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Steroids Might Benefit Critically Ill Patients with Suspected H1N1 Influenza

Combined treatment with antiviral agents and steroids led to significant improvements in organ function within 1 week.

Patients with severe 2009 pandemic influenza A (H1N1) virus infections who present with pneumonia might develop acute respiratory distress syndrome (ARDS). In a case series of 13 consecutive patients (mean age, 39) with suspected H1N1 influenza, severe hypoxia requiring ventilator support, and clinical sepsis, researchers prospectively evaluated response to treatment with a combination of oseltamivir and corticosteroids in addition to empiric antibiotics administered on admission to an intensive care unit (ICU) in Buenos Aires, Argentina. Patients with severe ARDS received methylprednisolone (1 mg/kg/day), and other patients received hydrocortisone (300 mg/day) for an average of 21 days. Most patients (62%) had vasopressor-dependent shock.

Twelve of the 13 patients had significant improvements in pulmonary and other organ function by the seventh day of treatment and were subsequently extubated and discharged from the ICU. Five nondiabetic patients developed hyperglycemia requiring insulin. No patient experienced either gastrointestinal (GI) bleeding requiring transfusion or neuromuscular weakness. The mortality rate at 60 days was 15%.

Comment: Steroids mitigate the inflammatory response that might be responsible for the high mortality from H1N1 influenza in young, otherwise healthy patients with strong immune systems who experience a cytokine storm. The promising results of this small nonrandomized study suggest that adding low- to moderate-dose steroids to the treatment of critically ill patients with suspected H1N1 influenza might be beneficial. However, such patients should be carefully monitored for deleterious effects of steroid treatment (i.e., hyperglycemia, GI bleeding, weakness, psychosis, aspergillosis, and avascular necrosis). Other treatments for critically ill patients with H1N1 influenza include intravenous peramivir and extracorporeal membrane oxygenation (JW Infect Dis Nov 4 2009 and JW Emerg Med Nov 13 2009).

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine January 8, 2010

Citation(s):

Quispe-Laime AM et al. H1N1 influenza A virus-associated acute lung injury: Response to combination oseltamivir and prolonged corticosteroid treatment. Intensive Care Med 2009 Nov 19; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-009-1727-6)