It’s Getting to Be Flu Season: - PowerPoint Presentation

Slide1

It’s Getting to Be Flu Season: Effective Management of URIs

Nicholas Fiebach, MD

Department of Medicine

Columbia University Medical CenterSlide2

Upper Respiratory Infections (URIs)ColdsFluSinusitisPharyngitisSlide3

Upper Respiratory Infections (URIs)ColdsFluSinusitisPharyngitis

Sinusitis (acute bacterial)

2% URIs

15% URI visits

Strep pharyngitis (GABH)

~ 10% adult sore throat

~ 50% adults with URI complaints got antibioticsSlide4

Today’s ObjectivesColdsFluSinusitisPharyngitis

Maximize flu vaccination

Distinguish specific syndromes which may benefit from antibiotics or antiviral

rx

Limit antibiotic

rx

Provide effective symptomatic treatmentsSlide5

Microbial Etiologies of URIs

VIRUSES

rhinovirus

coronavirus

influenza

parainfluenza

respiratory syncytial virus (RSV)

adenovirus

enterovirus

human

metapneumovirus

(HMPV)

BACTERIA

streptococcus (

pneumonia

, GABH, C and G)

Haemophilus

influenzae

Moraxella

catarrhalisSlide6

http://www1.nyc.gov/assets/doh/downloads/pdf/hcp/weekly-surveillance12302017.pdfSlide7

URIs: Clinical Epidemiology

Sep Dec Apr

Incidence of respiratory infections

Adapted from

Glezen

Epidemiol

Rev 1982;4:25Slide8

URIs: Clinical Epidemiology

Sep Dec Apr

Incidence of respiratory infections

Adapted from

Glezen

Epidemiol

Rev 1982;4:25

enterovirus

enterovirus

mycoplasma

parainfluenza

r

hinovirus

RSV

influenzaSlide9

New York City Department of Health and Mental Hygienehttp://www.nyc.gov/html/doh/flu/html/data/lab-surv.shtmlSlide10

InfluenzaSlide11

Influenza VirusSlide12

INFLUENZA A SUBTYPES WHICH CAUSE WIDESPREAD DISEASE IN HUMANS

HEMAGGLUTININ

1

2

3

3

4

5

6

7

8

9

10

11

12

13

14

15

16

N

E

U

R

A

M

I

N

…

1

2

3

4

5

6

7

8

9Slide13

INFLUENZA A STRAINS WHICH CAUSE WIDESPREAD OR

SPORADIC

DISEASE IN HUMANS

HEMAGLUTININ

1

2

3

3

4

5

6

7

8

9

10

11

12

13

14

15

16

N

E

U

R

A

M

I

N

…

1



2

3

4

5

6

7

8

9Slide14

Burden of Yearly Influenza Epidemics

https://www.cdc.gov/flu/about/disease/burden.htmSlide15

Question #1Which of the following persons should get influenza vaccine?62 yo man with COPD

33

yo

woman with asthma who is allergic to eggs

26

yo

woman with acne

1 and 3

All of the aboveSlide16

Question #1Which of the following persons should get influenza vaccine?62 yo man with COPD

33

yo

woman with asthma who is allergic to eggs

26

yo

woman with acne

1 and 3

All of the aboveSlide17

Influenza Vaccine: Indications

UPDATED

INDICATIONS

Age

≥

50

yo

√

Chronic illnesses

√

Pregnant women

√

Health care workers

√

Caregivers

< 6

months

√

≥ 65 yo √Slide18

Influenza Vaccine: Indications

UPDATED

INDICATIONS

Age

≥

50

yo

√

Chronic

illnesses

√

Pregnant women

√

Health care workers

√

Caregivers

< 6

months

√ ≥ 65 yo √√Chronic illnesses which increase risks for influenza illness, complications and mortality:PulmonaryCardiovascularRenalHepaticNeurologic, neuromuscularHematologicDiabetes (and other metabolic ds)ImmunosuppressionMalignancy Morbid obesity (BMI > 40)Slide19

