Systemic corticosteroids and early administration of antiviral agents for pneumonia with acute wheezing due to influenza A(H1N1)pdm09 in Japan

Abstract

Background: Pneumonia patients with wheezing due to influenza A(H1N1)pdm09 were frequently treated with systemic corticosteroids in Japan although systemic corticosteroid for critically ill patients with pneumonia caused by influenza A(H1N1)pdm09 has been controversial. Applicability of systemic corticosteroid treatment needs to be evaluated.

Methods/principal findings: We retrospectively reviewed 89 subjects who were diagnosed with influenza A(H1N1)pdm09 and admitted to a national hospital, Tokyo during the pandemic period. The median age of subjects (45 males) was 8 years (range, 0-71). All subjects were treated with antiviral agents and the median time from symptom onset to initiation of antiviral agents was 2 days (range, 0-7). Subjects were classified into four groups: upper respiratory tract infection, wheezing illness, pneumonia with wheezing, and pneumonia without wheezing. The characteristics of each group was evaluated. A history of asthma was found more frequently in the wheezing illness (55.6%) and pneumonia with wheezing (43.3%) groups than in the other two groups (p = 0.017). Corticosteroid treatment was assessed among subjects with pneumonia. Oxygen saturation was lower in subjects receiving corticosteroids (steroid group) than in subjects not receiving corticosteroids (no-steroid group) (p<0.001). The steroid group required greater oxygen supply than the no-steroid group (p<0.001). No significant difference was found by the Kaplan-Meier method between the steroid and the no-steroid groups in hours to fever alleviation from the initiation of antiviral agents and hospitalization days. In logistic regression analysis, wheezing, pneumonia and oxygen saturation were independent factors associated with using systemic corticosteroids.

Conclusion: Patients with wheezing and a history of asthma were frequently found in the study subjects. Systemic corticosteroids together with early administration of antiviral agents to pneumonia with wheezing and possibly without wheezing did not result in negative clinical outcomes and may prevent progression to severe pneumonia in this study population.

Figure 1. Study population.

A total of 104 patients were diagnosed with pandemic influenza A(H1N1)pdm09. Five patients (one of whom died) were admitted to the ICU and were excluded from the study. The remaining 99 patients were the study subjects. Among them, 89 subjects presented with respiratory disorders and 10 presented with symptoms other than respiratory disorders, including encephalopathy. The subjects with respiratory disorders were classified into the following four groups: upper respiratory tract infection (n = 22), wheezing illness (n = 9), pneumonia with wheezing (n = 30), and pneumonia without wheezing (n = 28). The total number of subjects with pneumonia was 58.

Figure 2. Systemic corticosteroids treatment in the relation0 to clinical time course assessed by Kaplan-Meier methods.

Kaplan-Meier curves of the number of hours to fever alleviation (A) and hospitalization days (B) according to systemic corticosteroid treatment among subjects with viral pneumonia in steroid (n = 46) and non-steroid (n = 12) groups There were no significant differences between the groups in terms of either hours to fever alleviation (log rank test, p = 0.835) or hospitalization days (log rank test, p = 0.626).