Secondary bacterial pneumonia due to Staphylococcus aureus complicating 2009 influenza A (H1N1) viral infection

A novel DNA vaccine expressing the Ag85A-HA2 fusion protein provides protection against influenza A virus and Staphylococcus aureus

Secondary pneumonia due to Staphylococcus aureus (S. aureus) causes significant morbidity and mortality. The aim of the research was designed a novel DNA vaccine encoding the Mycobacterium tuberculosis secreted antigen Ag85A fused with the influenza A virus (IAV) HA2 protein to provide protection against both influenza and secondary infection with S. aureus. The DNA vaccine vector efficiently expressed the encoded antigen in mammalian cells, as determined by RT-PCR, Western blotting and immunofluorescence analysis. Mice were immunized with the vaccine by intramuscular injection before challenge with IAV and S. aureus. The pulmonary and the splenocyte culture IFN-γ levels were significant higher in immunized mice than their respective controls. Although the antibody titer in the HI test was low, the sera of mice immunized with the novel vaccine vector were effective in neutralisation assay in vitro. The vaccine could reduce the loss of body weight in mice during IAV challenge. Both Western blotting and RT-PCR showed that the vaccine markedly enhanced toll like receptor 2 (TLR2) expression in splenocytes after the secondary infection with S. aureus. The survival rate of mice with high TLR2 expression (pEGFP/Ag85A-HA2 or iPR) was significantly increased compared with mice immunized with pEGFP/HA2 after challenge with S. aureus. However, the pulmonary IL-10 concentration and S. aureus titer were significantly decreased in immunized mice, and expression of TLR2 was increased after challenge with S. aureus. These results demonstrated that Ag85A could strengthen the immune response to IAV and S. aureus, and TLR2 was involved in the host response to S. aureus.

Limiting severe outcomes and impact on intensive care units of moderate-intermediate 2009 pandemic influenza: role of infectious diseases units

PURPOSE

The rate of severe outcomes of patients with 2009 pandemic (A/H1N1) influenza (2009pI) hospitalized in non-intensive care units (ICUs) has not been defined thus far. This study aims to assess the efficacy of the management of patients with influenza-like illness (ILI) of moderate intermediate severity in an infectious diseases unit (IDU) during the first wave of 2009pI and its influence on the burden of ICUs.

METHODS

All patients hospitalized from October 27, 2009, to February 5, 2010, with ILI were included in this prospective observational study. The IDU was organized and the staff was trained to provide intermediate care; patients were transferred to the ICU only if they required invasive ventilation, extracorporeal membrane oxygenation, or advanced cardiovascular support. Demographic data, clinical presentation, coexisting medical conditions, and laboratory and radiological findings were recorded and analyzed, as well as treatment and outcome data.

RESULTS

Overall, 108 patients (median age 36 years [IQR 27-54], 57.4% males) including 66.7% with ≥ 1 risk factor for severe influenza, 47.2% with confirmed 2009pI by RT-PCR and 63.9% with pneumonia, were enrolled in the study. All subjects received intravenous fluids and 83.3% were administered oseltamivir, 96.3% antibacterials, 19.4% oxygen therapy without ventilatory support, and 10.2% non-invasive ventilation. A total of 106 (98.1%) subjects were discharged after a 6-day median hospital stay [IQR 4-9]. Two patients (1.9%) were transferred to the ICU. There were no deaths.

CONCLUSIONS

These results suggest that the aggressive treatment of patients with moderate intermediate severity 2009 pandemic ILI in non-ICU wards may result in a low rate of severe outcomes and brief hospitalization. IDUs, if properly organized for intermediate care, may efficiently provide correct disease management, in addition to complying with infection control requirements, thus reducing the burden of the pandemic on ICUs. Further studies are warranted to evaluate the outcome of patients with moderate intermediate 2009pI in different non-ICU settings.

