Should “Non-High Risk Patients” With Uncomplicated Influenza be Given Antivirals?

Should “Non-High Risk Patients” With Uncomplicated Influenza be Given Antivirals? 150 150 Michael T. Brady, MD

This question references a recommendation from the Centers for Disease Control and Prevention that is open to interpretation. For years, the CDC has recommended that all “hospitalized, severely ill and high-risk patients with suspected or confirmed influenza should be treated with antivirals.” Those at high risk include children younger than 2 years of age and people with certain underlying conditions (a list of those conditions is here).

The potentially unclear part involves people with suspected or confirmed influenza who are not severely ill and who are not in these high-risk categories. The CDC guidance says antivirals may be prescribed “on the basis of clinical judgement” for these patients, because they can reduce the duration of uncomplicated illness.

What factors, though, make up that clinical judgement?

  • Duration of symptoms. There is limited benefit if symptoms have been present for more than 48 hours.
  • The age of the patient. Children younger than 2 years and adults older than 65 years are in the high risk category, but children ages 2-5 are also at an increased risk of complications compared to the general population.
  • Severity of illness. Even if a patient does not present as severely ill, a suspicion that symptoms are worsening or could progress to severe illness may warrant antivirals.
  • Community influenza rates/Suspicion of influenza. While a provider may delay prescribing without confirmation of influenza, high local influenza rates or a true suspicion of influenza may suggest the use of empiric therapy.

Parents may request medications for their children in some cases, and providers would typically like to satisfy their patients’ parents. However, the decision to prescribe medications, whether antiviral medications for influenza or antibiotics for viral colds, should be based on evidence that the patient will derive benefit — not just to satisfy parents’ requests.

Prescription of antivirals for children should be limited to those children who fit into the above criteria. Parents understandably want what is best for their children, and a provider should discuss with parents that in relatively uncomplicated and low risk cases, the best course of action is often conservative.

About the author

Michael T. Brady, MD, is associate medical director at Nationwide Children’s Hospital, co-medical director for Patient Safety, a member of the hospital’s Division of Infectious Diseases and a Professor of Pediatrics at The Ohio State University College of Medicine. An infectious disease specialist for more than three decades, Dr. Brady began focusing on the emerging HIV epidemic in the mid-1980s and its implications for infants, children and adolescents. He created the country’s first family-centered pediatric HIV program at Nationwide Children’s in 1987. While still involved with the HIV program, his interests in recent years have included promoting immunization in children, reducing healthcare associated infections and providing guidance on emerging infections.

Dr. Brady served as physician-in-chief at Nationwide Children’s from 2005 to 2013 and chair of the Department of Pediatrics at OSU’s College of Medicine from 2006 to 2013. Under his leadership, OSU’s Pediatrics faculty nearly doubled in size. Dr. Brady also oversaw the development of Physician Direct Connect at Nationwide Children’s, a service that puts community pediatricians in nearly immediate contact with specialists for consultations. He is a long-time member of Nationwide Children’s Graduate Medical Education Committee, influencing the training of the next generation of physicians.

At the national level, Dr. Brady has served as chair of the American Academy of Pediatrics’ Committee on Infectious Diseases. He is currently the associate editor of Red Book, the comprehensive infectious disease reference from the AAP. He is also a member of the editorial panel for Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children: Recommendations from the NIH, CDC, HIV Medicine Association, PIDS and AAP. Other activities have involved global immunization advocacy, ongoing education of pediatricians across the country and service on task forces handling issues ranging from circumcision to meningococcal vaccines.