Diagnosis and management of influenza: Information for medical staff and ANPs Follow us on Twitter @NHSaaa Find us on Facebook at www.facebook.com/nhsaaa Visit our website: www.nhsaaa.net All our publications are available in other formats
Health Protection Scotland stance on use of antivirals for flu Clinicians may be aware of a Cochrane Review on the efficacy of antivirals, published in 2014 2. Despite this Cochrane Review, the National Institute for Health and Clinical Excellence (NICE), the World Health Organisation (WHO), and Health Protection Scotland (HPS) continue to recommend antivirals both for the treatment and prophylaxis of seasonal influenza 1. There is good evidence that antivirals can reduce the risk of death in patients hospitalised with influenza 3. HPS has previously endorsed the detailed response published by PHE to the Cochrane Review 3. When to suspect flu Patients with flu classically present with fever, coryza, headache, malaise, myalgia, arthralgia and sometimes gastrointestinal symptoms 1. However, not all patients with flu develop fever, and patients who are immunosuppressed or at the extremes of age may present atypically. A history of recent flu immunisation does not exclude flu as a possible diagnosis 1. Clinicians in secondary care should use their clinical judgement to diagnose flu and to prescribe antiviral medicines 1. 2
How to manage a patient with possible flu 1. Health care workers who are pregnant or immunosuppressed should avoid all contact with patients with possible or confirmed flu. Occupational Health can be contacted for further advice. 2. Wear appropriate PPE for self-protection (see Appendix 1), and isolate the patient if possible 3. One of the following respiratory samples should be sent, requesting Respiratory PCR. Samples at the top of the list are preferred where possible: Bronchoalveolar lavage sample Combined throat and nose swab (using a pink tipped viral swab) Sputum Gargle Throat swab 4. Consider antiviral treatment with Tamiflu (oseltamivir) or Relenza (zanamivir) See page 17 of the Health Protection Scotland guidance Guidance on use of antiviral agents 1 5. Consider antiviral prophylaxis for patient and health care worker (HCW) contacts at risk of developing complicated influenza See pages 13 and 14 of the Health Protection Scotland guidance on use of antiviral agents 1 3
Antiviral prophylaxis is generally only useful if it can be started following <48 hours exposure. Patient Close Contact Definition Staff Close Contact Definition Patient sharing the same room with the index case. There is no minimum exposure time. HCWs working directly with the patient without appropriate PPE whilst a patient is considered infectious, OR HCWs present during Aerosol Generating Procedures without wearing FFP3 Respirators. 6. Droplet / airborne precautions can be discontinued when: A suspected case tests negative for flu on PCR testing or All respiratory symptoms have resolved / returned to baseline for 24 hours Information for use in conjunction with the HPS guidance Complicated flu 4 Complicated flu is defined as requiring hospital admission and/or with signs and symptoms of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical condition 1.
Risk factors for developing complicated flu 1 Chronic neurological disease Chronic liver disease Chronic kidney disease Chronic lung disease Chronic heart disease Diabetes mellitus Asplenia Severe immunosuppression* Age > 65 years Age < 6 months Morbid obesity (BMI 40) Pregnancy (including up to 2 weeks post-partum) *Examples of severe immunosuppression include the following 1 : 1. Patients currently receiving high dose systemic corticosteroids (equivalent to 40 mg prednisolone per day for >1 week in an adult, or 2mg/kg/day for 1 week in a child), and for at least 3 months after treatment has stopped 2. Severe primary immunodeficiency 3. Current or recent (within 6 months) chemotherapy or radiotherapy for malignancy 5
4. Solid organ transplant recipients on immunosuppressive therapy 5. Bone marrow transplant recipients who have received immunosuppressive treatment in the last 12 months 6. Patients with current graft-versus-host disease 7. HIV infected patients with severe immunosuppression 8. Patients currently or recently (within 6 months) on other types of immunosuppressive therapy References 1. Guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza 2016-17. Health Protection Scotland. 2. Cochrane Acute Respiratory Infections Group (2014). Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. 3. The use of antivirals for the treatment and prophylaxis of influenza, PHE summary of current guidance for healthcare professionals. Public Health England (2014). 6
Appendix 1 Personal Protective Equipment (PPE) requirements and other relevant infection control issues when dealing with patients with suspected or confirmed flu. What PPE do I need to wear? Is an aerosol generating procedure (AGP) being conducted? Common AGPs include: Non invasive ventilation (NIV) e.g. BiPAP and CPAP Intubation, extubation and related procedures, for example manual ventilation and open suctioning Induction of sputum by chest percussion Bronchoscopy Cardiopulmonary resuscitation (CPR)* Use of nebulised hypertonic saline or other nebulised medications is not considered to be an AGP. No PPE requirements for staff Surgical mask + gloves + apron +/- eye protection Patient placement Single room Other patient infection control issues Patients should wear a surgical mask during transfers, and should be encouraged to cover their nose and mouth with a tissue when coughing, sneezing or blowing their nose. Yes During the AGP and for 1 hour afterwards PPE requirements for staff FFP3 mask (must be fit tested) + gloves + apron/gown + eye protection Patient placement Single room Negative Pressure Room preferable Other patient infection control issues Patients should wear a surgical mask during transfers, and should be encouraged to cover their nose and mouth with a tissue when coughing, sneezing or blowing their nose. *The urgency of CPR may reduce the likelihood of wearing adequate PPE. This may have implications for post-exposure antiviral prophylaxis. 7
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