Archive for the ‘Swine Flu’ Category
Current Recommendations for Antiviral Treatment of Patients with Confirmed or Suspected Influenza
Click here for Algorithm as of Nov 10 2009
Who needs to be treated with tamiflu?
What is the recommended dose of tamiflu?
How do you adjust tamiflu for patients with renal disease?
Who needs to be admited and if sent home, what are your discharge
instructions?
If you do not know (for sure) the answers, see [below].
Andy
With the continuing burden of 2009 H1N1 influenza (swine flu) in the community and questions regarding treatment, the Division of Infectious Diseases, the Antibiotic Assistance Program, and the Infection Control Department have drafted the following treatment guidelines to aid with both the inpatient and outpatient management of patients with influenza-like illness. Currently the overwhelming majority of circulating influenza is 2009 H1N1 (swine) influenza. 99% of 2009 H1N1 influenza remains susceptible to both oseltamivir (Tamiflu) and zanamivir (Relenza).
Recommendations
1. Diagnostic test results should not substitute for clinical judgment and if there is a suspicion of 2009 H1N1 influenza appropriate infection control precautions and management should be initiated early and empirically.
2. Most individuals without underlying medical conditions will have a self-limited respiratory illness. Those who present with an uncomplicated febrile illness generally do not require antiviral treatment. They are encouraged to remain out of work or school for at least 24 hours after fever has resolved.
3. Currently, when treatment is indicated, monotherapy with oseltamivir (Tamiflu) or zanamivir (Relenza) is sufficient. Please note that these recommendations may change throughout the course of the influenza season. Dosing recommendations for these agents are provided below.
4. There are groups who have been identified as being at increased risk for complications and/or severe disease from 2009 H1N1 influenza and these persons should be treated. These groups include:
- All hospitalized patients with an influenza-like illness or confirmed or suspected 2009 H1N1 Influenza.
- Persons who are at increased risk for complications or severe disease.
- Children ? 2 years old
- Adults ? 65 years of age
- Pregnant women and women up to 2 weeks postpartum (including following pregnancy loss)
- Persons with the following conditions:
- Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), or metabolic disorders (including diabetes mellitus)
- Disorders that that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders)
- Immunosuppression, including that caused by medications or by HIV or solid or stem cell transplantation
These recommendations should be used together with clinical judgment in making treatment decisions for both patients who are at higher risk for influenza-related complications and patients who are not at higher risk.
Dosing and administration
MEDICATION |
Treatment (5 days) |
Chemoprophylaxis (10 days) |
Oseltamivir (Tamiflu) | ||
ADULTS |
||
Creatinine Clearance ? 30 | 75 mg twice a day for 5 days | 75 mg once a day for 10 days |
Creatinine Clearance <30
Hemodialysis Peritoneal Dialysis |
75 mg once a day for 5 days | 75 mg every other day for 10 days |
CHILDREN ? 12 months |
||
? 15 kg | 30 mg twice a day for 5 days | 30 mg once a day for 10 days |
15-23 kg | 45 mg twice a day for 5 days | 45 mg once a day for 10 days |
24-40 kg | 60 mg twice a day for 5 days | 60 mg once a day for 10 days |
? 40 kg | 75 mg twice a day for 5 days | 75 mg once a day for 10 days |
INFANTS < 12 months |
||
< 9 months | 3 mg/kg twice a day for 5 days | Not recommended |
9-11 months | 3.5 mg/kg twice a day for 5 days | 3.5 mg/kg mg once a day for 10 days |
|
||
Zanamivir (Relenza) | ||
ADULTS |
||
10 mg (two 5 mg inhalations) twice a day | 10 mg (two 5 mg inhalations) once a day | |
CHILDREN |
||
? 7 years old for treatment | ? 5 years old for prophylaxis | |
10 mg (two 5 mg inhalations) twice a day | 10 mg (two 5 mg inhalations) once a day |
Please note that the oral inhalation formulation of zanamivir cannot be administered by nebulization therapy.
Alternative antiviral agents
For individuals who are perceived to be failing antiviral therapy there are two investigational agents available, intravenous peramivir and intravenous zanamivir, to treat these patients. It is strongly recommended that an Infectious Diseases consultation be obtained in cases where standard therapy is failing.
