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Influenza causes necrosis of the respiratory epithelium, which predisposes to secondary bacterial infections Bacterial enzymes in turn (eg, proteases, trypsin-like compounds, streptokinase, and plasminogen) activate influenza viruses Frequent complications are acute sinusitis, otitis media, purulent bronchitis, and pneumonia Children (6 59 months), pregnant women, the elderly (aged 65 years or older), and the chronically ill (including HIV-infected individuals) are at high risk for complications Rhabdomyolysis is a rare late complication Pneumonia is commonly due to bacterial infection with pneumococci or, less often, staphylococci or Haemophilus Primary viral pneumonia (caused by the influenza virus itself)
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the inactivated vaccine against type B viruses A nasally administered inactivated vaccine is in phase 1 trials HIV-infected persons can be safely vaccinated, and concerns about activating replication of the HIV virus by the immunogen appear to be exaggerated and may be less severe than the increase in HIV viral load associated with a full influenza infection Vaccination is less effective when CD4 counts are less than 100/mcL False-positive assays for HIV, HTLV-1, and HCV antibodies have been reported in the wake of influenza vaccination Chemoprophylaxis can be accomplished with the neuraminidase inhibitors oseltamivir and zanamivir It is recommended that the M2 inhibitors amantadine and rimantadine no longer be used for chemoprophylaxis or treatment in the United States due to high prevalence (> 90%) of resistant influenza A (H3N2) viruses The M2 inhibitors are also ineffective against influenza B and many avian strains Oseltamivir (75 mg/d) and zanamivir (10 mg once daily) are effective for prophylaxis against influenza A and B The neuraminidase inhibitors will reduce the attack rate among unvaccinated individuals if begun within 48 hours after exposure
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epidemics, the mortality rate has been low except in debilitated individuals If the fever persists for more than 4 days with productive cough and white cell count over 10,000/mcL, secondary bacterial infection should be suspected Pneumococcal pneumonia is the most common such infection, and staphylococcal pneumonia is the most serious
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Advisory Committee on Immunization Practices Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2006 Jul 28;55(RR-10):1 42 [PMID: 16874296] Baz M et al Characterization of multidrug-resistant influenza A/H3N2 viruses shed during 1 year by an immunocompromised child Clin Infect Dis 2006 Dec 15;43(12): 1555 61 [PMID: 17109288] Hayden FG et al Antiviral management of seasonal and pandemic influenza J Infect Dis 2006 Nov 1;194 Suppl 2:S119 26 [PMID: 17163384] Kawai N et al A comparison of the effectiveness of oseltamivir for the treatment of influenza A and influenza B: a Japanese multicenter study of the 2003 2004 and 2004 2005 influenza seasons Clin Infect Dis 2006 Aug 15;43(4):439 44 [PMID: 16838232] Ohmit SE et al Prevention of antigenically drifted influenza by inactivated and live attenuated vaccines N Engl J Med 2006 Dec 14;355(24):2513 22 [PMID: 17167134] Sugaya N et al Lower clinical effectiveness of oseltamivir against influenza B contrasted with influenza A infection in children Clin Infect Dis 2007 Jan 15;44(2):197 202 [PMID: 17173216]
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Many patients with influenza prefer to rest in bed Analgesics and a cough mixture may be used Ribavirin (11 g/d, diluted to 20 mg/mL and delivered as particulate aerosol with oxygen over 12 18 hours a day for 3 7 days [see Table 32 1]) helps severely ill patients with influenza A or B The neuraminidase inhibitors, either inhaled zanamivir (two 5-mg inhalations twice daily for 5 days) or oral oseltamivir (75 mg twice daily for 5 days), are equally effective in the treatment of influenza Clinical trials have shown a reduction in the duration of symptoms but not in the rate of hospitalizations or mortality when using these agents These agents are most effective when given within 48 hours after symptom onset and are shown to be effective mainly in high-risk patients over age 12 years Amantadine and rimantadine are no longer recommended for treatment because of widespread resistance Resistance to the neuraminidase inhibitors is also a concern Oseltamivir resistance can occur with prolonged use in immunocompromised patients or in avian (H5N1)-infected patients Oseltamivir also appears less effective in treating influenza B than influenza A viruses There is only one documented case of zanamivir resistance in an immunocompromised host Zanamivir is relatively contraindicated among persons with asthma because of the risk of bronchospasm Antibacterial antibiotics should be reserved for treatment of bacterial complications Acetaminophen rather than aspirin should be used for fever in children
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