Goldschmidt tables.doc

MINA MATIN, MD, and RONALD H. GOLDSCHMIDT, MD American Family Physician November 15, 2010 University of California, San Francisco Online Table A. Influenza Management Guide 2010-2011
BACKGROUND
2009 H1N1
Other Seasonal Influenza
Special Considerations for HIV-
Positive Patients
Culprit viruses
2009 H1N1, a subtype of
Commonly H3N2, another
Sporadic cases of influenza have primarily been 2009 H1N1 influenza A, also known as
subtype of influenza A
since the 2009-2010 influenza season, although H3N2 and influenza B have had increasing incidence worldwide.
Influenza B
Route of transmission
Infectious period begins 24 hours before symptom onset and extends to 24 hours after fever ends. Amount of viral shedding correlates with the magnitude of fever.
Health care personnel precautions: do not return to work until 24 hours after fever ends or seven days post onset of Patients receiving antiviral treatment continue to be potentially infectious for four or more days after treatmentinitiation.
Aerosol is a possible route of transmission, although limited to short distances of possibly a few feet.
Surgical face masks recommended for health care personnel caring for known or suspected infected patients.
Wash hands often. Use alcohol-based hand sanitizer when Avoid touching face, especially eyes, nose, or mouth.
Avoid close contact with sick people.
Maintain healthy lifestyle (e.g., balanced diet, sleep Symptoms
Abrupt onset of influenza-like
Abrupt onset of influenza-like
Nausea, vomiting, and diarrhea reported more frequently with 2009 H1N1 than other seasonal influenza.
Probability of influenza as etiology when a patient presents course of illness might be prolonged.
with influenza-like illness: in season - approximately counts are at higher risk of lowerrespiratory tract infections andrecurrent pneumonias.
Persons most susceptible to
Infants and young children at highest risk of severe disease infection
Little is known about prevention of influenza in infants.
Vaccination of pregnant women might also provide a degree of protection for their infants. Infants younger than 6 months are not candidates for vaccination. If possible, adults who are not sick should care for infants, includingfeedings—pumped milk.
NOTE: Influenza transmission through breast milk is unlikely; reports of viremia with seasonal influenza arerare, suggesting that risk of virus crossing into breast milkprobably is rare.
BACKGROUND
2009 H1N1
Other Seasonal Influenza
Special Considerations for HIV-Positive
Patients
Highest rates of
Patients at high risk of influenza-related complications:
Historically, HIV-positive patients have had hospitalization and
Age younger than 5 years, especially younger than 2 years Pregnancy (up to two weeks postpartum, including Certain chronic medical conditions (e.g., lung disease [including asthma, chronic obstructive pulmonary Ensure that HIV-positive patients are up
disease], cardiovascular [excluding hypertension], renal, to date on pneumococcal vaccinations.
hepatic, conditions with increased risk of aspiration,hematologic, or metabolic [e.g., diabetes]) Immunosuppression, including HIVPersons younger than 19 years who are receiving long-term Obesity (BMI > 30 kg per m2, and particularly if BMI > 40) Cause of death is usually bacterial superinfections, most commonly staphylococcal and pneumococcal pneumonia.
NOTE: Minority of patients with indications for
pneumococcal vaccination have actually been
vaccinated.
DIAGNOSIS
2009 H1N1
Other Seasonal Influenza
Special Considerations for HIV-Positive
Patients
Testing usually not warranted; management is by clinical Testing generally restricted to settings where management is impacted (e.g., in hospitalizations where isolation of patient with influenza would be required).
If testing is pursued, specimens should be collected as close as possible to onset of symptoms (within first few days).
Utility of RIDT is limited: low sensitivity, low specificity.
False-positive results can occur when disease prevalence is low (e.g., early and late in influenza season). False- negative results can be common when disease prevalence is high (e.g., at the height of influenza season).
RIDT can distinguish between influenzas A and B. Cannot distinguish between subtypes of influenza A.
TREATMENT
2009 H1N1
Other Seasonal Influenza
Special Considerations for HIV-Positive
Patients
Chemoprophylaxis
Early empiric treatment is favored over
chemoprophylaxis to avoid resistance. Early empiric
treatment focuses on ensuring that patients at high risk of complications from influenza have access to antiviral Chemoprophylaxis is generally not recommended.
However, in the rare circumstance that chemoprophylaxis is being considered, it is especially not recommended if more than 48 hours have passed since last contact with an [Symmetrel]), do not use
adamantanes as a sole agent for
chemoprophylaxis or treatment.
TREATMENT
2009 H1N1
Other Seasonal Influenza
Special Considerations for HIV-Positive
Patients
Early Empiric Treatment
Neuraminidase Inhibitor options:
Neuraminidase Inhibitor options:
Most healthy patients with no risk factors for complications HIV-positive patients with influenza-like recover without antiviral medications.
Treat with
Oseltamivir (Tamiflu)
Oseltamivir
neuraminidase
Early empiric treatment of influenza-like illness
inhibitor for five days
recommended for patients at high risk of influenza-
related complications.
chemoprophylaxis, particularly if they are SPECIAL CONSIDERATIONS:
Zanamivir (Relenza)
Zanamivir
Risk of complications decreases if treated with antiviral drugs within 48 hours of symptom onset; might offer Zanamivir: can cause bronchial spasm; do not prescribe for
patients with asthma or chronic lung disease.
Hospitalized patients: treatment may be extended beyond
contraindications for co-administration of five days for complicated illness. Some experts favor double dosage of antivirals; risks and benefits not available HIV antiretroviral medications.
Pregnancy: pregnant women are at high risk of
[Flumadine]), do not use
complications and should receive prompt antiviral adolescents who have received oseltamivir adamantanes as a sole agent for
therapy. Oseltamivir and zanamivir are labeled by the U.S. Food and Drug Administration as “PregnancyCategory C” drugs. Pregnancy is NOT a contraindication Breastfeeding: treatment is not a contraindication to
breastfeeding; ideally, breast milk pumped and fed to Health care personnel: consider chemoprophylaxis if
unvaccinated and within 48 hours of unprotected close contact with confirmed or suspected influenza.
Closed or semi-closed settings (e.g., nursing homes and
chemoprophylaxis if exposure to known influenza occurs.
Generally does NOT include schools, camps, orworkplaces where outbreaks might occur.
Potential adverse effects of oseltamivir in children: nausea and vomiting; taking with food can reduce side effects.
Rare reports of delirium, self-injury among children aftertaking neuraminidase inhibitors, which can also occurwith clinical influenza.
PREVENTION
2010-2011 Influenza Vaccine
Special Considerations for HIV-Positive
Patients
Vaccines
The 2010-2011 influenza vaccine is a trivalent vaccine including 2009 Persons with moderate to severe febrile illness should not be The intranasal live attenuated influenza
H1N1, and seasonal variants H3N2 and influenza B vaccines are contraindicated for HIV-
Most common side effect of injected vaccine is soreness at the injection site. Other adverse effects include fever, Two doses, four or more weeks apart if 6 months to 8 years of age and did body aches, and fatigue. Most common adverse effects of not receive at least one dose of the 2009 H1N1 vaccine plus at least one nasal vaccine include rhinorrhea or nasal congestion, sore dose of the seasonal influenza vaccine previously throat in adults and low-grade fever in children 2 to 6 Injectable vaccine can be given at any CD4 Do not vaccinate patients younger than 6 months
Contraindications to intranasal vaccine include age
NOTE: Household contacts and health
In case of vaccine shortage, Advisory Committee on Immunization younger than 2 years or older than 50 years, pregnancy, care personnel working with HIV-
Practices (ACIP) prioritizes vaccination for the following groups: age younger than 19 years on aspirin therapy (risk of Reye positive patients may receive the
syndrome), chronic illness including asthma, chronic lung intranasal live attenuated vaccine.
Caretakers of infants younger than 6 months disease, heart disease, diabetes, kidney failure, weakened Health care personnel who have direct contact with patients or infectious immune system, or taking immunosuppressive close contacts of patients with severe
Contraindications to intranasal and injectable
formulations include severe or life-threatening allergies
to hen eggs and a history of onset of Guillain-Barrésyndrome during the six weeks after previous vaccination.
Afluria, the trade name of one of the injectable formulations of the vaccine, should not be used in children 6 months
to 8 years of age because of increased frequency of fever
or febrile seizures reported among young children (mostly
children younger than 5 years).
