What is the management of miscellaneous considerations in influenza?

Management of Miscellaneous Considerations in Influenza

Special Populations Requiring Modified Antiviral Approach

Patients who cannot mount an adequate febrile response—including the immunocompromised and very elderly—remain eligible for antiviral treatment despite lacking documented fever (>38°C), and should receive oseltamivir 75 mg twice daily for 5 days if they present with influenza-like illness within 48 hours of symptom onset. 1

Severely Ill Hospitalized Patients

• Hospitalized patients who are severely ill, particularly if immunocompromised, may benefit from antiviral treatment initiated beyond the standard 48-hour window from disease onset, though evidence for benefit in this scenario is lacking 1
• This represents a pragmatic clinical decision in the context of severe illness where potential benefits outweigh minimal risks 1

Antibiotic Management in Influenza Without Pneumonia

Previously Healthy Adults with Acute Bronchitis

• Previously well adults with acute bronchitis complicating influenza, in the absence of pneumonia, do not routinely require antibiotics 1, 2, 3
• This is a strong recommendation to avoid unnecessary antibiotic exposure and resistance development 3

When to Consider Antibiotics

Antibiotics should be considered in two specific scenarios:

• Previously well adults who develop worsening symptoms, specifically recrudescent fever or increasing dyspnea 1, 2, 3
• Patients at high risk of complications or secondary infection who develop lower respiratory tract features 1, 2, 3

Antibiotic Selection for Non-Pneumonic Complications

• Most patients can be adequately treated with oral antibiotics 1
• Preferred oral choices include co-amoxiclav or a tetracycline 1
• Alternative regimens include a macrolide (clarithromycin or erythromycin) or a fluoroquinolone with activity against Streptococcus pneumoniae and Staphylococcus aureus 1

Pediatric Considerations

Antipyretic Use

• Children with coughs and mild fevers should be treated at home with antipyretics and fluids, but aspirin must not be used in children due to risk of Reye's syndrome 1

High-Risk Features Requiring Medical Attention

• Children with high fever (>38.5°C) and cough or influenza-like symptoms should seek advice from a community health professional 1
• If no high-risk features are present, they should be treated with oseltamivir at 2 mg/kg twice daily for 5 days 1

Monitoring and Discharge Criteria

Inpatient Monitoring Parameters

• Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation, and inspired oxygen concentration should be monitored at least twice daily, more frequently in severe illness 1, 2, 3
• An Early Warning Score system provides a convenient monitoring framework 1

Discharge Readiness Assessment

Patients should be reviewed 24 hours prior to discharge, and those with two or more of the following unstable clinical factors should remain hospitalized:

• Temperature >37.8°C 1, 2, 3
• Heart rate >100/min 1, 2, 3
• Respiratory rate >24/min 1, 2, 3
• Systolic blood pressure <90 mmHg 1, 2, 3
• Oxygen saturation <90% 1, 2, 3
• Inability to maintain oral intake 1
• Abnormal mental status 1

Follow-Up Planning

• Follow-up clinical review should be arranged for all patients who suffered significant complications or experienced significant worsening of underlying disease, either with their general practitioner or in a hospital clinic 1, 2
• At discharge or follow-up, patients should receive information about their illness, take-home medications, and follow-up arrangements 1
• It is the hospital team's responsibility to arrange the follow-up plan with both the patient and the general practitioner 1

Supportive Care Considerations

Oxygen Therapy

• Hypoxic patients should receive oxygen therapy targeting PaO2 >8 kPa and SaO2 ≥92% 1, 2
• High concentrations of oxygen can safely be administered in uncomplicated pneumonia 1

Special Respiratory Support

• In patients with pre-existing COPD complicated by ventilatory failure, oxygen therapy should be guided by repeated arterial blood gas measurements 1
• Non-invasive ventilation may be helpful in COPD patients with ventilatory failure 1
• In patients without pre-existing COPD who develop respiratory failure, NIV may serve as a bridge to invasive ventilation when ICU beds are limited, but should only be used in respiratory/critical care units experienced with infection control measures 1

Additional Supportive Measures

• Patients should be assessed for cardiac complications and volume depletion requiring intravenous fluids 1
• Nutritional support should be provided in severe or prolonged illness 1

Common Pitfalls to Avoid

• Do not withhold antivirals from elderly or immunocompromised patients solely based on absence of documented fever—these populations may not mount typical febrile responses 1
• Do not routinely prescribe antibiotics for uncomplicated bronchitis in previously healthy adults—this promotes resistance without proven benefit 1, 3
• Do not discharge patients prematurely—ensure clinical stability for 24 hours with normalized vital signs before discharge 1, 3