Clinical outcomes and prognostic factors of patients with severe influenza receiving intravenous peramivir salvage therapy in intensive care units

Changes in clinical parameters and inflammatory markers after blood culture collection facilitate early identification of positive culture in adult patients with COVID-19 and clinically suspected bloodstream infection

OBJECTIVE

We explored whether changes in clinical parameters and inflammatory markers can facilitate early identification of positive blood culture in adult patients with COVID-19 and clinically suspected bloodstream infection (BSI).

METHODS

This single-center retrospective study enrolled 20 adult patients with COVID-19 admitted to the intensive care unit who underwent blood culture for clinically suspected BSI (February 2020-November 2021). We divided patients into positive (Pos) and negative blood culture groups. Clinical parameters and inflammatory markers were obtained from medical records between blood culture collection and the first positive or negative result and compared between groups on different days.

RESULTS

Patients in the positive culture group had significantly older age and higher D-dimer, immunoglobulin 6 (IL-6), and Sequential Organ Failure Assessment score as well as lower albumin (ALB). The area under the receiver operating characteristic curve (AUC) was 0.865 for IL-6, D-dimer and ALB on the first day after blood culture collection; the AUC was 0.979 for IL-6, IL-10, D-dimer, and C-reactive protein on the second day after blood culture collection.

CONCLUSION

Changes in clinical parameters and inflammatory markers after blood culture collection may facilitate early identification of positive culture in adult patients with COVID-19 and clinically suspected BSI.

Treatment and prevention of influenza in geriatric patients

INTRODUCTION

Older adults are the most vulnerable population to the effects of influenza. These patients have age-related characteristics that make response to both infection and therapeutics different than younger patients.

AREAS COVERED

Influenza vaccination and antiviral therapy are the foundational approaches to preventing and treating influenza in geriatric patients. Older adults should receive one of the three enhanced vaccines before influenza season beings. There are five antivirals used in influenza. Geriatric patients have been under-enrolled in antiviral studies but have been included in small numbers. Oseltamivir has the most abundant evidence, including in the hospital and long-term care (LTC) facilities, and the strongest evidence for reducing mortality and complications. Peramivir offers the shortest time for symptom alleviation, while baloxavir is best tolerated.

EXPERT OPINION

Oseltamivir has the most versatility in preventing and treating influenza in geriatric patients. Parenteral peramivir and zanamivir are second-line alternatives for complicated influenza when oseltamivir cannot be used. Single-dose peramivir and baloxavir are attractive alternatives to oseltamivir in uncomplicated influenza but will not increase in utilization until more evidence is available regarding mortality and complications, particularly in hospitalized and LTC patients. More studies, including comparative trials, are required to elucidate the role in therapy for each therapeutic in the geriatric population.

Invasive pneumococcal disease affected the fatal outcome in a COVID-19 patient

A 68-year-old man experienced fever and cough and was referred to a hospital for day 4. He had a positive reverse transcription-polymerase chain reaction result for severe acute respiratory syndrome coronavirus-2. On day 12, his PaO₂/FiO₂ ratio worsened to 120 and he was transferred to Sapporo Medical University Hospital for treatment using extracorporeal membrane oxygenation. Venous blood cultures were positive for Streptococcus pneumoniae, which were serotype 3, mucoid-type, and penicillin susceptible. Coinfections with coronavirus disease-2019 and invasive pneumococcal disease are rare; however, they are associated with a higher case fatality than either of the conditions manifesting alone.

Bacteremia and Blood Culture Utilization during COVID-19 Surge in New York City

A surge of patients with coronavirus disease 2019 (COVID-19) presenting to New York City hospitals in March 2020 led to a sharp increase in blood culture utilization, which overwhelmed the capacity of automated blood culture instruments. We sought to evaluate the utilization and diagnostic yield of blood cultures during the COVID-19 pandemic to determine prevalence and common etiologies of bacteremia and to inform a diagnostic approach to relieve blood culture overutilization. We performed a retrospective cohort analysis of 88,201 blood cultures from 28,011 patients at a multicenter network of hospitals within New York City to evaluate order volume, positivity rate, time to positivity, and etiologies of positive cultures in COVID-19. Ordering volume increased by 34.8% in the second half of March 2020 compared to the level in the first half of the month. The rate of bacteremia was significantly lower among COVID-19 patients (3.8%) than among COVID-19-negative patients (8.0%) and those not tested (7.1%) (P < 0.001). COVID-19 patients had a high proportion of organisms reflective of commensal skin microbiota, which, when excluded, reduced the bacteremia rate to 1.6%. More than 98% of all positive cultures were detected within 4 days of incubation. Bloodstream infections are very rare for COVID-19 patients, which supports the judicious use of blood cultures in the absence of compelling evidence for bacterial coinfection. Clear communication with ordering providers is necessary to prevent overutilization of blood cultures during patient surges, and laboratories should consider shortening the incubation period from 5 days to 4 days, if necessary, to free additional capacity.