Influenza Vaccine: Indications

UPDATED

INDICATIONS

Age

≥

50

yo

√

Chronic illnesses

√

Pregnant women

√

Health care workers

√

Caregivers

< 6

months

√

≥ 65 yo √Age > 6 months (ie. almost everyone)√Slide20

Influenza Vaccine: Effectiveness

RR (95% CI) for outcome among

healthy

vaccinated persons:

HEALTHY

ADULTS

Influenza

ILI

Hospitalization

Mortality

vaccine

matched

0.38 (0.31-0.48)

0.84 (0.77-0.91)

--

--

vaccine not matched

0.45 (0.34-0.59)

0.90 (0.69-1.18)

----Data from pooled studies in Cochrane Library 2014, Issue 3Slide21

Influenza Vaccine: EffectivenessRR (95% CI) for outcome among

elderly

vaccinated persons:

ELDERLY

(> 60 – 65)

Influenza

ILI

Hospitalization

Mortality

Nursing

homes

1.04 (0.43-2.51)

0.77 (0.64-0.96)

0.55 (0.36-0.84)

0.40 (0.21-0.77)

Community

0.19

(0.02-2.01)

1.05 (0.58-1.89)

0.73 (0.67-0.79)0.53 (0.46-0.61)Community0.73 (0.68-0.77)Community (match)0.48 (0.39-0.51)0.48 (0.46-0.51)Community (mismatch)0.64 (0.52-0.78)0.63 (0.57-0.69)Data from large pooled studies (1990s-2000s) Lancet 2005;636:1165 NEJM 2007;357:13 Lancet Inf Ds 2014;14:1228 Slide22

Influenza Vaccine: Effectiveness

2012-13

49%

2013-14

52%

2014-15

19%

2015-16

48%

2016-17

42%

Year-to-year variation related to circulating strains and vaccine match:

overall 

reduction

across the US population in acute respiratory illness

associated with influenza A and B virus infections among vaccinated persons Slide23

Influenza Vaccines 2017-18

Trivalent (1

A-H1N1, 1 A-H3N2

and 1

B)

s

tandard-dose

trivalent

shot

IIV3

s

tandard-dose trivalent jet injector

IIV3

needle

free

high-dose

trivalent shot

hdIIV3 > 65 yo trivalent shot grown in cell culture ccIIV3 > 18 yo (but not egg-free) recombinant trivalent shotRIV3 egg-free ( > 18 yo)

adjuvanted

trivalent shot

aIIV3

> 65

yo

Quadrivalent

(1

A-H1N1, 1 A-H3N2

and 2

B)

standard dose

quadrivalent

shot

IIV4

AIM this year

intradermal

quadrivalent

shot

IIV4

smaller needle (

<

65

yo

)

recombinant

quadrivalent

shot

RIV4

egg-free (

>

18

yo

)

quadrivalent

nasal

spray

LAIV

18

– 49

yo

not recommendedSlide24

Influenza Vaccines 2017-18

Trivalent (1

A-H1N1, 1 A-H3N2

and 1

B)

s

tandard-dose

trivalent

shot

IIV3

s

tandard-dose trivalent jet injector

IIV3

needle

free

high-dose

trivalent shot

hdIIV3 > 65 yo (AIM this year) trivalent shot grown in cell culture ccIIV3 > 18 yo (but not egg-free) recombinant trivalent shotRIV3

egg-free (

>

18

yo

)

adjuvanted

trivalent shot

aIIV3

> 65

yo

Quadrivalent

(1

A-H1N1, 1 A-H3N2

and 2

B)

standard dose

quadrivalent

shot

IIV4

intradermal

quadrivalent

shot

IIV4

smaller needle (

<

65

yo

)

recombinant

quadrivalent

shot

RIV4

egg-free (

>

18

yo

)

quadrivalent

nasal

spray

LAIV

18

– 49

yo

not recommendedSlide25

Influenza VaccineEffectiveness: High Dose v. Standard Dose

Risk (95% CI) of outcome among vaccinated persons

>65

yo

:

Influenza

ILI

Hospitalization

Mortality

RCT

(n=31,989)

0.76 (0.63-0.90)

Medicare cohort

(n=2,545,275)

0.78 (0.71-0.85)

