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Skip to main content. Log In Sign Up. Score to identify the severity of adult patients with influenza A H1N1 virus infection at hospital admission. See discussions, stats, and author profiles for this publication at: The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document and are linked to publications on ResearchGate, letting you access and read them immediately.

Six factors were independently associated with prognostic index for severe complications among hospital- SIHC: The score shows an area under the receiver operating char- Risk factors evaluated included host-related factors and acteristic ROC curve of 0. The SIHC rate was 1. We developed a composite index the low-risk group, The odds ratio for mortality, mechanical ventilation, septic shock, acute respi- complications was This easy-to-score influenza A A.

Initially, it was patients hospitalized for H1N1 virus infection into low- regarded as a potentially severe disease, with a high mortality intermediate- and high-risk groups for SIHC.

Obesity and pregnancy were Abbreviations identified as risk factors [4, 7—9]. ARDS Acute respiratory distress syndrome In this context, extraordinary measures were taken with AUC Area under the receiver operating characteristic respect to the care of hospitalized patients.

For example, the curve isolation of patients together with thorough cleaning and BMI Body mass index protection of health care personnel, both steps aimed to limit CI Confidence intervals contagion. Molecular microbiological determinations were ED Emergency department used to provide an early diagnosis rf the virus. Extraordinary resources were provided Ref. Reference group in order to increase formulaeio care unit ICU staff.

However, RT- Real-time polymerase chain reaction we lacked specific tools for the early identification of adult PCR patients hospitalized with a bad prognosis. SD Standard deviation Although a large amount of information about the epide- SIHC Severe in-hospital complications miology and clinical management of influenza A H1N1 virus infection has been obtained in a remarkably short period, a major gap exists in understanding disease severity and identifying at-risk populations.

Most studies have fo- cused on epidemiological aspects of the general population Introduction and on patients admitted to ICUs. Selecting the most seri- ously ill patients exclusively according to ICU admittance The influenza A H1N1 virus pandemic in shocked the involves fprmulario bias, due to the variability in ICU se- health systems of many countries and raised great social lection 6608 [10, 11], especially if the initial alarm raised alarm.

Much of this alarm was due to the information emitted by the pandemic and the emphasis on critical care is taken on the epidemiological and clinical characteristics of the in- into account.

In addition, the information available on risk fection: It is reasonable Unlike seasonal influenza, the infection affected mostly young to suppose that serious risk factors could differ between T. No in-depth Madrid, Spain studies have been carried out to identify risk factors of severe evolution for adult patients hospitalized for influenza A S.

Cases and Galdakao, Bizkaia, Spain controls were recruited between July and February e-mail: Shock was recruited ivaa each of the 36 study hospitals, and were defined as systolic blood pressure below fformulario mmHg without chosen by the systematic sampling of all patients admitted anti-hypertensive drugs and the need for vasopressive with laboratory-confirmed influenza A H1N1 virus agents. Mechanical ventilation was included when it was infection [12].


For the purpose of this article, only the pro- needed for at least 24 h and always after influenza A spective cohort of patients admitted to any of the participant diagnosis in the Emergency Department ED.

We did not hospitals were included the cases and the controls are not include patients who received non-invasive positive pres- included. Therefore, for this study, based in our selection sure ventilation. All information collected was Univariate and multivariate logistic regression models were treated as confidential, in strict observance of legislation on then constructed to identify the statistical significance of observational studies.

The study was approved by the Ethics each risk factor. Written informed con- the independent variables were factors with a significance sent was obtained from all patients included in the study.

Data collection The possible interaction between variables was also exam- ined. The predictive accuracy of the model was determined A structured questionnaire was administered to patients by by calculating the area under the receiver operating charac- specifically trained personnel. We collected information on teristic curve AUC for discrimination [13] and by compar- sociodemographic characteristics, pre-existing medical condi- ing predicted and observed SIHC using the Hosmer— tions, vaccinations, toxic habits, previous medications, expo- Lemeshow test for calibration [14].

Multilevel analysis with sure to social environments which could contribute to generalized estimated equations was carried out to deter- contagion, and the adoption of measures to prevent influenza.

Then, we added the weights of each of the risk factors presented by The following demographic variables and pre-existing med- a patient. The predictive accuracy of the influenza risk score ical conditions were considered for this study: That is, structive pulmonary disease, asthma, other chronic respira- the model is validated in a random subsample which was not tory diseases, cardiovascular disease, renal failure, diabetes, involved in the development of the model.

