We are getting ready for the 2017/18 flu season. Unfortunately, the level of protection from the flu vaccine is still less than 100%, many people will remain unvaccinated, and multiple other viruses also cause influenza-like illness. We expect that many people will experience influenza-like illness (ILI) and turn to HealthTap for help.
Similar to last year, here are top 3 steps to take when evaluating and treating people with ILI who request your help via virtual consultation:
1. Understand the Clinical Presentation of ILI
An ILI has the syndrome:
- fever >101 °F
- cough or sore throat
- generalized symptoms such as malaise or myalgia
- plus the lack of any other explanation for these symptoms
Influenza symptoms include:
- sudden onset and illness of <7 days duration
- sudden onset of high fever, chills, dry hacking cough, sore throat, rhinitis, and myalgias
- however individual cases are impossible to distinguish with confidence from other viral respiratory infections
During your evaluation, be aware of other complications such as otitis, sinusitis, bacterial pneumonia, or viral pneumonitis. Refer patients who appear dyspneic or more significantly ill for an in-person evaluation.
Is the patient experiencing a sore throat? Could it be strep?
- Isolated sore throat without fever does not require either throat swab or treatment, unless there is documented contact with proven strep pharyngitis.
- Sore throat after documented exposure to culture-proven strep pharyngitis warrants empiric antibiotic treatment.
- You can ask patients with sore throat to take a photo of the back of their throat using their cell phone camera with the flash on. Mothers or a helper can use the handle of a fork if needed to get the tongue out of the way for the photo.
- Patients with sore throat and fever but no cough, myalgia or arthralgia should be evaluated for strep pharyngitis. In the presence of tender cervical adenopathy, and visible purulent pharyngeal exudate, empiric antibiotic therapy after a virtual consult is reasonable. In the absence of exudate or adenopathy, a referral to a PCP or urgent care for rapid strep test is the best course.
2. Send for Diagnostic Testing
For suspected new onset of influenza:
- it’s not necessary or helpful to obtain nasal or throat swabs (for viral or strep cultures or influenza RT-PCR) prior to treatment
For detecting recurring influenza:
- nasal swabs are better than throat swabs
- however rapid diagnostic influenza tests have low sensitivity, thus, a negative test should not be relied on – especially during active flu season
3. Provide Care or Treatment
In cases of uncomplicated ILI:
- there is no role for antibiotics for treatment or prophylaxis
If a patient’s symptoms typical of influenza began within 48 hours:
- Consider anti-viral treatment, whether or not they received the influenza vaccine
For those at higher risk of complications (such as those with COPD, CHF, conditions causing immunosuppression or simply age > 65 or infants <1 yr old, regardless of time since onset*):
- Consider antiviral treatment
Please note, current strains of influenza are >99% susceptible to both Oseltamivir (Tamiflu) and zanamivir (Relenza). Influenza resistance to the adamantanes (amantadine, rimantidine) is very high (>92% since 2006).
Don’t forget to remind your patients of good hygiene as a means to limit spread, especially hand washing and limiting skin to skin contact. Encourage your patients and their family members to get vaccinated now if they haven’t already. It’s not too late to gain protection this season!
1. Recommended oseltamivir (Tamiflu) regimens for adults include:
Oseltamivir 75mg bid x 5 days (treatment) or 75mg qd x 10 days (chemoprophylaxis after exposure)
<1 yr, 3 mg/kg po bid x 5 days
<15 kg, 30 mg po bid x 5 days
<23 kg, 45 mg po bid x 5 days
<40 kg, 60 mg po bid x 5 days
Chemoprophylaxis is the same dosage delivered once daily for 10 days.
2. The CDC recommends antiviral treatment for influenza
- anyone <2 yrs or >=65 yrs,
- women who are pregnant or postpartum (within 2 weeks after delivery);
- persons with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
- persons with immunosuppression, including that caused by medications or by HIV infection;
- persons aged <19 years who are receiving long-term aspirin therapy;
- American Indians/Alaska Natives;
- persons who are morbidly obese (i.e., BMI ≥40);
- and residents of nursing homes and other chronic-care facilities.
Do you have tips about how to combat ILI? Create a Tip or Checklist on flu prevention today: