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9

THE ASSOCIATION OF IMPROVED SURVIVAL WITH EARLY-ONSET ADMINISTRATION OF METHYLPREDNISOLONE IN CRITICALLY ILL PATIENTS CONFIRMED WITH H1N1.

Friday, 27 May, 2011 - 11:24
Board 2

The novel influenza A(H1N1) pandemic affected Greece during 2009. Vaxination was incomplete and as a result, an outbreak during the period January-March in 2011 took place. It caused an epidemic of severe pneumonia and some patients developed severe acute respiratory distress syndrome (ARDS).

Influenza A (H1N1) virus is a subtype of influenza A virus and was the most common cause of human influenza (flu) in 2009. Some strains of H1N1 are endemic in humans and cause a small fraction of all influenza-like illness and a small fraction of all seasonal influenza. H1N1 strains caused a few percent of all human flu infections in 2004–2005.[1] Other strains of H1N1 are endemic in pigs (swine influenza) and in birds (avian influenza).

In June 2009, the World Health Organization declared the new strain of swine-origin H1N1 as a pandemic. This strain is often called swine flu by the public media. This novel virus spread worldwide and had caused about 17,000 deaths by the start of 2010. On August 10, 2010, the World Health Organization declared the H1N1 influenza pandemic over, saying worldwide flu activity had returned to typical seasonal patterns.[2]

As of 26 April 2011, an H1N1 pandemic preparedness alert has been issued by the World Health Organisation (WHO) for the Americas. See Recombinomics- H1N1 WHO Alert 2011. The affected areas have included the Chihuahua region of Mexico where its severity and work load have been high. It is reported by the aforementioned Recombinomics source that the current vaccine (California/7/2009) for H1N1 influenza might be losing its effectiveness in 2011. This point is all the more significant since it is the current virus target for the northern hemisphere's flu vaccine, and is the intended choice for the southern hemisphere.

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ARDS

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IntroductionThe novel influenza A(H1N1) pandemic affected Greece during 2009. Vaxination was incomplete and as a result, an outbreak during the period January-March in 2011 took place. It caused an epidemic of severe pneumonia and some patients developed severe acute respiratory distress syndrome (ARDS).

Influenza A (H1N1) virus is a subtype of influenza A virus and was the most common cause of human influenza (flu) in 2009. Some strains of H1N1 are endemic in humans and cause a small fraction of all influenza-like illness and a small fraction of all seasonal influenza. H1N1 strains caused a few percent of all human flu infections in 2004–2005.[1] Other strains of H1N1 are endemic in pigs (swine influenza) and in birds (avian influenza).

In June 2009, the World Health Organization declared the new strain of swine-origin H1N1 as a pandemic. This strain is often called swine flu by the public media. This novel virus spread worldwide and had caused about 17,000 deaths by the start of 2010. On August 10, 2010, the World Health Organization declared the H1N1 influenza pandemic over, saying worldwide flu activity had returned to typical seasonal patterns.[2]

As of 26 April 2011, an H1N1 pandemic preparedness alert has been issued by the World Health Organisation (WHO) for the Americas. See Recombinomics- H1N1 WHO Alert 2011. The affected areas have included the Chihuahua region of Mexico where its severity and work load have been high. It is reported by the aforementioned Recombinomics source that the current vaccine (California/7/2009) for H1N1 influenza might be losing its effectiveness in 2011. This point is all the more significant since it is the current virus target for the northern hemisphere's flu vaccine, and is the intended choice for the southern hemisphere.Objectives To describe the clinical outcome of 6 critically ill patients with confirmed influenza A (H1N1) after co- administration of early onset methylprednisolone along with supportive treatment.Materials & MethodsThis is a clinical observation of 6 critically ill patients with confirmed influenza A(H1N1) in ICU of General Hospital of Trikala during 2011 outbreak in Greece, from January until March. Demographic data, symptoms, medical history, comorbid conditions, illness progression, days of hospitalization, APACHE II of the 1st day, in association with early- onset treatment with cortisone were collected to describe the effectiveness of treatment to a better clinical outcome. Results

  1. 6 patients with severe pneumonia of confirmed influenza A(H1N1) were admitted to ICU.
  2. Patients were young ( median, 46.16[ range,36-57]), all presented with fever and respiratory symptoms.
  3. 4 (66%) were obese.
  4. ICU stay duration- median,9 [ range, 5-17].
  5. 4(66%) patients received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia.
  6. All patients received, from the 1st day of admission methylprednisolone in a dose of 40*4 along with oseltamivir 75mgr 2*2 for 10 days and other supportive and antibiotic treatment.
  7. All patients survived. After adjusting for a reduced opportunity of patients dying early to receive methylprednisolone was associated with improved survival.
  8. 5(83,3%) had free medical past history and were healthy without any medication at home.
  9. APACHE II Score- median 14.83 ( range 10-19).
  10. Predicted death rate wtih a range 32.2%-11.3%.
  11. The findings in almost all patients in chest CT were: multiple alveolar type opacifications , diffuse along with interstitial opacities, similar to the findings in influenza pneumonias.
  12. 4 patients had procalcitonin(PCT) levels < 0.5, 1 patient =2, and 1 patient 2<PCT>10.
  13. In all patients the tests of urine for antigens of Legionella and Pneumococcus were negative.
  14. 1 patient had also Staphylococcus epidermidis in blood culture, 2 patients had Acinetobacter baumanii in bronchial secretions and 1 patient had Staphylococcus epidermidis in bronchial secretions.
  15. All patients except from the treatment with oseltamivir and methylprednisolone received and other antibiotics specific in each case due to the severity of the infection.

ConclusionsThe early onset administration of methylprednisolone in a dose of 40*4, showed improved survival in patients co-treated with neuraminidase inhibitors.

According to the literature reports more than 34% of H1N1-virus severe infections were treated with corticosteroids. This report and our experience may suggest a possible life-saving use of corticosteroids at a stress dose in severely ill patients with an H1N1-virus infection that is not responding to the most advanced treatments (3).References1. "CDC – Influenza (Flu): Weekly Report: Influenza Summary Update 20, 2004–2005 Season".

2. "CIDRAP News - WHO says H1N1 pandemic is over".

3. Methylprednisolone infusion for life-threatening H1N1-virus infection.

Confalonieri M, Cifaldi R, Dreas L, Viviani M, Biolo M, Gabrielli M.

Ther Adv Respir Dis. 2010 Aug;4(4):233-7. Epub 2010 Jul 16.