NOTE: As a living document, this table was last reviewed and updated September 30, 2010. This guide will continue to be updated throughout the 2010-2011 influenza season. The latest PDF version of this table isavailable at http://www.nccc.ucsf.edu. BMI = body mass index; CDC = Centers for Disease Control and Prevention; HIV = human immunodeficiency virus. Adapted with permission from Matin M, Goldschmidt RH. Influenza Management Guide 2010-2011. The National HIV/AIDS Clinicians’ Consultation Center (NCCC) is in the University of California, San Francisco (UCSF), Department of Family & Community Medicine at San Francisco General Hospital. 2010. The NCCC is funded by the Health Resources and Services Administration (HRSA) AIDS Education and Training Centers (AETC) Grant No. H4AHA01082, and receives additional funding from the Centers for DiseaseControl and Prevention (CDC). The NCCC’s National HIV Telephone Consultation Service (Warmline) offers health care professionals expert clinical consultation on influenza management in patients affected by HIV. The Warmline is available at 1-800-933-3413, Monday through Friday, 9 a.m. to 8 p.m. Eastern Standard Time. AcknowledgementsThanks to the National HIV/AIDS Clinicians’ Consultation Center (NCCC) physicians and pharmacists who contributed to this document.
Address correspondence to Mina Matin, MD, at [email protected].
Online Table B. Dosing Recommendations for Antiviral Treatment or Chemoprophylaxis of 2009 H1N1 Infection
Medication
Treatment (5 days)
Chemoprophylaxis (10 days)
Oseltamivir (Tamiflu), oral*
Adults
Children ≥ 12 months
Body weight
≤ 15 kg (33 lb)
Children 3 months to < 12 months†
Children 0 to < 3 months‡
Not recommended unless situation judged critical (due to Zanamivir (Relenza), inhaled§
Adults
Children (7 years or older for treatment; 5 years or older for chemoprophylaxis)
NOTE: This table is from the following web site: http://www.cdc.gov/h1n1flu/recommendations.htm. These treatment recommendations are based on guidance previously published for the 2009-2010influenza season. Antiviral drug treatment recommendations are not yet updated for the 2010-2011 season. This table will be revised when new information becomes available. *—Oseltamivir is administered orally without regard to meals, although administration with meals may improve gastrointestinal tolerability. Oseltamivir is available in 30-mg, 45-mg, and 75-mgcapsules; and as a powder for oral suspension that is reconstituted to provide a final concentration of 12 mg per mL. If the commercially manufactured oral suspension is not available, the capsulesmay be opened and the contents mixed with a sweetened liquid to mask the bitter taste or a suspension can be compounded by retail pharmacies (final concentration 15 mg per mL). In patients withrenal insufficiency, the dose should be adjusted based on creatinine clearance. For treatment of patients with creatinine clearance 10 to 30 mL per minute: 75 mg once daily for five days. Forchemoprophylaxis of patients with creatinine clearance 10 to 30 mL per minute: 30 mg once daily or 75 mg once every other day continuing for 10 days after exposure. †—Weight-based dosing is preferred, however, if weight is not known, dosing by age for treatment (give two doses per day) or prophylaxis (give one dose per day) of influenza in full-term infantsyounger than 1 year may be necessary: 0 to 3 months (treatment only) = 12 mg (1 mL of 12 mg per mL commercial suspension); 3 to 5 months = 20 mg (1.6 mL of 12 mg per mL of commercialsuspension), 6 to 11 months = 25 mg (2 mL of 12 mg per mL commercial suspension). ‡—Current weight-based dosing recommendations are NOT intended for premature infants. Premature infants may have slower clearance of oseltamivir because of immature renal function, anddoses recommended for full-term infants may lead to very high drug concentrations in this age group. Limited data from a cohort of premature infants receiving an average dose of 1.7 mg per kg twicedaily demonstrated drug concentrations higher than those observed with the recommended treatment dose in term infants (3 mg per kg twice daily). Observed drug concentrations were highly variableamong premature infants. These data are insufficient to recommend a specific dose of oseltamivir for premature infants. §—Zanamivir is administered by inhalation using a proprietary “Diskhaler” device distributed with the medication. Zanamivir is a dry powder, not an aerosol, and should not be administered usingnebulizers, ventilators, or other devices typically used for administering medications in aerosolized solutions. Zanamivir is not recommended for persons with chronic respiratory diseases, such asasthma or chronic obstructive pulmonary disease, that increase the risk of bronchospasm. Adapted from Centers for Disease Control and Prevention. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009-2010 season. http://www.cdc.gov/h1n1flu/recommendations.htm. Accessed September 30, 2010.

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