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

January 31, 2019

Michael Brady, MD, an Infectious Diseases specialist at Nationwide Children’s Hospital, answers this common question from primary care providers.

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.