Stanford Antimicrobial Safety and Sustainability Program

12/2019

Management of Influenza in Adult Patients –

Outpatient Setting
For outpatients, diagnostic testing for influenza virus is not required to prescribe antiviral
medication. The decision to prescribe antivirals should take into consideration patients at high-
risk for influenza-related complications or time since onset of symptoms in lower risk groups.

Treatment
• Do not wait for laboratory confirmation of influenza to start treatment when indicated
Clinical Setting Antimicrobial Therapy Duration Comments
Treatment Indications: Preferred:
Oseltamivir and
Oseltamivir 75 mg PO (or via zanamivir may rarely
Symptomatic patients at high- feeding tube) BID cause
risk for influenza (requires dose-adjustment for renal neuropsychiatric
insufficiency; See SHC Antimicrobial
complications (not all 5 days effects
Dosing Reference Guide or
inclusive): Lexicomp® for recommendations)
• Age 65 years and older Oseltamivir is the
• Chronic pulmonary Alternative in clinically preferred choice for
disease, cardiovascular stable, patients intolerant pregnant women
disease, metabolic to oseltamivir:
disorders, and neurologic Zanamivir should be
disorders* Zanamivir 2 puffs (10 mg) via avoided in patients
• Immunosuppressed inhalation BID with underlying lung
• Pregnant or immediately disease due to
post-partum potential for
• Extremely obese (i.e. BMI bronchospasm
> 40)
• American Indians/Alaska
Natives Alternative (restricted in Avoid in pregnant
• Residents of nursing inpatient setting): women, breast-feeding
homes or other chronic 1 day mothers, severely
care facilities Baloxavir immunosuppressed
40 kg to < 80 kg: 40 mg PO patients, and those
Symptomatic patients with once with complicated or
confirmed or suspected ≥80 kg: 80 mg PO once progressive illness.
influenza within 48 hours of
symptom onset Do not administer
baloxavir with
polyvalent cations as
this may decrease
plasma concentrations
• Amantadine and rimantadine should not be used for treatment or chemoprophylaxis of
influenza given high rates of resistance
• Combination antiviral therapy for treatment of influenza has not demonstrated clinical benefit
in prospective randomized trials
• For restricted antivirals, see SHC Antimicrobial Restriction Policy for use criteria
• * For details, see: CDC Influenza Antiviral Medications: Summary for Clinicians
Original Date: 9/2/2019 Revised: 12/2019 ABX Subcommittee approved: 1/2020
Authors: William Alegria, PharmD; Stanley Deresinski, MD; Marisa Holubar, MD MS; Lina Meng,
PharmD; Emily Mui, PharmD
 Stanford Antimicrobial Safety and Sustainability Program
12/2019
Chemoprophylaxis
• Peramivir and baloxavir are not recommended for prophylaxis of influenza
• Prophylaxis is not routinely recommended if more than 48 hours have elapsed since last
exposure to a person with influenza
Clinical Setting Antimicrobial Therapy Duration Comments
Prophylaxis may be Preferred: Oseltamivir may rarely
considered in the following cause neuropsychiatric
patients after exposure to a Oseltamivir 75 mg PO (or via 7 days effects
person with influenza: feeding tube) once daily
(requires dose-adjustment for renal
insufficiency; See SHC Antimicrobial
• High risk for influenza- Dosing Reference Guide or
related complications Lexicomp® for recommendations)
during the first two weeks
following vaccination or in
those who cannot receive Zanamivir should be
influenza vaccine due to Alternative: avoided in patients with
a contraindication underlying lung disease
• Patients who might not Zanamivir 2 puffs (10 mg) via 7 days due to potential for
respond to influenza inhalation once daily bronchospasm
vaccination, such as
people receiving Zanamivir may rarely
immunosuppressive cause neuropsychiatric
medications effects

MedFinder
Medfinder is a resource that can be used if antivirals become hard to find in outpatient pharmacies, or
for less commonly stocked antivirals. Instructions cut/pasted below:
Quick Start:
1. Open https://www.medfinder.org/ in your browser
2. Click “Yes, Find Medication” (blue button)
3. Select the medication (Tamiflu, Relenza, or Xofluza)
4. Type in dosage (Keep in mind for pediatric patients)
5. Type in location (Stanford, CA for the hospital, or another address as necessary). Search area
defaults to 10 miles (can be changed).
6. Hitting search will show all pharmacies in your search area with the drug and a qualitative
measure of their current supply

Notes:
• The supply data is updated daily by each participating pharmacy so is at most 24-hours delayed
(reasonably accurate).
• Only chain pharmacies participate currently, independents hopefully coming but likely not this
year.
• Most, but not every, chain pharmacy participates. Non-participants are shown in gray in the
search map.

Original Date: 9/2/2019 Revised: 12/2019 ABX Subcommittee approved: 1/2020

Authors: William Alegria, PharmD; Stanley Deresinski, MD; Marisa Holubar, MD MS; Lina Meng,
PharmD; Emily Mui, PharmD
 Stanford Antimicrobial Safety and Sustainability Program
12/2019

SHC Influenza Testing

Test Viruses Sample Turnaround Time
Cepheid FluA/B/RSV Influenza A/B, Respiratory Nasopharyngeal 1 hour
(ED only) syncytial virus (RSV) swab

Cepheid FluA/B/RSV: Influenza A/B, RSV Nasopharyngeal 30 minutes - 1 hour

Point-of-Care swab
(ED walk-in-clinic and
Express Care only)
GenMark ePlex Influenza A, Influenza A H1, Nasopharyngeal 2 hours
Respiratory Pathogen Influenza A H3, Influenza A swab
Panel 2009 H1N1, Influenza B, RSV,
Coronavirus, Parainfluenza
1/2/3/4, Human
Metapneumovirus (MPV),
Rhinovirus, Enterovirus,
Adenovirus, Chlamydia
pneumoniae, Mycoplasma
pneumoniae
GenMark XT-8 Influenza A, Influenza A H1, Bronchoalveolar 24 hours
Respiratory Virus Influenza A H3, Influenza A Lavage
Panel: 2009 H1N1, Influenza B, RSV
subtype A and B, Parainfluenza
1,2 and 3; Human
Metapneumovirus, Rhinovirus,
and Adenovirus species B/E
and C

References:

Recommendations adapted from the Centers for Disease Control and Prevention (CDC). Click here for
additional information available through their website

Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical Practice Guidelines by the Infectious Diseases Society
of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak
Management of Seasonal Influenza. Clin Infect Dis. 2019;68(6):e1-e47.

Ariano RE, Sitar DS, Zelenitsky SA, et al. Enteric absorption and pharmacokinetics of oseltamivir in
critically ill patients with pandemic (H1N1) influenza. CMAJ. 2010;182(4):357-63.

Beigel JH, Bao Y, Beeler J, et al. Oseltamivir, amantadine, and ribavirin combination antiviral therapy
versus oseltamivir monotherapy for the treatment of influenza: a multicentre, double-blind, randomised
phase 2 trial. Lancet Infect Dis. 2017;17(12):1255-1265.

Original Date: 9/2/2019 Revised: 12/2019 ABX Subcommittee approved: 1/2020

Authors: William Alegria, PharmD; Stanley Deresinski, MD; Marisa Holubar, MD MS; Lina Meng,
PharmD; Emily Mui, PharmD