Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

Abstract

Seasonal influenza A and B virus epidemics are associated with significant morbidity and mortality each year in the United States and worldwide. One study estimated that during 2010–2016, the seasonal incidence of symptomatic influenza among all ages in the United States was approximately 8% and varied from 3% to 11% [1]. Most people recover from uncomplicated influenza, but influenza can cause complications that result in severe illness and death, particularly among very young children, older adults, pregnant and postpartum women within 2 weeks of delivery, people with neurologic disorders, and people with certain chronic medical conditions including chronic pulmonary, cardiac, and metabolic disease, and those who are immunocompromised [2–8]. During 2010–2018, seasonal influenza epidemics were associated with an estimated 4.3–23 million medical visits, 140 000–960 000 hospitalizations, and 12 000–79 000 respiratory and circulatory deaths each year in the United States [9]. A recent modeling study estimated that 291 243–645 832 seasonal influenza–associated respiratory deaths occur annually worldwide [10]. Use of available diagnostic modalities and proper interpretation of results can accurately identify patients presenting with influenza. Timely diagnosis may decrease unnecessary laboratory testing for other etiologies and use of antibiotics, improve the effectiveness of infection prevention and control measures, and increase appropriate use of antiviral medications [11, 12]. Early treatment with antivirals reduces the duration of symptoms and risk of some complications (bronchitis, otitis media, and pneumonia) and hospitalization, and may decrease mortality among high-risk populations [13–16]. Annual vaccination is the best method for preventing or mitigating the impact of influenza, but in certain situations, chemoprophylaxis with antiviral medications can be used for preexposure or postexposure prevention and can help control outbreaks in certain populations. These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009 [17]. The guidelines consider the care of children, pregnant and postpartum women, and nonpregnant adults and include special considerations for patients who are severely immunocompromised such as hematopoietic stem cell and solid organ transplant recipients. The target audience includes primary care clinicians, obstetricians, emergency medicine providers, hospitalists, and infectious disease specialists. The guidelines may be also useful for occupational health physicians and clinicians working in long-term care facilities. It adds new information on diagnostic testing, use of antivirals, and considerations of when to use antibiotics and when to test for antiviral resistance, and presents evidence on harm associated with routine use of corticosteroids. The panel followed a process used in the development of previous IDSA guidelines that included a systematic weighting of the strength of recommendations and quality of evidence based upon the US Public Health Service Grading System for ranking recommendations in clinical guidelines as utilized in the previous 2009 guidelines (Table 1) [17]. Summarized below are the recommendations. A detailed description of background, methods, evidence summary, and rationale that support each recommendation, and research needs are included in the full document. Infectious Diseases Society of America–US Public Health Service Grading System for Ranking Recommendations in Clinical Guidelines Adapted from the Canadian Task Force on the Periodic Health Examination [6]. Infectious Diseases Society of America–US Public Health Service Grading System for Ranking Recommendations in Clinical Guidelines Adapted from the Canadian Task Force on the Periodic Health Examination [6]. Because prevention and control of influenza is a dynamic field, clinicians should consult the website of the Centers for Disease Control and Prevention (CDC) for the latest information about influenza vaccines, influenza tests, and approved antiviral medications. 1. During influenza activity (defined as the circulation of seasonal influenza A and B viruses among persons in the local community): Clinicians should test for influenza in high-risk patients, including immunocompromised persons who present with influenza-like illness, pneumonia, or nonspecific respiratory illness (eg, cough without fever) if the testing result will influence clinical management (A-III). Clinicians should test for influenza in patients who present with acute onset of respiratory symptoms with or without fever, and either exacerbation of chronic medical conditions (eg, asthma, chronic obstructive pulmonary disease [COPD], heart failure) or known complications of influenza (eg, pneumonia) if the testing result will influence clinical management (A-III) (see Table 3). Clinicians can consider influenza testing for patients not at high risk for