Guía clínica para pacientes hospitalizados y no hospitalizados cuando el SARS-CoV-2 y los virus de la influenza circulan simultáneamente

[Con base en los datos de vigilancia de salud pública local y la realización de pruebas en establecimientos de atención médica locales]

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Pacientes de clínicas ambulatorias o departamentos de emergencia con síntomas de enfermedad respiratoria aguda (con o sin fiebre)*

¿El paciente requiere ingreso en el hospital?

SÍ

  1. Recolección de muestras
  • Implement recommended infection prevention and control measures and collect respiratory specimens for influenza and SARS-CoV-2 testing.1 (Two different specimens may need to be collected if multiplex testing is unavailable.2-4)
  1. Realización de pruebas de SARS-CoV-2 e influenza
    a) Order multiplex nucleic acid detection assay for influenza A/B/SARS-CoV-2.2,3 OR
    b) If multiplex nucleic acid detection assay is not available, order SARS-CoV-2 nucleic acid detection assay3 or antigen detection assay and Influenza nucleic acid detection assay.4
    (Note: Because antigen detection assays have lower sensitivity than nucleic acid detection assays, a negative SARS-CoV-2 antigen detection assay result does not necessarily exclude SARS-CoV-2 infection and should be confirmed by SARS-CoV-2 nucleic acid detection assay or repeat antigen testing 48 hours later, especially if suspicion for COVID-19 is high - such as in the setting of high SARS-CoV-2 community prevalence or recent close exposure to a person with COVID-19.)  Si la segunda prueba de antígenos es negativa, de conformidad con la guía de la FDA, se puede considerar una tercera prueba de antígenos si existe una sospecha clínica considerable de COVID-19. Rapid influenza antigen detection assays are not recommended for hospitalized patients due to low sensitivities.)
    (Note: Because SARS-CoV-2 and influenza virus co-infection can occur, and may result in severe disease,5-7 a positive influenza test result without SARS-CoV-2 testing does not exclude COVID-19, and a positive SARS-CoV-2 test result without influenza testing does not exclude influenza.)
  • In critically ill intubated and mechanically ventilated patients who are suspected to have COVID-19 or influenza without a confirmed diagnosis, including when upper respiratory tract specimens are negative, lower respiratory tract (e.g. endotracheal aspirate) specimens should be collected for SARS-CoV-2 and influenza virus testing by nucleic acid detection assay per NIH COVID-19 Treatment Guidelines,8 and Infectious Diseases Society of America Influenza Clinical Practice Guidelines.9
  1. RSV testing
  1. Tratamiento
  • If bacterial pneumonia or sepsis is suspected, consider testing recommendations and empiric antibiotic treatment per American Thoracic Society-Infectious Diseases Society of America Adult Community-acquired Pneumonia Guidelines.10
  • Administer supportive care and treatment for suspected or confirmed COVID-19 patients per NIH COVID-19 Treatment Guidelines.8
    (Note: community-acquired bacterial co-infections can occur but appear to be uncommon with COVID-19,11-13 and more common with influenza.9)
  • Start empiric oseltamivir treatment for suspected influenza as soon as possible regardless of illness duration, without waiting for influenza testing results, per Infectious Diseases Society of America Influenza Guidelines,9,14 and administer supportive care.
  1. Vaccination at discharge

NO

  1. Recolección de muestras
  • Implement recommended infection prevention and control measures and collect respiratory specimens as indicated for influenza and SARS-CoV-2 testing.1 (Two different specimens may need to be collected if multiplex testing for influenza viruses and SARS-CoV-2 is unavailable on-site.2-4)
  1. Realización de pruebas de detección del SARS-CoV-2
    Test for SARS-CoV-2 nucleic acid detection3 OR SARS-CoV-2 antigen detection assay,15 especially in persons at increased risk for progression to severe COVID-19.
     (Note: Because antigen detection assays have lower sensitivity than nucleic acid detection assays, a negative SARS-CoV-2 antigen detection assay result does not necessarily exclude SARS-CoV-2 infection and should be confirmed by SARS-CoV-2 nucleic acid detection assay or repeat antigen testing 48 hours later, if clinical suspicion for COVID-19 is high - such as in the setting of high SARS-CoV-2 community prevalence or recent close exposure to a person with COVID-19.) Si la segunda prueba de antígenos es negativa, de conformidad con la guía de la FDA, a third antigen test could be considered if there is a high clinical suspicion of COVID-19
  1. Exámenes de influenza
    Test for influenza if results will change clinical management or for infection control decisions (e.g. long-term care facility resident returning to a facility, or a person of any age returning to a congregate setting): order rapid influenza nucleic acid detection assay; 2,4 if rapid influenza nucleic acid detection assay is not available on-site, order rapid influenza antigen detection assay16 (If available, multiplex nucleic acid detection assay for SARS-CoV-2, influenza A and B viruses can be performed on-site, or at an offsite clinical laboratory.2)
    (Importante: Como es posible la infección simultánea por los virus SARS-CoV-2 y de la influenza, un resultado positivo para influenza sin una prueba de detección del SARS-CoV-2 no excluye la infección por SARS-CoV-2, y un resultado positivo para SARS-CoV-2 sin una prueba de detección de la influenza no excluye la infección por el virus de la influenza).
  1. Tratamiento
  • If a SARS-CoV-2 test result is positive, administer supportive care. If the patient is at high risk for progression to severe COVID-19, prescribe treatment for nonhospitalized patients as recommended per NIH COVID-19 Treatment Guidelines.8
  • Prescribe influenza antiviral treatment if on-site influenza testing is positive OR prescribe empiric antiviral treatment without influenza testing based upon a clinical diagnosis of influenza for patients of any age with progressive disease of any duration, and for children and adults at high risk for influenza complications with illness.9,14,17 Encourage patients to start antiviral treatment as soon as possible.
  • For adult patients with suspected community-acquired pneumonia who do not require hospitalization, see antibiotic treatment recommendations from the American Thoracic Society-Infectious Diseases Society of America Adult Community-acquired Pneumonia Guidelines.10
  • For otherwise healthy non-high-risk persons with influenza-like illness (fever and either cough or sore throat) with illness ≤2 days, empiric antiviral treatment of suspected influenza can be prescribed based upon clinical judgement.9,14
  • For otherwise healthy non-high-risk persons without influenza-like illness or with illness duration >2 days, antiviral treatment of influenza is unlikely to provide significant clinical benefit.9
  1. Siga las recomendaciones de aislamiento y cuarentena para el SARS-CoV-2.,18 and arrange follow-up for any pending testing results.
  2. Vaccination at discharge