This process is liver disease, HIV infection, disabling neurological disease, repeated sequentially for all partitions of the original sam- rheumatologic diseases, cancer, ica, asple- ple. For each vaccine, a case was considered to be validated it by predicting the remaining formularik part of the data.

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Outcomes Once the influenza risk score was developed, we created three categories low, intermediate, and high risk in relation Severe in-hospital complications SIHC were the primary to the predicted SIHC. The performance of the index score outcome of interest.

This was a composite variable includ- categories was studied using a logistic regression model and ing: Chronic obstructive pulmonary disease 72 Cardiovascular disease 89 All statistical analyses were performed Diabetes 89 Patient charac- Rheumatologic disease 21 3.

The mean age Neoplasia 62 Of the women No. A total of patients 0 The SIHC rate was 2 The risk score In the multivariate analysis, six factors formklario independent- was significantly associated with the likelihood of develop- ly associated with SIHC: The model was 0.

Three risk categories were assigned using the influenza Based on the multivariate logistic model, a weight was risk score Table ova Yes 7 20 2. Yes 10 27 3.

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CI, confidence interval; Ref. Only factors with a No 6 3. The OR for have an increased risk. However, the greatest risk factors are the high-risk group formularuo The risk categories showed good discrimination, a patient with dyspnea and confusion, and, for example, with an AUC value of 0. The main value of this predictive score is Discussion its ability to identify patients who need additional monitor- ing and more aggressive treatment after the first ED evalu- This study was able to derive and validate a H1N1 ation, either in the ICU, intermediate care units, or virus infection influenza risk score with acceptable validity, specialized regular wards, depending on the severity.


The discriminative ability, and generalizability, using data from a ED is the natural setting for the use of this severity score, but large cohort of inpatients from 36 geographically distinct it could also be useful in outpatient services, as an adjunct to Spanish hospitals. The risk score has various strengths. It is easy and quick to apply. The tool can be readily emergency basis. However, Risk group No. Further investigation is needed in order to clarify the association gormulario obesity and severe influenza.

In previous influenza epidemics and pandemics, pregnan- cy has been associated with an increased risk of severe The strengths of the study include the relatively large cohort disease [35, 36]. Likewise, recent reports suggest that there of patients recruited from different settings during the influenza is an increased hospitalization rate and severity of illness in A H1N1 pandemic and the amount of clinical informa- pregnant women infected by influenza A H1N1 virus tion collected.

The main limitation of this study comes from its [8, 9, 19], while a Chinese study found that pregnancy was original design as a tormulario study, where only 25 patients an independent risk factor associated with severe illness [7].

Although we performed cross-validation, external similar to the results of a previous Spanish study [34] and validation of our score is still required.

Preventive measures have been established as risk factors for influenza A H1N1 – carried out in Spain, together with a fast diagnosis, early associated complications in earlier studies. Comorbidities have evaluation, and early antiviral treatment, may explain the been associated with an increased risk of complications both in relatively low rate of severity in pregnant women infected seasonal influenza [17, 18] and in the influenza A H1N1 with the influenza A H1N1 virus.

On the other We found that men had a higher risk of SIHC than hand, the risk of death from influenza A infection is not the women: We considered in- [7]. Another previous study showed that male sex was an hospital death, mechanical ventilation, septic shock, ARDS, independent risk factor for prolonged RT-PCR positivity in and resuscitation maneuvers as endpoints, given their more cases infected by influenza A H1N1 virus [23].

Men have objective nature as variables [10]. This is a major strength of been found to be at a higher risk than women for death due our study. Patterns of inflammation, coagulation, and fibrinolysis biomarkers in men may explain the reduced survival [27]. Conclusions A preliminary report of 32 patients with influenza A H1N1 virus infection hospitalized in a Spanish ICU Although the pandemic is over, gaining deeper knowl- showed that pneumonia was associated with a relatively edge of influenza A H1N1 remains essential, as it high case—fatality rate [28].

The rate of patients hospitalized will plan for the next, unavoidable pandemic and because, in wards and the ICU with pneumonia in the pandemic as in the — seasonal influenza in Spain [37], the was higher [3, 4, 8, 19, 29]. N Engl J Med N Engl J Crit Care Med McQuillan P, Pilkington S, Allan A et al Confidential patients with severe respiratory failure caused by Influenza A inquiry into quality of care before admission to intensive care.

H1N1 v in Spain. Emerg Infect Dis Rev Esp Salud Publica Springer, adult influenza pneumonia. Sxteyerberg EW Clinical prediction models. Springer, New Life-style factors associated with overweight and obesity York among Spanish adults.

Euro Surveill 15 Harris JW Influenza occurring in pregnant women.