nosocomial)influenza)(ni))in)cancer)pa5entsduring)a)high ......paents(tested((n=102)(posi#ve...
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Pa#ents tested (n=102)
Posi#ve 46 (45.1%)
Influenza AH1N1 33 (71.7%)
Influenza AH3N2 13 (28.3%)
Background: Hospital onset influenza (HOI) cons#tutes a serious risk among pa#ents with immunodeficiency. Vaccina#on of health-‐care workers (HCW) and infec#on control measures compliance is the cornerstone for the preven#on of NI. We present a cluster of pa#ents with cancer and NI during a high ac#vity season in Mexico (winter 2013-‐14). Methods: Pa#ents and HCW with influenza-‐like illness (ILI) from Ins#tuto Nacional de Cancerologia in Mexico City (126-‐bed, teaching, referral cancer hospital for adult pa#ents) are regularly evaluated by the Infec#ous Diseases Department. Those with high suspicion of ILI are tested for influenza by rtPCR. Pa#ents who developed ILI between 1/1/2014 and 3/31/2014 and tested posi#ve to influenza were included; those who had been in-‐hospital >= 3 days were considered asHOI. We studied pa#ents characteris#cs, hospital length of stay, neoplasia related variables and respiratory tract infec#on (RTI) symptoms, clinical course and outcomes. Results: Between January and March, 2014, 102 pa#ents and 50 HCW were evaluated with ILI. Sixty two pa#ents were admiaed because of ILI; 6 (8.8%) developed ILI while in-‐hospital. Forty-‐six pa#ents tested posi#ve for influenza (AH1N1: 33 (71%); AH3N2: 13 (28%). Twenty-‐six confirmed cases with community onset influenza were admiaed to the hospital (AH1N1: 22, AH3N2: 4). Four and 2 pa#ents with HOI were posi#ve to AH1N1 and H3N2, respec#vely. Two had leukemia, 2 lymphoma, 1 aplas#c anemia and 1 breast cancer. Five (83.3%) received chemotherapy within 30 days of the onset of symptoms; 5 (83%) had lymphopenia and 4 (66.7%) had < 500 neutrophils. All were treated with oseltamivir. Two (33.3%) pa#ents with HOI died, both posi#ve to H1N1. Conclusion: HOI accounted for 18.7% of the confirmed influenza pa#ents admiaed to the hospital, mostly, with hematological neoplasia. Aaributable mortality rate was 33.3%, similar to that observed for community-‐acquired influenza. Most cases were related to AH1N1, as was reported for North America during this last influenza season.
Influenza poses important infec#on control risks and challenges to both pa#ents and health-‐care workers (HCWs). There is increasing recogni#on of the importance of nosocomial transmission. Hospital onset influenza (HOI) is associated with considerable morbidity and mortality. Among the severely immunocompromised, including pa#ents with cancer receiving chemotherapy, influenza infec#on is associated with severe disease, pneumonic complica#ons, secondary bacterial infec#on, prolonged viral shedding and higher rates of death. Although vaccina#on of HCWs is cornerstone for preven#ng influenza, and is consistently recommended by public-‐health authori#es, vaccine uptake among HCWs remains low. Influenza outbreaks increase the complexity of medical care. We describe characteris#cs of adult pa#ents with HOI and cancer iden#fied during a high ac#vity 2013-‐2014 influenza season in a cancer hospital in Mexico City, and compare them with pa#ents hospitalized with community-‐onset (CO) influenza.
We included pa#ents with influenza-‐like illness (ILI) from Ins#tuto Nacional de Cancerologia (INCan) (126-‐bed, teaching, referral cancer hospital for adult pa#ents) in Mexico City between 1/1/2014 and 3/31/2014. HOI was considered in pa#ents admiaed for a non-‐respiratory illness who subsequently developed fever or respiratory illness and had confirma#on of influenza (rt-‐PCR) > 3 calendar days afer hospital admission. Community onset (CO) cases were pa#ents with rt-‐PCR confirmed influenza with symptoms prior to hospital evalua#on or ≤ 3 calendar days afer hospital admission. Pa#ents characteris#cs, hospital length of stay, neoplasia related variables and respiratory tract infec#on symptoms, influenza vaccina#on, clinical course, and outcomes were studied for all pa#ents. A descrip#ve analysis was conducted. We compared HOI and CO influenza. Student T-‐test and chi-‐square or Fisher exact test were used as appropriate.
