nosocomial)influenza)(ni))in)cancer)pa5entsduring)a)high ......paents(tested((n=102)(posi#ve...

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.    

List  your  informa#on  on  these  lines.    

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  

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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  diana_vilar@yahoo.com.mx  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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