0.78 (0.73-0.84)

VA cohort

(n=165,225)

0.99 (0.86-1.16)

1.05 (0.87-1.26)VA subgroup > 85 yo(n=21,826)0.52 (0.29-0.92)NEJM 2014;371:17Lancet Inf Ds 2015;15:293Clin Inf Ds 2015;61:171Slide26

Influenza Vaccine: Timing

As

soon as

available

Ideally by October

Through the end of influenza season (Feb-Mar)

Immunity

develops over 2 weeksSlide27

Influenza Vaccine: Adverse EffectsInactivated/parenteral

sore arm (common)

constitutional (10% - fever, headache,

myalgias

)

anaphylaxis (very rare, if not egg allergic)

Guillain-Barre (rare)

Flu – NEVERSlide28

Influenza Vaccination: Patient ResistanceEfficacy

emphasize reduction in hospitalization and mortality

Fear of side effects

emphasize coincidence of URIs and flu vaccination seasons

Never or not recently vaccinated

improvement in available vaccines

Make a strong recommendation

Slide29

Influenza Clinical DiagnosisBest predictors:fever ( ~ 100o F or higher)

cough

acute onset

80-90% positive predictive value

when influenza is circulatingSlide30

Influenza Diagnostic Tests

Method

Types Detected

Acceptable Specimens

Test Time

Sensitivity

Specificity

RT-PCR 

A and B

NP

swab, throat swab, NP or bronchial wash, nasal or endotracheal aspirate,

sputum

Varied

(1-6

hours)

Very

high

Very

high

Rapid Influenza Diagnostic TestsA and BNP swab, (throat swab), nasal wash, nasal aspirate<30 min.40 – 70%90 – 95%Slide31

Influenza Clinical Diagnosis Interpreting clinical findings and making treatment decisions depends on knowing if influenza is circulating:

CDC hotline, website (www.cdc.gov)

State and local health departments (www.nyc.gov)

Local surveillance networks

Hospital labs

Local wisdom and mediaSlide32

http://www1.nyc.gov/assets/doh/downloads/pdf/hcp/weekly-surveillance12302017.pdfSlide33

https://www.health.ny.gov/diseases/communicable/influenza/surveillance/2017-2018/flu_report_current_week.pdfSlide34

Influenza - Testing and TreatingInfluenza-like Illness (ILI): T > 100.4°F (38°C)

and

cough or sore throat

Mild-moderate symptoms or signs

Moderate - severe

symptoms or signs

Refer to ED or

hospital for evaluation,

testing, and treatment

Underlying

conditions

No

underlying

conditions

Do not test

Home isolation

? Treat

Do not test

Home isolationTreatSlide35

Influenza TreatmentSlide36

SinusitisSlide37

Diagnosis of acute bacterial sinusitis

From Williams JW Jr, Simel DL. JAMA 1993;270:1242-6

Slide38

Question #2A 50 yo man comes to the office for nasal congestion with yellow rhinorrhea and “sinus pain” for the past 3 days. He is afebrile with mild maxillary tenderness bilaterally. You should:

Order a single Waters view sinus x-ray

Rx azithromycin (Z-Pak) x 5 days

Rx amoxicillin-

clavulanate

(Augmentin) x 10 days

Rx a decongestant

2 and 4Slide39

Question #2A 50 yo man comes to the office for nasal congestion with yellow rhinorrhea and “sinus pain” for the past 3 days. He is afebrile with mild maxillary tenderness bilaterally. You should:

Order a single Waters view sinus x-ray

Rx azithromycin (Z-Pak) x 5 days

Rx amoxicillin-

clavulanate

(Augmentin) x 10 days

Rx a decongestant

2 and 4Slide40

Diagnosis of acute bacterial sinusitisPrevious history of sinus disease not necessarily informative

Symptoms not sufficiently specific individually, but combinations are suggestive

colored nasal discharge

unilateral maxillary pain (facial, tooth)

symptoms lasting longer than 7-10 days, or worsening after initial improvement

Unreliable signs

percussion

transilluminationSlide41

Imaging acute bacterial sinusitis

Sensitivity

Specificity

Xrays

good

(90%)

fair

(80-85%)