Notas a pie de página (*También están disponibles los algoritmos específicos para pacientes admitidos en hospitales, y para pacientes que no requieren hospitalización.)

  1. Implement recommended infection prevention and control measures for SARS-CoV-2; including while collecting respiratory specimens for SARS-CoV-2 y for influenza virus testing. Consulte el prospecto del fabricante sobre las muestras respiratorias aprobadas. Nota: No hay pruebas de diagnóstico de la influenza aprobadas por la FDA que utilicen muestras de saliva.
  2. La autorización de uso de emergencia de la FDA autorizó las pruebas multiplex para la detección simultánea de los virus de la influenza y el SARS-CoV-2.
  3. Autorizaciones de uso de emergencia (EUA, por sus siglas en inglés) para pruebas de diagnóstico molecular del SARS-CoV-2.
  4. Pruebas del virus de la influenza basadas en la detección de ácido nucleico aprobadas por la FDA. https://www.cdc.gov/flu/professionals/diagnosis/table-nucleic-acid-detection.html
  5. Stowe J, Tessier E, Zhao H, Guy R, Muller-Pebody B, Zambon M et al. Interactions between SARS-CoV-2 and influenza, and the impact of coinfection on disease severity: a test-negative design. Int J Epidemiol. 2021 Aug 30;50(4):1124-1133. Doi: 10.11/ije/dyab081.
  6. Swets MC, Russell CD, Harrison EM, Docherty AB, Lone N, Girvan M et al. SARS-CoV-2 co-infection with influenza viruses, respiratory syncytial virus, or adenoviruses. Lancet. 2022 Apr 16;399(10334):1463-1464. Doi: 10.1/S0140-6736(22)00383-X.
  7. Adams K, Tastad KJ, Huang S, Ujamaa D, Kniss K, Cummings C et al. Prevalence of SARS-CoV-2 and Influenza Coinfection and Clinical Characteristics Among Children and Adolescents Aged <18 Years Who Were Hospitalized or Died with Influenza - United States, 2021-22 Influenza Season. MMWR Morb Mortal Wkly Rep. 2022 dic. 16;71(50):1589-1596. Doi: 10.16/mmwr.mm7150a4.
  8. Directrices de tratamiento para la enfermedad del coronavirus 2019 (COVID-19) de los NIH. https://www.covid19treatmentguidelines.nih.gov/management/
  9. Directrices de prácticas clínicas de la Infectious Diseases Society of America: actualización 2018 sobre el diagnóstico, el tratamiento, la quimioprofilaxis y el manejo institucional de brotes de la influenza estacional
  10. IDiagnosis and Treatment of Adults with Community-acquired Pneumonia. Directrices oficiales sobre prácticas clínicas de la American Thoracic Society y la Infectious Diseases Society of America.
  11. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Jul 22:S1198-743X(20)30423-7. Doi: 10.1/j.cmi.2020.07.016. Publicación por Internet previa a la edición impresa.
  12. Adler H, Ball R, Fisher M, Mortimer K, Vardhan MS. Low rate of bacterial co-infection in patients with COVID-19. Lancet Microbe. 2020 Jun;1(2):e62.
  13. Vaughn VM, Gandhi T, Petty LA, Patel PK, Prescott HC, Malani AN et al. Empiric Antibacterial Therapy and Community-onset Bacterial Co-infection in Patients Hospitalized with COVID-19: A Multi-Hospital Cohort Study. Clin Infect Dis. 2020 Aug 21:ciaa1239. Doi: 10.11/cid/ciaa1239.
  14. Resumen para médicos sobre medicamentos antivirales contra la influenza.
  15. EUA para pruebas de diagnóstico in vitro: pruebas de diagnóstico de antígenos para el SARS-CoV-2
  16. Pruebas de diagnóstico rápido de la influenza (RIDT)
  17. Personas con alto riesgo de presentar complicaciones por la influenza.
  18. Ending Isolation and Precautions for People with COVID-19: Interim Guidance (cdc.gov)

Descargo de responsabilidad: Es posible que en este sitio encuentre algunos enlaces que le lleven a contenido disponible sólo en inglés. Además, el contenido que se ha traducido del inglés se actualiza a menudo, lo cual puede causar la aparición temporal de algunas partes en ese idioma hasta que se termine de traducir (generalmente en 24 horas). Llame al 1-800-CDC-INFO si tiene preguntas sobre la influenza estacional, cuyas respuestas no ha encontrado en este sitio. Agradecemos su paciencia.