Briefly, intravenous peramivir is a neuraminidase inhibitor that works similarly to oseltamivir. It is currently available through the FDA under an emergency use authorization.(1) Its use should be reserved for patients deemed to be failing conventional antiviral therapy or unable to tolerate oral oseltamivir or inhaled zanamivir. Due to reporting issues and complicated dosing regimens Infectious Diseases consultation is required.
There have been sporadic oseltamivir-resistant cases of 2009 H1N1 influenza reported worldwide.(2-3) Most of these cases have been in the setting of oseltamivir treatment or chemoprophylaxis. In these cases susceptibility to zanamivir has been retained. In patients unable to tolerate inhaled zanamivir (e.g., ventilated patients) intravenous zanamivir is available in limited supply through a compassionate use program through the manufacturer.(4) Infectious Disease consultation is required to aid in the administration and procurement of this agent if clinically warranted.
Chemoprophylaxis (5)
Post-exposure chemoprophylaxis can be considered for:
- Persons at higher risk for complications due to influenza.
- Health care workers exposed to influenza without adequate personal protective equipment.
Chemoprophylaxis is generally not recommended if >48 hours have elapsed since last the contact with the infectious person. Chemoprophylaxis for exposure to 2009 H1N1 influenza is not recommended for persons who have received the H1N1 vaccine more than 14 days prior to exposure. Chemoprophylaxis is not currently recommended for prevention of illness in healthy children or adults.
References
1 http://www.cdc.gov/H1N1flu/EUA/peramivir_recommendations (updated October 24, 2009)
2 MMWR 2009; 58 (32): 893-6
3 MMWR 2009; 58 (35): 969-72
4 Lancet 2009; 374: 1036
5 http://www.cdc.gov/h1n1flu/recommendations (updated October 16, 2009)
Tamiflu Approval
Wed Jun 10, 2009 14:12
From: Sara Bingel, RPH
Subject: ID APPROVAL *NOT* NEEDED FOR TAMIFLU AND RELENZAFrom site: Mount Sinai ED
Hello,
As of June 10, 2009, you do NOT need to page 9407 for ID approval for Tamiflu or Relenza for ADULT patients needing anti-viral treatment. Have a nice day!
Influenza Like Illness Isolation
Given the current difficulty in obtaining single rooms (particularly airborne isolation – negative pressure rooms), we wanted to remind everyone that patients with suspected or confirmed influenza require only Droplet Precautions (not airborne precautions) and can be admitted to any single room. (Of course, if TB or varicella/zoster is present or on the differential, then airborne isolation would be required.)
We have had a few patients waiting in ED for negative-pressure room who required only a single room. Thus, this clarification with staff may reduce ED waiting times for admitted patients.
Tamiflu Pharmacies
The pharmacy has contacted all of the local pharmacies, below is their stock of both capsules and liquid.
Capsules Liquid
Apthorp West 77-78 & Broadway 10 boxes 6 bottles
Chateau Drug Amsterdam and W 68th Street 4 boxes (tomorrow) 2 bottles
CVS 540 Amsterdam & 86th Street 2 boxes 20 bottles
Drug Loft 1412 Madison & 96th Street 1 box 6 bottles
Duane Reade 3rd Ave & 115th Street 15 boxes 10 bottles
Duane Reade West 181st Street & St. Nicholas 4 boxes None
Duane Reade Broadway & 97th Street 7 boxes None
Madison Avenue Madison & 97th Street 5 boxes 3 bottles
Rite Aide Amsterdam & 70th Street None None
Rite Aide Broadway & 110th Street 6 None
Rite Aide West 125th Street & St. Nicholas None None
Town Drugs West 113th Street & Amsterdam 3 Boxes 2 Bottles
Town Health 45 E 30th St. between Park & Madison 1 box None
Swine Flu Surge Coverage
It has been noted that a lot of attendings are behind in hours. Not as far behind as I, but behind non-the-less.
We have negotiated a “pot-sweetener”: if you are behind in hours to double- digits (that’s more than 10), you can be re-imbursed for swine hours at almost double. That’s right- 5 hours for 3.
Note that if you are ahead in hours, not behind, you are being paid at $150, which is higher than moonlighting rate. It seemed unfair to pay those ahead at a higher rate, while re-imbursing those behind at the base rate.
We are now re-imbursing both those ahead and those behind at higher, crisis pay rates.
Take another look at the spreadsheet now.
If you have a gmail account, you can add your name to the schedule yourself.