Antiviral Treatment and Prophylaxis for seasonal Influenza QRG 2017/18

Transcription

1 Antiviral Treatment and Prophylaxis for seasonal Influenza QRG 2017/18 Selection of antiviral therapy for treatment of influenza (definitions + doses on p.2) When indicated, treatment should be started as soon as possible do not wait for lab confirmation Personal Protective Equipment Close contact <2metres - Fluid repellent surgical mask - Gloves - Plastic apron - Eye protection if splash risk Aerosol generating procedure (AGP) - Fit tested FFP3 mask - Gloves - Fluid repellent gown - Eye protection AGPs are: Nasopharyngeal aspiration, Tracheostomy care, Chest physio, Intubation, Manual ventilation/suctioning, Bronchoscopy, CPR, Surgery & post mortem procedures with high- speed devices The following hospitalised patients may be considered for IV zanamivir: - patients who have already failed to respond to nebulised zanamivir - patients who have developed respiratory conditions affecting nebuliser delivery (eg airways disease, pulmonary oedema) - patients with multi-organ involvement / requiring intensive care & not absorbing, after d/w micro ** Clinical follow-up advise patient to seek medical attention if illness worsens. Patient may need to be reswabbed for influenza if this occurs, noting on the request they are already on antivirals The circulating influenza strain can be checked via the National Flu Report. Commencing oseltamivir and zanamivir treatment more than 48 hours after symptom onset (36 hours for zanamivir use in children) is an off-label use use clinical judgement. There is evidence of mortality reduction up to 5 days in complicated influenza. Definitions: Title: Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 ID: 144TD(C)25(I3)QRG Issue No: 6 Review Date: Dec 20 Page 1

2 Uncomplicated influenza: Influenza presenting with fever ( 37.8 C), coryza, generalised symptoms (headache, malaise, myalgia, arthralgia), sometimes GI symptoms, but not features of complicated influenza. Complicated influenza: Influenza requiring hospital admission and/or with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical condition. At risk groups for complicated influenza: a) Neurological, hepatic, renal, pulmonary and chronic cardiac disease. b) Diabetes mellitus. c) Severe immunosuppression. d) Age over 65 years. e) Pregnancy (including up to 2 weeks post partum). f) Children under 6 months of age. g) Morbid obesity (BMI 40). Severe immunosuppression: a) Severe primary immunodeficiency. b) Current or recent (<6 months) chemotherapy/radiotherapy. c) Solid organ transplant recipients on immunosuppressants. d) BM transplant recipients on immunosuppressant in last 12 months or with current graft-versushost disease. e) Patients on high dose systemic corticosteroids (equivalent 40mg prednisolone/day for >1 week in adults, 2mg/kg/day for 1 week in children) and for at least three months after treatment has stopped. f) HIV with CD4< 500/μl or <15% of total lymphocytes in an adult (seek advice in children) g) Other types of highly immunosuppressive treatment currently or within last 6 months, or where patient s specialist regards them as severely immunosuppressed. Treatment dosage (see p4 for renal dosing) TREATMENT Oseltamivir PO (5 days) Zanamivir inhaler (5 days) Premature (<36 weeks post 1mg/kg/dose (Unlicenced) 0-12 months ( 36 weeks post 3mg/kg/dose >1-12 years: Dose according to weight below 15kg >15- >23- >40kg 23kg 40kg 30mg 45mg Not licenced for children <5 years old Children 5 years: 10mg 60mg 75mg Adults (13 yrs and over) 75mg 10mg Notes on zanamivir Use 2 nd line treatment if there is poor response to oseltamivir, or if there is poor gastrointestinal absorption. Inhaled zanamivir via Diskhaler may not be an effective delivery route in some patients, including those unable to administer the Diskhaler and patients with severe underlying respiratory disease. It is not licensed for use in children less than five years. The powder preparation for the Diskhaler should NEVER be made into nebuliser solution or administered to a mechanically ventilated patient. Zanamivir solution for IV or nebulised administration is an unlicensed medication and is available on a compassionate use basis for named patients in the UK. For full guideline see the 2017/18 Public Health England guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza Title: Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 ID: 144TD(C)25(I3)QRG Issue No: 6 Review Date: Dec 20 Page 2

3 Post exposure prophylaxis for influenza Post-exposure prophylaxis is indicated for people at risk of complicated influenza (see p.1), irrespective of whether they have received vaccine, if they have contact with a case of influenzalike illness, defined as: - Household or residential setting contact - Face to face contact - Same hospital bay for 15 minutes or longer Commencing prophylaxis with oseltamivir later than 48 hours after exposure, or with zanamivir, later than 36 hours after exposure is an off-label use. Specialist advice referred to in this table may be obtained from a local infection specialist such as a microbiologist or virologist. Title: Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 ID: 144TD(C)25(I3)QRG Issue No: 6 Review Date: Dec 20 Page 3

4 Prophylaxis dosage (see below for renal dosing) PROPHYLAXIS Oseltamivir PO (10 days) Zanamivir inhaler (10 days) Premature (<36 weeks post conceptual age) Seek specialise advice 0-12 months ( 36 weeks post 3mg/kg/dose >1-12 years: Dose according to weight below 15kg >15- >23- >40kg 23kg 40kg 30mg 45mg Not licenced for children <5 years old Children >5 years: 10mg 60mg 75mg Adults (13 yrs and over) 75mg 10mg Oseltamivir dosing in renal impairment These doses are taken from the renal database and may differ from Public Health England guidance and the information in the drug Summary Of Product Characteristics (SPC). Treatment (adults and 13yrs old) CrCl (ml/min) >60ml/min 31-60ml/min 11-30ml/min <10ml/min APD/CAPD HD CVVH Oseltamivir PO for 5 days 75mg bd 75mg bd 75mg ONCE 30 mg ONCE 30 mg ONCE, then 30mg after each dialysis 75 mg bd Prophylaxis (adults and 13yrs old) CrCl (ml/min) >60ml/min 31-60ml/min 11-30ml/min <10ml/min APD/CAPD HD CVVH Oseltamivir PO for 10 days 30mg od 30mg weekly (2 doses) 30 mg weekly 30 mg ONCE, then 30mg after each dialysis 75 mg od For the full national guideline please see the 2017/18 Public Health England guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza Title: Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 ID: 144TD(C)25(I3)QRG Issue No: 6 Review Date: Dec 20 Page 4

5 Antiviral Treatment and Prophylaxis for seasonal Influenza QRG 2017/18 Parent Document: Public Health England Guidance on Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 Scope: Trust-wide Author: Antibiotic Steering Committee Contact details: Ext 64570/65030 Author s Division: CSSTM Approval: Medicines Management Group December 2017 Keywords: Influenza, Flu, Oseltamivir, Zanamivir, Tamiflu, Relenza, H1N1, H3N2, Seasonal, Prophylaxis Review date: December 2020 Title: Antiviral Treatment and Prophylaxis for seasonal Influenza 2017/18 ID: 144TD(C)25(I3)QRG Issue No: 6 Review Date: Dec 20 Page 5