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References: 1. Memoli MJ, Athota R, Reed S, et.al. The natural history of influenza infec#on in the severly immunocompromised vs. nonimmunocompromised hosts. Clin Infect Dis 2014; 58: 214-‐24. 2. Jhung MA, D’Mello T, Pérez A, Aragon D, et.al. Hospital-‐onset influenza hospitaliza#ons-‐United States, 2010-‐2011. Am J Infect Control 2014; 42: 7-‐11. 3. Maltezeou HC. Nosocomial influenza. New concepts and prac#ce. Current Opinion Infect Dis 2008; 21. 337-‐43. 4. Minnema BJ, Husain S, Mazzulli T, et.al. Clinical characteris#cs and outcome associated with pandemic (2009) H1N1 influenza infec#on in pa#ents with hematologic malignancies: a retrospec#ve cohort study. Leukemia & Lymphoma 2012; 54: 1250-‐5
Health-‐care workers
Con
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Nosocomial Influenza (NI) in Cancer Pa5ents during a High Ac5vity Season in Mexico City Diana Vilar-‐Compte, MD, MSc; Carolina Perez-‐Jimenez, MD; Alexandra Mar#n-‐Onraet, MD; Patricia Cornejo-‐Juarez, MD, MSc; Marco Antonio Lopez-‐
Velazquez, MD; Alvaro Tamayo-‐Gu#errez, MD and Patricia Volkow, MD. Infec#ous Diseases Department, Ins#tuto Nacional de Cancerología (INCan), Mexico City, Mexico,
Table 2. Influenza related variables in pa#ents with ILI Variable N (%) Pneumonia 50 (49.0) Days between onset of symptoms and medical aaen#on (mean±SD) 4.1 ± 3.15 Dura#on of symptoms (mean±SD) 8.6 ± 4.42 Admission to intensive care 10 (9.8) Mechanical ven#la#on 10 (9.8) All cause mortality -‐ Related to influenza
14 (13.7) 4 (28.6)
0
10
20
30
40
50
60
70
80
90
100
No. of p
aLen
ts
Table 3. Community and hospital onset influenza (confirmed cases)
Figure 1. Symptoms of pa#ents with ILI (n=102)
Variable N (%) Age 42.8 ± 15.2 Male 54 (53) Body mass index 27.1 ± 5.35 Malignancy: -‐ Leukemia -‐ Lymphoma -‐ Mul#ple myeloma -‐ Solid tumors -‐ Other
34 (33.3) 25 (24.2) 10 (9.8) 28 (27.4) 5 (4.9)
Steroids (within 3 months) 20 (19.6) Diabetes mellitus 11 (10.7) Chemotherapy within 30 days 62 (60) Neutropenia at onset of sympotms 36 (35) Influenza vaccina#on (season 2013-‐14) 4 (3.9) Contact with a confirmed influenza case 16 (15.6)
Figure 2. Confirma#on of influenza by rt-‐PCR
Table 1. Baseline characteris#cs of pa#ents with ILI (n=102) Variable Community
onset influenza (n= 40)
Hospital onset influenza (n= 6)
P value
Age 42.8 ± 15.2 34.5 ± 12.1 0.19 Hematological malignancies Solid tumors
25 (62.5) 15 (37.5)
5 (83.3) 1 (16.6)
0.42
Symptoms: -‐ Cough -‐ Fever -‐ Malaise -‐ Rhinorrea -‐ Sore throat -‐ Headache -‐ Dyspnea -‐ Chills -‐ Myalgias
38 (95.0) 35 (87.5) 32 (80.0) 27 (67.5) 23 (57.5) 19 (47.5) 26 (65.0) 26 (65.0) 18 (45.0)
4 (66.7) 3 (50.0) 4 (66.7) 3 (50.0) 5 (83.4) 3 (50.0) 2 (33.3) 2 (33.3)
0
0.009 0.18 0.46 0.40 0.19 0.91 0.19 0.19 0.07
Steroids 8 (20.0) 2 (33.3) 0.24 Chemotherapy within 30 days 26 (65.0) 5 (83.3) 0.32 Pneumonia 16 (40.0) 2 (33.3) 1.00
Neutropenia at onset of symptoms -‐ DuraLon of neutropenia prior to influenza
8 (20.0) 4.63 ± 1.97
4 (66.7) 8.2 ± 5.2
0.11 0.52
Dura#on of symptoms of influenza 8.5 ± 3.6 7.0 ± 4.8 0.38 Lenght of hospital stay (days) -‐ Lenght of hospital stay prior to influenza
4.78 ± 6.27* NA
16.7 ± 9.1 8.7 ± 5.6
< 0.0001 -‐-‐-‐
Days of treatment with oseltamivir 6.80 ± 3.10 7.83 ± 4.71 0.47
Admission to ICU (mechanical ven#la#on) 6 (23.1)* 1 (16.7) 0.91 Overall mortality: -‐ Aaributable to influenza **
5 (12.5) 2 (40.0)
2 (33.3) 2 (100)
0.37 1.00
Contact informaLon: Diana Vilar-‐Compte [email protected] Abstract #: 47942
ParLcipants
During the study period 50 HCWs developed ILI, 12 (24%) had confirmed influenza (AH1N1: 9 [75%], AH3N2: 3 [25%]). Sixteen (32%) reported contact with confirmed influenza pa#ents. All HCWs except one had upper respiratory tract infec#on that resolved within 5-‐7 days; all were treated with oseltamivir. Influenza vaccina#on was only reported in 9 (18%); none of the confirmed cases had been immunized for influenza during the current season.
In this series, exclusively of pa#ents with cancer, a high frequency of influenza-‐related pneumonia (39.1%) was reported. Pa#ents with hematologic malignancies were the most affected. Pa#ents with HOI in average, experienced less symptoms, were neutropenic for longer periods (p= NS), received more days of an#viral treatment (p= NS) and had longer hospital stay (p < 0.0001). Most of them probably experienced prolonged viral shedding. Very low rates of influenza vaccina#on within the previous year were observed in both, pa#ents and HCWs. Star#ng this fall, more strict policies for influenza vaccina#on have been implemented.
• Pa#ents admiaed to the hospital with community onset influenza (n=26). ** Aaributable mortality in community onset influenza was caused in 1 case by influenza AH1N1. In HOI aaributable mortality was caused by influenza AH1N1 in both cases.
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