Elsevier

Journal of Infection

Volume 64, Issue 3, March 2012, Pages 311-318
Journal of Infection

Corticosteroid therapy in patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza

https://doi.org/10.1016/j.jinf.2011.12.010Get rights and content

Summary

Objective

During the first pandemic, some patients with pandemic (H1N1) 2009 influenza were treated with corticosteroids. The objective of this study was to assess the effect on survival of corticosteroid therapy in patients with pandemic (H1N1) 2009 influenza.

Methods

Prospective, observational, multicenter study performed in 148 ICU. Data were recorded in the GTEI/SEMICYUC registry. Adult patients with pandemic (H1N1) 2009 influenza confirmed by rt-PCR were included in the analysis. Database records specified corticosteroid type and reason for corticosteroid treatment.

Results

372 patients with the diagnosis of primary viral pneumonia and completed outcomes treated in an ICU were included in the database. Mechanical ventilation was used in 70.2% of the patients. 136 (36.6%) patients received corticosteroids after a diagnosis of primary viral pneumonia. Obesity (35.6% vs 47.8% p = 0.021) and asthma (7.6% vs 15.4% p = 0.018), were more frequent in the group treated with corticosteroids. A Cox regression analysis adjusted for severity and potential confounding factors found that the use of corticosteroid therapy was not significantly associated with mortality (HR = 1.06, 95% CI 0.626–1.801; p = 0.825).

Conclusions

Corticosteroid therapy in a selected group of patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza does not improve survival.

Introduction

The 2009 flu pandemic was an outbreak of a new strain of H1N1 influenza virus which was first described in April 2009, and to which many people had no pre-existing immunity. Infection with the pandemic (H1N1) 2009 influenza virus caused a broad spectrum of clinical syndromes, ranging from non-febrile upper respiratory illness to fulminant viral pneumonia. The principal clinical syndrome leading to hospitalization and intensive care was diffuse viral pneumonitis associated with severe hypoxemia, acute respiratory distress syndrome (ARDS), and sometimes shock and renal failure.1, 2, 3, 4

The most common pulmonary presentation of patients with pandemic (H1N1) 2009 influenza infection was a rapidly progressive viral pneumonia with bilateral alveolar infiltrates on chest radiography and ARDS.5

The efficacy of systemic corticosteroids has been extensively studied in ARDS but their therapeutic value remains unclear; several meta-analyses and reviews have offered conflicting perspectives.6, 7

Recent guidelines for the management of human infection with pandemic (H1N1) 2009 influenza argue against routine corticosteroid therapy, although low doses may be considered for patients in septic shock who require vasopressors and have suspected adrenal insufficiency.8, 9 Data supporting this recommendation, however, remain scarce and controversial10 and steroids are still administered in more than 40% of patients with pandemic (H1N1) 2009 influenza.

The main objective of this study was, therefore, to assess the effect on survival of corticosteroid therapy, compared to those who did not receive corticosteroid or received them subsequently as rescue therapy, in a cohort of patients hospitalized with a severe presentation of pandemic (H1N1) 2009 influenza infection in the intensive care unit (ICU).

Section snippets

Participants

Study data were recorded in a voluntary registry created by the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) after the first reported ICU case. SEMICYUC is a scientific association of doctors specializing mainly in Intensive Care Medicine. It was created in 1972 with the aim of improving care for critically ill patients across Spain and today has over 2600 affiliated members. Inside the SEMICYUC a working group (Grupo de Trabajo de la Gripe A Grave, GETGAG)

Results

From a total of 968 patients with confirmed pandemic (H1N1) 2009 influenza infection at 148 Spanish ICUs, 372 with the diagnosis of primary viral pneumonia were analyzed. All patients received antiviral therapy.

Two hundred and five patients (55.1%) were male, and the mean age was 43.41 ± 13.34 years. Mean APACHE II score was (12.8 ± 6.54), and the mean SOFA was (5.16 ± 3.06) on admission (Table 1). Mechanical ventilation was used in 70.2% of the patients; 60.2% with invasive modes and 23.1%

Discussion

The main finding of this study is that corticosteroid therapy does not improve survival in patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza virus infection. In contrast to a previous study which explored the role of corticosteroids in a mixed population of patients infected with pandemic (H1N1) 2009 influenza virus,18 in our study the target population comprised only patients with viral pneumonia due to this virus; all patients with other forms of infection requiring

Conflict of interest

Authors declare no conflict of interest regarding the present manuscript.

Acknowledgments

We are indebted to Michael Maudsley for editing the final version of the manuscript.

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