populations and the questions that remain to be answered. If current trends continue, nearly 50% of the worldwide population is projected to be obese by 2050. This population will have a growing impact on both non-communicable and communicable diseases and may affect global evolutionary trends of influenza virus.

Luteolin decreases the yield of influenza A virus in vitro by interfering with the coat protein I complex expression

Influenza is an acute transmissible respiratory infectious disease in humans and animals with high morbidity and mortality. It was reported that luteolin, extracted from Chinese herbs, could potently inhibit influenza virus replication in vitro. To assess the effect and explore the fundamental mechanism of luteolin, we infected several cell lines with two subtypes of influenza A virus (IAV), including A/Jiangxi/312/2006 (H3N2) and A/Fort Monmouth/1/1947 (H1N1) and demonstrated that luteolin suppressed the replication of IAV by cytopathic effect reduction method, qRT-PCR, immunofluorescence and Western blot assays. A time-of-addition assay indicated that this compound interfered with viral replication at the early stage of infection. In addition, we found that luteolin suppressed coat protein I complex expression, which was related to influenza virus entry and endocytic pathway. Overall, our findings demonstrated the antiviral effect of luteolin against IAV and its novel antiviral mechanism.

Rapid Point-of-Care Influenza Testing for Patients in German Emergency Rooms - A Cost-Benefit Analysis

BACKGROUND

Each year, influenza causes significant morbidity and death worldwide and produces significant economic losses at the expense of the healthcare system.

OBJECTIVE

To assess the cost-benefit relationship of implementing a rapid point-of-care (POC) influenza test in emergency rooms (ERs) of German hospitals.

METHODS

A deterministic decision-analytic model simulated the incremental costs of using the Sofia^® Influenza A+B test compared to those of using clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients in German ERs prior to hospitalization. Direct costs, with and without subsequent oseltamivir treatment, were evaluated from the hospital perspective as well as indirect costs incurred by nosocomial influenza transmission to hospital employees.

RESULTS

In base-case analysis, taking the influenza prevalence of 25.9% in the season 2018/2019 and assuming a hospitalization rate among influenza suspects of 21.9%, rapid testing with the Sofia^® followed by administering oseltamivir to patients testing positive reduced average costs of hospitalized ILI patients by €52.16 per tested patient. If oseltamivir was not offered, testing with the Sofia^® reduced costs by €42.28 in favor of the hospital.In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Sofia^® saved on average €119.89 as compared to applying the clinical-judgement-only strategy. The major part of the cost savings, €113.17 or 94.4%, was due to the POC test's high specificity, which led to 91% reduction in needless bed-blocking on the first day of hospitalization. However, as the sensitivity of 75.3% was only slightly higher than that of conventional clinical judgement, improved classification of patients with true influenza and a correspondingly lower rate of illness in hospital employees could not be achieved.

CONCLUSIONS

Using highly specific rapid POC influenza tests in ILI patients at German ER, despite their sub-optimal sensitivity, may significantly reduce hospital expenditures.

Community-Acquired Pneumonia in Adults

BACKGROUND

The clinical spectrum of community-acquired pneumonia ranges from infections that can be treated on an outpatient basis, with 1% mortality, to those that present as medical emergencies, with a mortality above 40%.

METHODS

This article is based on pertinent publications and current guidelines retrieved by a selective search of the literature.

RESULTS

The radiological demonstration of an infiltrate is required for the differentiation of pneumonia from acute bronchitis regardless of whether the patient is seen in the outpatient setting or in the emergency room. For risk prediction, it is recommended that the CRB-65 criteria, unstable comorbidities, and oxygenation should be taken into account. Amoxicillin is the drug of choice for mild pneumonia; it should be given in combination with clavulanic acid if there are any comorbid illnesses. The main clinical concerns in the emergency room are the identification of acute organ dysfunction and the management of sepsis. Intravenous beta-lactam antibiotics should be given initially, in combination with a macrolide if acute organ dysfunction is present. The treatment should be continued for 5-7 days. Cardiovascular complications worsen the patient's prognosis and should be meticulously watched for. Structured followup care includes the follow-up of comorbid conditions and the initiation of recommended preventive measures such as antipneumococcal and anti-influenza vaccination, the avoidance of drugs that increase the risk, smoking cessation, and treatment of dysphagia, if present.

CONCLUSION

Major considerations include appropriate risk stratification and the implementation of a management strategy adapted to the degree of severity of the disease, along with the establishment of structured follow-up care and secondary prevention, especially for patients with comorbidities.