The diagnosis of
influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with
fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical
antiviral treatment. Molecular methods based on
nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of
influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active
infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting
antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative
leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of
thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications.
Antiviral administration (
oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early
antiviral administration is associated to improved survival in
critically ill patients. New
antiviral drugs, especially those formulated for
intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of
influenza A/H1N1
infection must continue with
antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of
influenza. In patients with
influenza A/H1N1
pneumonia, empirical
antibiotic therapy should be provided due to the possibility of bacterial
coinfection. A
beta-lactam plus a
macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of
antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose
corticosteroids has been proposed for the treatment of
influenza A/H1N1
pneumonia, the existing scientific evidence is not sufficient to recommend the use of
corticosteroids in these patients. The treatment of
acute respiratory distress syndrome in patients with
influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and
positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive
mechanical ventilation cannot be considered a technique of choice in patients with
acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of
respiratory failure associated with
chronic obstructive pulmonary disease exacerbation or
heart failure.
Extracorporeal membrane oxygenation is a rescue technique in refractory
acute respiratory distress syndrome due to
influenza A/H1N1
infection. The scientific evidence is weak, however, and
extracorporeal membrane oxygenation is not the technique of choice.
Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of
extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of
influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing
cardiomyopathy,
myocarditis,
ischemic heart disease and
right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems.
Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the
vaccine against A/H1N1 flu is similar to that of seasonal flu.
Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.