Excess mortality from seasonal influenza is negligible below the age of 50 in Israel: implications for vaccine policy

Purpose

Evaluation of the severity of pandemic influenza requires reliable estimates of mortality attributable to the seasonal influenza.

Methods

Excess age-specific mortality during periods of influenza activity was evaluated in Israel during the period 1999–2006 for three death categories. For each respiratory year, the lowest monthly moving average for the mortality rate was subtracted from each month in the period of influenza activity. Average mortality rates in years with minimal influenza activity were deducted from corresponding months to exclude winter mortality unrelated to influenza. The sums of these results were used as estimates of excess mortality rates.

Results

Overall excess mortality rates ranged from 7.7 to 36.1 per 100,000 for all causes, and from 4.4 to 24.4 per 100,000 for respiratory and circulatory causes. Influenza was associated with an average of 869 (range 280–1,516) deaths annually from respiratory and circulatory diseases during seasons with significant influenza activity. About 90% of the influenza-associated mortality from respiratory and circulatory diseases was in the age group 65+ years and about 1% in the age group <50 years. The age group <50 years accounted for an annual average of seven deaths from respiratory and circulatory diseases.

Conclusion

Annual mortality associated with seasonal influenza is highly variable. Under the age of 50 years, there is minimal seasonal influenza associated mortality. This information provides an important baseline for evaluating the severity of the A(H1N1) 2009 influenza pandemic, where persons under 50 years of age were often disproportionately represented.

2009 pandemic influenza A (H1N1) in pregnancy: a systematic review of the literature

To summarize the literature regarding 2009 H1N1 influenza A during pregnancy, we conducted a systematic literature review using a PubMed search and other strategies. Studies were included if they reported 2009 H1N1 influenza in pregnant women as original data. In all, 2153 abstracts were reviewed, and a total of 120 studies were included. Data were extracted regarding number of cases, additional risk factors for influenza-associated complications, treatment, and maternal and pregnancy outcomes. Authors were contacted to determine the extent of overlap when it was suspected. Pregnancy was associated with increased risk of hospital and intensive care unit admission and of death. Pregnant women who received delayed treatment with neuraminidase inhibitors or who had additional risk factors were more likely to develop severe disease. Preterm and emergency cesarean deliveries were frequently reported. These results reinforce the importance of early identification and treatment of suspected influenza in this high-risk population.

Clinical aspects of 2009 pandemic influenza A (H1N1) virus infection in Austria

Purpose

To describe the clinical features, risk factors for severe disease and effectiveness of oseltamivir in patients with 2009 pandemic influenza A (H1N1) virus infection.

Methods

In a prospective, cross-sectional, multicentre study, data on 540 patients with confirmed 2009 H1N1 infection from seven Austrian hospitals were collected using a standardised online case-history form.

Results

The median age of the patients was 19.3 years (range 26 days–90.8 years); point-of-care testing yielded false-negative results in 60.2% of the 176 cases tested. The most common symptoms were fever, cough, fatigue and headache. Overall, 343 patients (63.5%) were hospitalised, 49 (9.1%) were admitted to an intensive care unit (ICU) and 14 (4.1%) died. Case fatality rates were highest (9.1%) in those aged 65 years or older. Factors significantly associated with a higher risk for ICU admission included age, neurological disease, adipositas, and both interstitial pathology and lobular pathology on chest X-ray. No association with pregnancy, malignancy or immunosuppressive therapy was detected. Antiviral treatment significantly reduced the duration of fever by 0.66 days and lowered the risk of ICU admission, but had no significant benefit on survival.

Conclusions

During the 2009 H1N1 influenza pandemic, elderly or obese patients and those with neurological disease had an increased risk for severe H1N1 infection in Austria. Pregnancy was not associated with a higher risk for severe disease in the later phase of the 2009 H1N1 pandemic. Antiviral treatment provided a minimal effect on the symptoms of influenza but reduced the risk of admission to an ICU.