What is the management of influenza complicated by collapse?

Management of Influenza Complicated by Collapse

Patients with influenza complicated by collapse require immediate hospital admission, supportive care, antiviral therapy, and careful monitoring for clinical stability before discharge. 1

Initial Assessment and Management

Immediate Stabilization

• Assess vital signs: temperature, respiratory rate, heart rate, blood pressure, oxygen saturation, and mental status
• Provide supplemental oxygen for hypoxemia (aim to maintain PaO2 >8 kPa and SaO2 ≥92%) 2
• Assess for volume depletion and provide IV fluids as needed
• Monitor using an Early Warning Score system at least twice daily 2

Diagnostic Evaluation

• For severe cases (CURB-65 Score 3,4, or 5, or bilateral CXR changes):
  • Blood cultures (before antibiotics if possible)
  • Pneumococcal urine antigen test
  • Sputum Gram stain, culture, and antimicrobial susceptibility tests
  • Chest X-ray to assess for pneumonia or other complications 2

Antiviral Treatment

Initiation Criteria

• Start antiviral therapy (neuraminidase inhibitors) for patients with:
  • Acute influenza-like illness
  • Fever (>38°C)
  • Symptoms for two days or less 2

Dosing

• Oseltamivir 75 mg twice daily for 5 days (reduce to 75 mg once daily if creatinine clearance <30 ml/min) 2, 1
• Consider antiviral treatment beyond 48 hours from symptom onset in hospitalized patients who are severely ill, particularly if immunocompromised 2

Antibiotic Therapy

Non-severe Influenza-related Pneumonia

• Oral therapy with co-amoxiclav or a tetracycline is preferred
• When oral therapy is contraindicated, use IV co-amoxiclav or a second/third generation cephalosporin 2

Severe Influenza-related Pneumonia

• Immediate parenteral antibiotics after diagnosis
• IV combination therapy with:
  • Broad-spectrum beta-lactamase stable antibiotic (co-amoxiclav or cephalosporin)
  • PLUS a macrolide (clarithromycin or erythromycin) 2
• Administer antibiotics within four hours of admission 2

Monitoring and Discharge Criteria

Ongoing Monitoring

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation, and inspired oxygen concentration at least twice daily 2
• Assess for cardiac complications and nutritional needs in severe or prolonged illness 2

Discharge Criteria

• Review patients 24 hours prior to discharge
• Do not discharge if two or more of these unstable factors are present:
  1. Temperature >37.8°C
  2. Heart rate >100/min
  3. Respiratory rate >24/min
  4. Systolic blood pressure <90 mmHg
  5. Oxygen saturation <90%
  6. Inability to maintain oral intake
  7. Abnormal mental status 2, 1

Follow-up Care

• Arrange follow-up clinical review for all patients who suffered significant complications or worsening of underlying disease 2
• Provide patients with information about their illness, take-home medications, and follow-up arrangements 2
• The hospital team is responsible for arranging the follow-up plan with the patient and general practitioner 2

Special Considerations

• For patients with pre-existing COPD and ventilatory failure, guide oxygen therapy with repeated arterial blood gas measurements 2
• Non-invasive ventilation may be helpful in patients with respiratory failure, particularly when level 3 beds are in high demand 2
• Patients who are unable to mount an adequate febrile response (e.g., immunocompromised or elderly) may still be eligible for antiviral treatment despite lack of documented fever 2

By following this structured approach to managing influenza complicated by collapse, clinicians can optimize patient outcomes and reduce the risk of further deterioration.