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July 2009
Vol. 19 No. 7
Patient Care and Science
EIN: Treatment Options for H1N1 Pneumonia and Antiviral Use in Infants

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

As the novel influenza A:H1N1 outbreak continues, EIN members have been discussing related treatment questions. One EIN member from Massachusetts asked about the value of corticosteroid therapy for patients with influenza viral pneumonia who are not responding to oseltamivir.

One member from North Dakota reported anecdotal improvement with methylprednisolone; however, other respondents urged caution. A member in Utah cited guidance from a WHO expert consultants group that reviewed data on steroids and avian influenza A:H5N1 and concluded steroids were associated with increased mortality. While the respondent noted the significant differences between the two influenza strains, he added that both are characterized by hemorrhagic pneumonitis and acute respiratory distress syndrome in immunologically naïve subjects.

A Florida EIN member referred to WHO’s initial guidance document regarding clinical management of the latest H1N1 strain. The member’s review of the literature also found:

  • no benefit from steroids for severe acute respiratory syndrome (SARS), avian influenza, hantavirus pulmonary syndrome, respiratory syncytial virus (RSV), or pneumocystis pneumonia (PCP)
  • some benefit in cases of parainfluenza and in croup from parainfluenza in children
  • “lots of literature on steroids increasing the risk of secondary infections such as mold and CMV”

In addition, the member cited a 2008 article in the International Journal of Hematology that described a bone marrow transplant recipient with severe parainfluenza 3 pneumonia who was successfully treated with oral ribavirin and methylprednisolone.

“I have seen many cancer and [bone marrow transplant] patients improve dramatically with severe viral pneumonia when corticosteroids are added with antivirals and aggressive follow-up and, at times, prophylaxis for secondary infections and rapid steroid taper over 1-2 weeks,” the member said. “However, many reputable colleagues who are very anti-steroid will disagree with me.” The truth, he added, is in the middle: “Some patients benefit, and many have no benefit, and in some it is detrimental.”

In a related thread, a member from Minnesota asked whether influenza can spread from a mother to an unborn child. The question followed the case of a 24-year-old pregnant mother at 31-weeks gestation with a confirmed case of H1N1. She was admitted, started on ceftriaxone and azithromycin (Zithromax), transferred to the intensive care unit secondary to respiratory failure, and intubated several days later. The patient was then started on oseltamivir. The baby was delivered by caesarian section “due to decreased variability and poor BPP.”

The infant is doing well without any influenza symptoms, although H1N1 testing is pending. “Tamiflu was not started due to concerns about sodium benzoate in the preparation,” the member said. “Given the nature of this exposure, would others have treated or prophylaxed this infant?”

A respondent in Utah said there is no evidence that seasonal influenza crosses the placenta and discouraged the use of prophylaxis in premature infants. The infection can probably be prevented, the member said. Also, if the mother has been sick for several days, she will have decreasing viral shedding and will possibly have started to make antibodies. “I think the risks of Tamiflu prophylaxis outweigh the benefits,” the member continued. “I worry about the mother infecting the baby, would use contact isolation type barriers, and be very careful about having her in the NICU.”

If needed for use in infants under other circumstances, FDA’s emergency use authorization of oseltamivir offers dosing guidance.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention, EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.
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