Coinfection of Respiratory Infections


Tina Tan, MD; Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP; Priya Nori, MD; Jacinda Abdul-Mutakabbir, PharmD; and Kevin Michael Reiter, MD, PA, comment on the overlap of respiratory infections and their approach to getting people treatment.

Tina Tan, MD: I know both Priya and Wendy mentioned this, but coinfection has now become a major issue. Can we comment on individuals who have coinfection? Are we seeing more severe diseases in these individuals? Why don’t we start with normal healthy individuals, Priya?

Priya Nori, MD: Tina, that’s a great question. I think we will need time, and certainly studies, to see if coinfection leads to worse illness or more complications. So time will tell, I think. But it is certainly true that we’re seeing an increasing frequency of coinfections. My pediatric colleagues in our children’s hospital here are telling me that increasingly every day they’re seeing more flu and RSV [respiratory syncytial virus] coinfection, or COVID-19 and flu coinfection. And certainly on the adult side where I practice I’ve seen my share of basically COVID-19 and flu. I’m sure you folks will agree, but I am kind of more worried about the flu this season. I tell my patients and when I speak to other providers in the hospital, flu is the one to watch this season because I feel that we have fewer tools. We have vaccines. We should be encouraging those vaccines.

But as far as antiviral medications go, we actually face somewhat of a challenge in the coming weeks, because it used to be that anyone who wanted a prescription for an influenza antiviral could get one. The CDC [Centers for Disease Control and Prevention] did have a fairly open stance on that because the thinking is, you treat more people, and you might reduce transmission. However, this year, hospitals and retail pharmacies are in a position where we cannot fill the orders that we need to fill, and things are on back order. There are manufacturing delays. So we have to be very mindful of who we offer treatment to, with an eye on the prize of the most infirm, the highest risk patients, those with serious comorbidities, and extremes of age, etc. We’re coming to this point where we sort of have to ration our tools and think more wisely about the apocalypse-type situation. Although I hope it doesn’t come to that.

Tina Tan, MD: Kevin?

Kevin Michael Reiter, MD, PA: I think what we’ve seen in the past, we can pretty much predict our flu activity based on what we saw happening in other parts of the world, such as Australia. We know they had a very terrible flu season this year. I almost feel like we were caught with our pants down to some degree. I feel like based on that severe prediction, like Priya mentioned, production of flu tests. We either run low or run out of flu tests. Our pharmacies were completely out of Tamiflu in the New York metro area in the days following Thanksgiving. So Friday, Saturday, Sunday, Monday, and Tuesday, you were essentially out of luck if you needed an oral antiviral agent on those days in the New York metro area. We’re not talking about out in the country or somewhere far out, we’re talking about the center of New York City, you couldn’t get a prescription for Tamiflu. I think there’s a struggle here. We’re definitely underprepared.

The flu season began earlier than expected. But I don’t think this was unexpected. I think, for those of you who have been practicing, I’ve been in the medical field for almost 23 years, and this is what we braced ourselves for. In a pre–COVID-19 world, we knew that the week after Thanksgiving straight through Easter was going to be rough. I think we’ve started a little bit earlier this year with RSV, and that kind of predisposed folks to the other coinfections and illnesses. And leading into the holidays, a lot of folks visited family and friends, and they probably shouldn’t have because they were feeling under the weather. But having been cooped up for 3 years, you can’t really blame people for wanting to get out and about and travel. But unfortunately, we’re dealing with the ramifications of that right now.

Tina Tan, MD: Are you all able to get baloxavir as another oral antiviral agent you could potentially use for your patients, especially in the adult population? The baloxavir suspension is not available this year. The manufacturers decided they weren’t going to release it. So, it’s only the tablets that are available. Are you able to get that, Priya?

Priya Nori, MD: I’ll start, and I’ll be brief because we don’t have a tremendous amount of experience with it. We did happen to secure a couple of orders worth of baloxavir as a backup. Now, the infectious diseases community does have some hesitation to use it, and Tina, you will probably echo this, but there are some concerns about decreased resistance barriers, etc. But the way that we envisioned using it here at some point, and we’d love to kick this off soon, is to establish a test, treat, and release program. Where even for, let’s say, very high-risk or elderly patients or even high-risk patients above age 12 for whom this drug is FDA approved, they could receive the drug, take it right there in the ED [emergency department], and avoid admission with some kind of discharge follow-up process by phone. We’re hoping to kick that off. But I feel that might be a niche for this particular drug. It is not really billed or considered to be a good inpatient drug because there are other options. But I’m hopeful that this drug will come into prime time this flu season because I feel like we’re going to need it.

Tina Tan, MD: Yes, and it is a single-dose drug. That is the beauty of using it on an outpatient basis. And this year, the FDA dropped the age limit, so that you can give it to any individual 5 years of age and older. But the problem is that children under 10, most of the time can’t swallow a capsule. And you can’t compound it; there are no instructions as to how to compound the capsule. So it has to be someone old enough to swallow a capsule who can take it. Wendy? I’m sorry.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: No, I’m sorry. I was just saying that I think it’s been hit or miss. There have been supply chain issues with everything out there, I’m sure you’re all hearing. We have parents who are raging because they can’t get their children amoxicillin for strep throat or whatever. I think for us, it’s been incredibly frustrating because you don’t know which pharmacy has it and which doesn’t, so people are calling around. It’s a real tax on the system. But getting back to coinfections, it really does worry me because, first of all, I’ve been around for 30 years in this business. This reminds me of H1N1 [swine flu] in the summer of, what was it Tina, 2009? Because I think we just heard from the CDC that this is the worst flu season thus far in 13 years. It brings me back to H1N1 when we were limiting antivirals because we couldn’t get them. I do worry about both of these conditions being inflammatory and cytokine storms, what does this do for people after having both of these illnesses together? I don’t think we know that.

Tina Tan, MD: We don’t, and long COVID-19 is showing us how much we don’t understand about the inflammatory aspects of these types of infections. JAM?

Jacinda Abdul-Mutakabbir, PharmD: One thing I think about with coinfections are the superimposed bacterial infections, or honestly, the thought-to-be superimposed bacterial infections. Now I’m thinking about antimicrobial misuse, and then more importantly, antimicrobial resistance. Because I am an antimicrobial resistance researcher, that’s the way my brain is thinking about this. So, I am definitely afraid and nervous that patients will be infected with these different viruses. But I’m thinking more about the collateral damage that will come from these infections and the things we will have to deal with. But I’m really happy Tina that you brought up long COVID-19 because I think that is also collateral damage that we don’t necessarily consider when we think about how these infections present.

Transcript edited for clarity

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