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

Abstract

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Keywords: chemoprophylaxis; diagnostic testing; institutional outbreaks; seasonal influenza; treatment.

Conflict of interest statement

Potential conflicts of interest. The following list is a reflection of what has been reported to the IDSA. To provide thorough transparency, the IDSA requires full disclosure of all relationships, regardless of relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of interest (COI) is determined by a review process that includes assessment by the Standards and Practice Guidelines Committee (SPGC) Chair, the SPGC liaison to the development panel and the Board of Directors (BOD) liaison to the SPGC, and if necessary, the COI Task Force of the BOD. This assessment of disclosed relationships for possible COI will be based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). The reader of these guidelines should be mindful of this when the list of disclosures is reviewed. H. H. B. reports grants from the New York State Department of Health and personal fees from Current Opinion in Pediatrics, Shire Human Genetic Therapies, the Harvard School of Public Health, and the American Academy of Pediatrics (AAP); H. H. B. is a member of the Advisory Committee on Immunization Practices at CDC; is an ex-officio member of the Committee on Infectious Diseases at AAP; and is an editor of the Red Book Online at AAP. J. A. E. reports personal fees from Sanofi Pasteur, Gilead, and the Bill & Melinda Gates Foundation and grants from Gilead, Chimerix, Novavax, the Bill & Melinda Gates Foundation, Alios/Janssen, and MedImmune, out-side the submitted work. T. M. F. reports personal fees from bioMerieux, Curetis AG, GlaxoSmithKline, Melinta, Meji Seika Pharma Co, Merck & Co, MotifBio, Nabriva, Paratek, and Shionogi, during the conduct of the study. S. G. reports grants, personal fees, and nonfinancial support from Sanofi and Seqirus; personal fees from Merck, Pfizer, Longevoron, Janssen, GSK, and the Gerontological Society of America; and grants from the National Institutes of Health (NIH), CDC, and Janssen. F. G. H. reports personal fees from the World Health Organization and the University of Alabama Antiviral Drug Discovery and Development Consortium; fees to the University of Virginia for serving on data safety monitoring boards for Celltrion, GSK, and Vaccitech; donations to a non-profit orphanage and school for consulting from PREP Biopharm and Sequiris; travel support and donations to a non-profit orphanage and school for consulting from Shionogi; and noncompensated consulting for various companies engaged in developing influenza therapeutics or vaccines (CoCrystal, Farmak, Genentech/Roche, GSK, Janssen, MedImmune, Medivector/ FujiFilm, Regeneron, resTORbio, SAB Biotherapeutics, Vir, and Visterra). J. M. H. reports personal fees from Pfizer; nonfinancial support from Global Blood Therapeutics; and grants from the NIH, Fogarty International Center, the Health Resources and Services Administration, the Centers for Medicare and Medicaid, and the Maryland Institute of Emergency Medical System Services, outside the submitted work. M. G. I. reports grants from Janssen and Emergent BioSolutions; personal fees from Celltrion, Genentech/ Roche, Medi Vector, Seqirus, VirBio, Alios, Biota, Crucell, Janssen, and NexBio, during the conduct of the study; and reimbursement for serving on a data safety monitoring board from GlaxoSmithKline. B. L. J. reports grants from Pfizer, Gilead, and the Canadian Institutes of Health Research (CIHR); and contracts for nosocomial infection surveillance from the Public Health Agency of Canada, outside the submitted work. A. M. reports grants and other from Crucell, Sanofi Pasteur, and GlaxoSmithKline; and grants from CIHR and the Ontario Workplace Safety Insurance Board, out-side the submitted work. L. E. R. served as a consultant to the Vaccines and Medications in Pregnancy Surveillance System; served as a speaker for the American College of Obstetricians and Gynecologists; served as a contributor for UpToDate; served as a consultant to Johns Hopkins University; reports grants from the Bill & Melinda Gates Foundation; and provided expert testimony for Ficks and Connolly, for Wiggins and Dana, LLP, and for McAloon & Friedman. A. T. P. reports grants from the National Institute of Allergy and Infectious Diseases (NIAID)/NIH, NIAID/Biofire, and the CDC; other from Antimicrobial Therapy Inc; and personal fees from WebMD and Johnson & Johnson, outside the submitted work. All other authors report no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Published by Oxford University Press for the Infectious Diseases Society of America 2018.

Figures

Figure 1.

Guide for considering influenza testing when influenza viruses are circulating in the community (regardless of influenza vaccination history). 1Confirmation of influenza virus infection by diagnostic testing is not required for decisions to prescribe antiviral medication. Decision making should be based upon signs and symptoms consistent with influenza illness and epidemiologic factors. Initiation of empiric antiviral treatment should not be delayed while influenza testing results are pending. Antiviral treatment is clinically most beneficial when started as close to illness onset as possible. 2Signs and symptoms of uncomplicated influenza (see Table 2). 3Clinical manifestations and complications associated with influenza (see Table 3) and persons who are at high risk of complications from influenza (Table 4). 4All hospitalized patients with suspected influenza should be tested, as detection of influenza virus infection and prompt initiation of antiviral therapy are most clinically beneficial, and implementation of infection prevention and control measures is essential for prevention of nosocomial influenza outbreaks. 5Influenza testing may be used to inform decisions on use of antibiotics or continuation of antiviral medication, on need for further diagnostic tests, on consideration for home care, or on recommendations for ill persons living with others who are at high risk for influenza complications (see Table 4). 6Influenza testing may be required to inform decisions on infection control practices. 7Antiviral treatment is recommended for outpatients with suspected influenza who are at high risk for complications from influenza, or those with progressive disease not requiring hospital admission. Antiviral treatment of outpatients who are not at high risk for influenza complications (see Table 4) can be considered based upon clinical judgment if presenting within 2 days of illness onset. Abbreviations: HF, heart failure; COPD, chronic obstructive pulmonary disease.