Influenza Treatment Guidelines

Introduction to Influenza Management

The American College of Physicians and Infectious Diseases Society of America recommends against the use of corticosteroids for the treatment of influenza, unless clinically indicated for other reasons, due to increased mortality and risk of secondary bacterial infections 1, 2

A meta-analysis of 13 observational studies (n=1,917 patients) showed a mortality odds ratio of 3.06 (95% CI: 1.58-5.92) against corticosteroid use, indicating significant harm 2
Analysis of four low-bias trials confirmed these findings (OR: 2.82; 95% CI: 1.61-4.92) with increased risk of superinfection 2
The Infectious Diseases Society of America guidelines state that corticosteroids are associated with significantly higher mortality, more secondary bacterial infections, and longer ICU stays in influenza pneumonia 2, 3, 4

The American College of Rheumatology recommends continuing glucocorticoids in patients with rheumatic diseases who develop influenza, but reducing to the lowest possible dose to control the underlying disease 2
The European Respiratory Society suggests avoiding abrupt cessation in patients receiving >5 mg/day prednisone equivalent due to adrenal suppression risk 2
Patients on chronic steroids (≥20 mg/day prednisolone for >1 month, or ≥1 mg/kg/day in children <20 kg) are considered high-risk for influenza complications, according to the Journal of Infection and Thorax 3, 4

The Centers for Disease Control and Prevention recommend initiating neuraminidase inhibitors (oseltamivir 75 mg twice daily for 5 days) immediately in all hospitalized patients with suspected influenza, patients with severe or progressive illness, and high-risk patients (age <2 years or ≥65 years, pregnant/postpartum women, immunocompromised, chronic cardiopulmonary disease) 1, 5, 6
The World Health Organization suggests investigating and empirically treating bacterial coinfection if severe initial presentation, clinical deterioration after initial improvement, or failure to improve after 3-5 days of antiviral treatment 1, 2, 5

The American Academy of Pediatrics recommends oral oseltamivir as the antiviral of choice for all ages, with weight-based dosing for children ≥12 months 6
The European Respiratory Society suggests continuing inhaled corticosteroids for asthma/COPD management during influenza, but may require systemic steroids specifically for asthma/COPD exacerbation, not for influenza itself 4
The Infectious Diseases Society of America guidelines state that patients on immunosuppressive doses of steroids (≥20 mg/day prednisolone for >1 month) are high-risk and should prioritize immediate antiviral therapy; do not add corticosteroids for influenza treatment 1, 2, 3, 4

The American College of Physicians and Infectious Diseases Society of America recommend never adding corticosteroids thinking they will reduce inflammation in influenza pneumonia—they increase mortality and delay viral clearance 2
The American College of Rheumatology suggests never abruptly stopping chronic steroids in patients who develop influenza—taper gradually while treating influenza with antivirals 2

High-risk patients, including those with chronic respiratory disease, immunosuppression, age ≥65 years or <2 years, pregnant/postpartum women, and those with chronic heart disease, diabetes, renal disease, or liver disease, require aggressive monitoring 7, 8

The American Thoracic Society recommends continuing chronic steroids at the lowest effective dose while prioritizing immediate antiviral therapy for patients with chronic steroid use 7, 8
The European Respiratory Society suggests adding systemic corticosteroids, short-acting bronchodilators, and antibiotics to oseltamivir for COPD exacerbation 8