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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)

Written by phil

November 6th, 2009 at 5:45 pm

Posted in ID,Swine Flu

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