Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.
Patients hospitalized with influenza may require extended care upon discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥65 years hospitalized with influenza.
Infectious disease situational awareness—the embodiment of perceiving community trends in disease prevalence—is a key component of early influenza recognition. We do have relatively effective antiviral medications for influenza, but their Achilles’ heel is the need for early application. Anticipation can help.
Influenza continues to be a very significant seasonal pathogen affecting our patients. For example, during the 2014/2015 influenza season one out of every 265 elders (aged ≥ 65 years) in the state of Wisconsin was hospitalized with laboratory-confirmed influenza. Elders comprised 70% of influenza-related hospitalizations and 60% of influenza-related ICU admissions. Similar effects were seen across the US. This comes at great personal and economic cost.
In a study of early vs. late initiation of antivirals, Chaves and colleagues provide some basic and sobering information on influenza’s toll on elders. The high rates of hospitalization are magnified by the revelation that an estimated 18% of community dwelling patients aged ≥ 65 years will require extended stays after discharge at skilled nursing or long-term care facilities. Predictors of need for extended stay included older age, coexisting neurological disorders, ICU admission, and pneumonia at admission.
The central study question was whether oseltamivir started within 4 days of illness onset, as compared to late initiation, resulted in reductions in the need for extended stay. The answer is a qualified yes. For patients admitted early (within 2 days of illness onset), prompt provision of oseltamivir was associated with a 62% reduction in the need for a post-hospitalization extended stay. For those admitted after the first 2 days of illness, prompt initiation of oseltamivir resulted in a more modest 25% reduction. The bottom line here… use antivirals early when influenza is suspected.
We are at the beginning of the 2015/12016 influenza season. Here are some basic pointers for your primary care influenza toolkit:
- Situational awareness is important. Keep tabs on what is going on with influenza in your community and state. An easy source of excellent information is found at: http://www.cdc.gov/flu/weekly/
- Provide influenza vaccine to all patients over the age of 6 months.
- Maintain a high index of suspicion for influenza in patients with acute respiratory infections during the influenza season.
- If influenza is suspected and treatment is indicated, do not delay initiation of an antiviral while awaiting the results of laboratory testing. Starting within 2 days is generally recommended.
- In hospitalized patients, starting an antiviral with 4 days of illness onset may offer additional benefit.
It was used used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility upon hospital discharge. The researchers focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay (LOS) using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤4 days) and late (>4 days) in reference to date of illness onset.
Among 6,593 community-dwelling adults aged ≥65 years hospitalized for influenza, 18% required extended care at discharge. Need for care increased with age and neurologic disorders, ICU admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤2 or >2 days from illness onset (adjusted odds ratio [aOR] 0.38; 95% confidence interval [CI] 0.17, 0.85, and aOR 0.75; 95% CI 0.56, 0.97 respectively).
Early treatment was also independently associated with reduction in LOS for those hospitalized ≤2 days from illness onset (adjusted hazard ratio [aHR] 1.81; 95% CI 1.43, 2.30) or >2 days (aHR 1.30; 95% CI 1.20, 1.40).
- Chaves SS, Pérez A, Miller L, et al. Impact of prompt influenza antiviral treatment on extended care needs after influenza hospitalization among community-dwelling older adults. Clinical Infectious Diseases Advance Access published September 2, 2015.