What is the recommended discharge plan for an outpatient diagnosed with influenza?

Discharge Plan for Outpatient with Influenza

For an outpatient diagnosed with influenza, initiate antiviral therapy immediately if the patient is at high risk for complications (chronic medical conditions, immunocompromised, age <2 or ≥65 years, pregnant/postpartum), prescribe oseltamivir 75 mg twice daily for 5 days, provide supportive care instructions, educate on warning signs requiring urgent re-evaluation, and arrange follow-up only if complications develop or the patient is high-risk. 1, 2

Antiviral Treatment Decision

High-Risk Patients Requiring Antivirals

Start antiviral treatment immediately for patients meeting any of these criteria, regardless of symptom duration: 1

• Chronic medical conditions (cardiac, pulmonary, renal, hepatic, metabolic disorders including diabetes) 1
• Immunocompromised status (HIV, malignancy, transplant recipients, chronic steroid use) 1
• Age extremes: Children <2 years or adults ≥65 years 1, 2
• Pregnancy or within 2 weeks postpartum 1, 2
• Severe or progressive illness at any age 1, 2

Otherwise Healthy Patients

For previously healthy outpatients without risk factors, antiviral treatment can be considered if initiated within 48 hours of symptom onset, as it reduces illness duration by approximately 24 hours. 2, 3, 4 However, this is optional rather than mandatory. 1

Antiviral Prescription

Prescribe oseltamivir (Tamiflu) 75 mg orally twice daily for 5 days as first-line therapy. 1, 2, 3

Alternative Options

• Zanamivir (Relenza): 10 mg (two 5-mg inhalations) twice daily for 5 days if oseltamivir cannot be tolerated 2, 5
  • Caution: Contraindicated in patients with underlying airways disease (asthma, COPD) due to bronchospasm risk 5
• Baloxavir: Single dose (40-80 mg based on weight) for patients ≥12 years as an alternative 2, 6
• Peramivir: Single 600 mg IV infusion for patients unable to absorb oral medication 2

Important Prescribing Notes

• Do not use combination neuraminidase inhibitors—single agent therapy only 1
• Do not use higher than FDA-approved doses 1
• Reduce oseltamivir dose by 50% if creatinine clearance <30 mL/min 7

Supportive Care Instructions

Provide clear written and verbal instructions on: 2, 7

• Hydration: Maintain adequate fluid intake 2
• Fever management: Acetaminophen or ibuprofen as needed for fever and myalgias 2
• Rest: Adequate rest during illness 2
• Isolation: Stay home and avoid contact with others for at least 24 hours after fever resolves without fever-reducing medications to prevent transmission 2

What NOT to Prescribe

• No antibiotics unless bacterial co-infection is suspected (new fever after initial improvement, focal chest findings, persistent fever >4 days) 1, 8
• No corticosteroids unless indicated for other medical conditions 2

Warning Signs Requiring Urgent Re-evaluation

Instruct patients to seek immediate medical attention for: 8, 7

• Respiratory distress: Increasing shortness of breath, rapid breathing (>30 breaths/min), or difficulty breathing 8, 7
• Persistent high fever: Fever lasting >4 days or recurring after initial improvement 8
• Altered mental status: Confusion, drowsiness, difficulty arousing 8, 7
• Severe symptoms: Chest pain, severe weakness, inability to maintain oral intake, vomiting >24 hours 8, 7
• Cyanosis or hypoxia: Blue lips or face, oxygen saturation <90% 7

Follow-Up Arrangements

Most Patients: No Routine Follow-Up Needed

Previously healthy adults with uncomplicated influenza do not require routine follow-up. 8 Most patients recover fully within 7 days, though cough and fatigue may persist for weeks. 8

High-Risk Patients: Arrange Follow-Up

Schedule follow-up within 3-5 days for patients who: 2, 8

• Have significant underlying medical conditions 8
• Are immunocompromised 8
• Are elderly (≥65 years) 8
• Experienced complications during initial presentation 8

Clinical Reassessment Triggers

Patients should return for evaluation if: 2, 8

• No improvement within 48 hours of starting antiviral therapy 2
• Worsening symptoms after initial improvement (suggests bacterial superinfection) 1, 8
• Persistent symptoms beyond 7 days without improvement 8

Common Pitfalls to Avoid

• Do not delay antiviral treatment while awaiting laboratory confirmation in high-risk patients—treat empirically based on clinical presentation during influenza season 1, 2
• Do not prescribe antibiotics prophylactically—reserve for documented or highly suspected bacterial co-infection 1
• Do not dismiss persistent cough alone as requiring intervention—this commonly persists for weeks after viral clearance 8
• Do not order chest X-rays routinely—only obtain if pneumonia is clinically suspected (focal findings, persistent fever >4 days, respiratory distress) 8
• Do not forget to assess vaccination status—document and recommend annual influenza vaccination for future seasons 4

Documentation for Discharge Summary

Include in discharge paperwork:

• Diagnosis: Influenza (specify A or B if known)
• Antiviral prescribed with dosing instructions
• Expected illness duration (typically 7 days, with possible prolonged cough)
• Warning signs requiring urgent return
• Follow-up plan (if applicable for high-risk patients)
• Isolation precautions and return-to-work/school guidance