Written by Caitlin Nicholson
Spoon Feed
Delayed initiation of antiviral therapy in adults hospitalized with influenza-associated pneumonia was associated with higher 30-day mortality and severe outcomes.
Considering antiviral treatment? Don’t delay!
This large retrospective cohort study evaluated the association between timing of antiviral therapy initiation and 30-day mortality in 26,233 adults hospitalized with influenza-associated pneumonia across seven influenza seasons using FluSurv-NET data. Patients starting antivirals on day 1 (aOR 1.14, 95%CI 1.01–1.27) or days 2-5 (aOR 1.40, 95%CI 1.17–1.66) after admission had significantly higher odds of death compared to those treated on admission day (day 0). Delayed antiviral initiation was consistently associated with increased mortality and other severe outcomes.
How will this change my practice?
This study underscores the critical role of antiviral treatment in the emergency department. A recent observational study, detailed on JournalFeed, shows similar findings. These results align with current IDSA guidelines, which recommend antiviral therapy for any influenza-positive patient hospitalized with acute respiratory illness. I will continue administering antivirals to influenza-positive patients requiring admission, regardless of symptom duration.
Source
Timing of Influenza Antiviral Therapy and Risk of Death in Adults Hospitalized With Influenza-Associated Pneumonia, Influenza Hospitalization Surveillance Network (FluSurv-NET), 2012-2019. Clin Infect Dis. 2025 Feb 24;80(2):461-468. doi: 10.1093/cid/ciae427. PMID: 39172994
This observational data is lower quality than all the RCTs and SR of RCTs where antivirals use didn’t have such a critical role. Not to mention all the controversy with Roche and not published probably negative RCTs.
For this reason, I wouldn’t say antivirals have a critical role in the ED, on the contrary.
Ongoing RECOVERY trial oseltamivir arm will possibly further elucidate us.
Agree, observational data is generally lower quality than RCTs. However, most oseltamivir RCTs were asking a much different question, in a very different population – largely healthy (skewing younger). A well done observational study with a striking, clinically relevant, strong association can still be actionable. In this study of >26,000 patients, there was a 40% greater odds of death when antiviral therapy was delayed. That is hard to just brush off as useless information just because it was not a RCT. It seems there is mounting evidence that timely antiviral therapy in sicker, hospitalized patients is a VERY good idea and most likely saves lives. If you want to forgo oseltamivir in a healthy 30-something who tests positive for flu, sure…don’t treat. Have a 65 year old with multiple health problems, hypoxemia, being admitted to the hospital with a positive flu test? I think it would be hard to explain why you would NOT use an appropriate (and timely!!) antiviral in such a case.