Are antibiotics indicated in patients with severe autoimmune disorders who test positive for influenza?

From the Guidelines

Antibiotics are indicated in patients with severe autoimmune disorders who test positive for influenza, especially if they have clinical and radiographic evidence of community-acquired pneumonia (CAP) or are at high risk of complications or secondary infection 1.

Key Considerations

• The Infectious Diseases Society of America recommends testing for influenza in high-risk patients, including immunocompromised persons, if the testing result will influence clinical management (A-III) 1.
• The American Thoracic Society recommends standard antibacterial treatment for adults with clinical and radiographic evidence of CAP who test positive for influenza (strong recommendation, low quality of evidence) 1.
• Patients with severe autoimmune disorders are considered high-risk and may benefit from empiric antibiotic therapy, even if they do not have CAP, if they develop worsening symptoms or have lower respiratory features 1.

Antibiotic Choices

• Co-amoxiclav or a tetracycline are preferred choices for oral antibiotics 1.
• A macrolide such as clarithromycin or a fluoroquinolone active against Streptococcus pneumoniae and Staphylococcus aureus is an alternative choice in certain circumstances 1.

Duration of Therapy

• The duration of antibiotic therapy can be reduced in patients with CAP with the use of a procalcitonin-guided pathway and serial procalcitonin measurement compared with conventional care 1.
• A variety of criteria for determining clinical improvement have been developed for patients with CAP, including resolution of vital sign abnormalities and ability to eat 1.

From the Research

Antibiotic Use in Patients with Severe Autoimmune Disorders and Influenza

• The use of antibiotics in patients with severe autoimmune disorders who test positive for influenza is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that antibiotics are often overprescribed for acute respiratory infections, including influenza 3, 5.
• Influenza vaccination is recommended for patients with autoimmune disorders to prevent severe influenza infections, which can be complicated by the use of immunosuppressive therapies 2, 4, 6.
• The prevention strategy and clinical management of infections in patients with autoimmune disorders need to be individually tailored, taking into account the characterization of the disease, the mechanism of action of immunosuppressive drugs, and the patient's risk factors 2.
• There is no clear evidence to support the routine use of antibiotics in patients with severe autoimmune disorders who test positive for influenza, and antibiotic use should be guided by clinical judgment and evidence-based guidelines 3, 5.

Influenza Vaccination and Autoimmune Disorders

• Influenza vaccination is effective in preventing influenza infections in patients with autoimmune disorders, although the antibody response may be lower compared to healthy controls 4, 6.
• Patients with systemic inflammatory and/or autoimmune diseases have an increased risk of severe influenza infections, and annual vaccination is recommended to prevent these infections 6.
• The use of immunosuppressive therapies may increase the risk of infections, and vaccination is an important preventive measure 2, 6.

Antibiotic Prescribing Practices

• Antibiotic overuse remains a concern in the treatment of outpatient acute respiratory infections, including influenza 3, 5.
• Targets for improved outpatient antibiotic stewardship include eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis, and improving adherence to prescribing guidelines for pharyngitis and sinusitis 5.
• Increased access to sensitive and timely virus diagnostic tests, particularly for influenza, may reduce unnecessary antibiotic use for these syndromes 3, 5.