CT

excellent (>90%)

poor Slide42

Imaging acute bacterial sinusitisBottom line:not recommended for most patients who present with acute symptoms suggesting sinusitis.

helpful in the evaluation of patients with:

unexplained headache

poor response to therapy

severe symptoms or who are toxic and require accurate diagnosis early

recurrent episodes of suspected acute bacterial sinusitisSlide43

Empiric diagnosis of acute bacterial sinusitis

Purulent nasal discharge reported or observed

or

Maxillary tooth or facial pain, tenderness on exam

days

Persistent

>

10

Severe, with fever

>

3

Worsening of nasal or sinus symptoms after initial improvement

>

5Slide44

Antibiotics for sinusitis

Recommended regimens

allergic to penicillin

amoxicillin

500 mg 3 times

daily for 5-7 days

doxycycline

100 mg twice

daily for 5-7 days

amoxicillin/

clavulanate

500 mg/125 mg 3 times

daily for 5-7 days

levofloxacin

500 mg once

daily for 5-7 days

amoxicillin/

clavulanate

875 mg/125 mg twice daily for 5 days*moxifloxacin400 mg once daily for 5-7 days* my preference to maximize spectrum, potency and adherenceSlide45

Treatment of sinusitisAntibiotics NOT recommended:Macrolides (azithromycin, clarithromycin)Trimethoprim/sulfamethoxazole

Adjunctive treatment:

Nasal steroid

Saline irrigation

Topical and systemic decongestantsSlide46

PharyngitisSlide47

Practical approach to pharyngitis in adultsExclude severe forms of bacterial pharyngitisPeritonsillar abscessRetropharyngeal abscess

Epiglottitis

F

necrophorum

/

Lemierre’s

syndrome

Assess for Group A Beta-Hemolytic Strep (GABHS)Slide48

Clinical predictors of GABHSCentor criteria:Tonsillar exudateTender anterior cervical lymph nodes

History of fever

or

temp > 38 C (100.4 F)

Absence of coughSlide49

Testing and Treating GABHS PharyngitisClinical predictors (

Centor

criteria):

Tonsillar exudate

Tender anterior cervical lymph nodes

History of fever

or

temp > 38 C (100.4 F)

Absence of cough

# predictors

PPV

NPV

Clinical Management

3 - 4

40-60%

Test or treat empirically

0 - 2

Do not test or treat

Rapid tests

65%98%Treat if positiveSlide50

Antibiotic Treatment for GABHS Pharyngitis

Benzathine

penicillin

1.2 x 10

6

u IM

Penicillin VK

500

po

bid x 10 days

Penicllin

allergic w/o anaphylaxis:

Cephalexin

Cefadroxil

500

po

bid x 10 days

1000

po

qd x 10 daysPenicillin allergic w/ anaphylaxis:Azithromycin*Clarithromycin*Clindamyin 500 po qd x 5 days250 po bid x 10 days300 po tid x 10 days* Not for empiric treatment when F necrophorum a possibilitySlide51

Summary: specific treatment for URIs

Acute cough

and fever during flu season

Neuraminidase inhibitor, especially

if severe or high risk

Prolonged or severe nasal and/or facial symptoms

Antibiotic

for bacterial sinusitis

3 or 4

Centor

criteria

for strep throat or positive rapid test

Penicillin for GABHSSlide52

Summary: specific treatment for URIs

Acute cough

and fever during flu season

Neuraminidase inhibitor, especially

if severe or high risk

Prolonged or severe nasal and/or facial symptoms

Antibiotic

for bacterial sinusitis

3 or 4

Centor

criteria

for strep throat or positive rapid test

Penicillin for GABHS

all

other

URIsSlide53

Symptomatic Treatments for URIsSlide54

Targeted Treatment of URI Symptoms

THERAPY

EVIDENCE

Analgesics – oral

?

Analgesics – topical

?

Decongestants – oral

±

Decongestants – topical

±

Antihistamines

±

Expectorants

±

Vitamin C

+ (higher doses)

Echinacea

-

Zinc lozenges

±

Chicken soup

+