Clinical Effectiveness of Intravenous Peramivir versus Oseltamivir for the Treatment of Influenza in Hospitalized Patients

Purpose

To compare the clinical efficacy between peramivir and oseltamivir in hospitalized patients with influenza.

Patients and Methods

Retrospective cohort study examined data from 542 adult patients with laboratory-confirmed seasonal influenza hospitalized in five teaching hospitals and one secondary hospital between August 2017 and May 2018. The main outcome was the defervescence rate within 3 days from the first administration of peramivir or oseltamivir. The secondary outcomes were mortality and duration of hospitalization/intensive care unit (ICU) stay.

Results

Of the 542 enrolled patients, 251 were administered the standard dose of peramivir (300 mg, single dose), 42 were administered peramivir at doses exceeding 300 mg, and 249 were administered oseltamivir (75 mg, twice daily for 5 days). There were more ICU and pneumonia cases and older patients in the peramivir group, especially the high-dose group. The Charlson comorbidity index (CCI) scores were similar among the three groups. There were no significant differences in defervescence rates within 3 days between the three groups. The mortality and duration of hospital and ICU stays also did not differ significantly. The factors associated with 30-day mortality were ICU admission, high CCI score, and pneumonia.

Conclusion

Treatment of influenza with either peramivir or oseltamivir in hospitalized adults resulted in generally similar clinical outcomes. Peramivir treatment showed good clinical response in influenza patients with pneumonia or admitted to the ICU.

A Retrospective Analysis of Three Antiviral Regimens of Peramivir in the Treatment of Severe Influenza A with Primary Viral Pneumonia

Objective

To evaluate the difference of clinical efficacy of peramivir alone and peramivir combined with immunomodulators (either ribonucleic acid or thymopetidum) in the treatment of severe influenza A with primary viral pneumonia.

Methods

A retrospective analysis was applied to 45 patients who were diagnosed with severe influenza A with primary viral pneumonia in our hospital from December 2017 to March 2018. The cases were divided into three groups: the peramivir group, the peramivir combined with ribonucleic acid group, and the peramivir combined with thymopetidum group.

Results

The duration of viral nucleic acid positivity in the peramivir group, the peramivir combined with ribonucleic acid group, and the peramivir combined with thymopetidum group was 6.13 ± 2.06, 6.53 ± 2.72, and 6.10 ± 1.37 days, respectively. The remission time of the clinical symptoms of the peramivir group, the peramivir combined with ribonucleic acid group, and the peramivir combined with thymopetidum group was 8.06 ± 2.73, 7.94 ± 2.89, and 7.67 ± 1.58 days, respectively. Comparisons between the peramivir group and the peramivir combined with ribonucleic acid group or the peramivir combined with thymopetidum group revealed no significant differences in the duration of virus nucleic acid positivity, remission time of clinical symptoms, time to fever alleviation, and time to cough alleviation.

Conclusions

There is no observed benefit in the addition of ribonucleic acid or thymopetidum when peramivir sodium chloride injection is used in the treatment of severe influenza A with primary viral pneumonia. This trial is registered with ChiCTR1800019417.

Contemporary management of severe influenza disease in the intensive care unit

Despite continued efforts to optimize vaccination composition, severe influenza disease requiring intensive care unit (ICU) admission remains a clinical issue. Influenza epidemics and pandemics worldwide continue to challenge clinicians with managing infected patients requiring ICU care. While routine use of antiviral therapy is deployed in ambulatory outpatients, their use in the ICU in patients with hypoxemic respiratory failure is less well established. Additionally, these therapies primarily target the neuraminidase protein, while contemporary research is increasingly demonstrating potential therapeutic benefits of targeting the hemagglutinin protein. These data have given rise to a growing interest in the use of immune modulating therapies for treatment of severe influenza. Additionally, pandemic outbreaks have revealed the growing need for salvage management, wherein lies the potential role for venovenous extracorporeal membrane oxygenation therapy in refractory respiratory failure. In this report, we review the contemporary ICU care of the severe influenza patient.

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Influenza remains a challenging disease in the intensive care unit.

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Early anti-viral therapy may be associated with reduced mortality in the critically ill.

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Evidence surrounding the use of immune modulating therapies is growing.

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Corticosteroids are harmful and should not be used during the treatment of influenza.

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Additional research and commercial optimization is needed for widespread application of immune therapies.

Severe community-acquired pneumonia due to Pseudomonas aeruginosa coinfection in an influenza A(H1N1)pdm09 patient

Coinfection with Pseudomonas aeruginosa in patients with influenza is rare. Herein, we report a 39-year-old female patient who presented with severe community-acquired pneumonia due to coinfection with influenza A(H1N1)pdm09 and P. aeruginosa, which progressed to multifocal pneumonia with a fatal outcome.