To Tamiflu or Not to Tamiflu?

 

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Sherita Holmes, MD sherita.holmes@emory.edu

Every year we expect a flu epidemic which usually starts in the fall and lasts until spring (as early as October and last until late May).  According to the most recent CDC Weekly U.S. Influenza Surveillance Report (week 8 – February 25th), flu activity remains elevated in the United States; although it appears to be downtrending.1
We know that in a majority of patients; the flu manifests as a nuisance that causes our patients to have high fevers with self-limited respiratory symptoms, fatigue, and myalgias. However, we also know that in the very young (age < 2 years) or very old (age > 65 years) as well as those with underlying medical conditions (i.e. asthma, immunosuppression, diabetes, heart disease) [see Table 1]; the flu can be fatal. This flu season there have been 40 pediatric deaths reported thus far [Figure 1].1 This underscores the importance of prevention and why it is critical that we encourage flu vaccination, especially in these high risk groups.

 

While vaccination is important in preventing influenza, we can use antiviral medications to shorten the length of illness (by 1-2 days), reduce complications such as pneumonia, and lessen severity.2 Antiviral medications should be started as soon as possible – ideally within the first 48 hours of illness – for any patient with suspected or confirmed influenza who: has severe, complicated, or progressive illness; is in a high risk group; or is hospitalized.3 Consider chemoprophylaxis in patients in high risk groups with known exposure to influenza.

 

There are two classes of antivirals for influenza: neuraminidase inhibitors (oseltamivir, zanamivir) and adamantanes (amantadine, rimantadine). The adamantanes are not effective against influenza B and there are high levels of resistance against the current influenza A viruses. For 2016-2017 flu season, the CDC only recommends using the neuraminidase class of antivirals. Oseltamivir (Tamiflu) is available in pill or liquid form, while zanamivir (Relenza) only available in inhaled form. Please refer to Tables 2 and 3 for further information regarding antiviral medication age designations, contraindications, adverse effects, and dosages.3,4

 

In the battle against influenza, we must do our best to not only identify the appropriate patients that would benefit from antiviral medications, but most importantly to encourage all patients and their loved ones to get vaccinated.

 

 

 

 

CDC https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

Table 3 Harper et al. https://doi.org/10.1086/598513

 

 

 

 

 

References:

 

  1. CDC Weekly U.S. Influenza Surveillance Report

https://gis.cdc.gov/grasp/fluview/flu_by_age_virus.html

 

  1. Campbell, Angela. CDC Expert Commentary 2016-2017 Influenza Antiviral Recommendations

http://www.medscape.com/partners/cdc/public/cdc-commentary

 

  1. Centers for Disease Control (CDC) and Prevention 2016-2017 Flu Season

https://www.cdc.gov/flu/about/season/current.htm

 

  1. Harper, S.A., Bradley, J.S., Englund, J.A., et al. Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America

https://doi.org/10.1086/598513

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Fever, Viral Symptoms and Testing for Viruses

 

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by Becky Burger, MD

BeckyBurger@emory.edu

As we approach respiratory viral season, we wanted to share our emergency department guideline for performing viral testing via the Respiratory Viral Panel (RVP) test. The RVP is a nasal swab test that detects viruses including influenza, RSV, and several other viruses. The turnaround time for the RVP result is between one and three hours. We have found that these tests sometimes delay disposition and often don’t change management of the patient in the ED. Our quality improvement committee developed the guidance below to optimize RVP testing in the ED.   Please note that we do not perform the new molecular rapid influenza test in the emergency departments at Children’s.

For ED patients being discharged home:

  • RVP usually not indicatedHealthy patients with viral symptoms.   This is because of the following reasons:
  • Prolonged positivity of RVPs from prior illnesses (unrelated to current symptoms)
  • Multiple positives
  • False sense of security
  • Management can usually be based on clinical grounds (e.g. treating influenza in high-flu season)
  • RVP may be done on a case-by-case basisPatients with underlying chronic medical condition, or patients in the age range 4-8 week old with fever etc. where a positive test may change management– in such instances, RVP is helpful only if we wait for result of the test for further decision making such as extent of work up, admission vs. discharge, etc.

For ED patients who require admission:

  • RVP indicatedImmunocompromised patients (such as transplants and certain chronic medical conditions) and other patients at high risk for complications of infection.
  • RVP usually not necessaryImmunocompetent patients (with or without chronic medical problems) – inpatient team may choose to order it themselves if desired.
  • All inpatient rooms at Children’s are private rooms so we don’t need to use RVPs for cohorting purposes.  Also, all respiratory illness patients need appropriate infection control precautions regardless of the result of the RVP.

We do not recommend referral to the emergency department just for RVP testing in well appearing children who have symptoms consistent with viral respiratory infection. For patients with symptoms concerning for influenza who are at higher risk (based on age, severity, or underlying medical conditions), treatment with antiviral medications can be started without the need for lab confirmation of influenza, (particularly during high flu prevalence).

If you have any questions about RVP testing, feel free to contact: Becky Burger, MD, BeckyBurger@emory.edu