Critically Ill patients with 2009 influenza A(H1N1) in Mexico

JAMA. 2009 Nov 4;302(17):1880-7. doi: 10.1001/jama.2009.1536. Epub 2009 Oct 12.

Abstract

Context: In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness.

Objective: To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1).

Design, setting, and patients: Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form.

Main outcome measures: The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1-related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay.

Results: Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of Pao(2) to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 8.5; 95% confidence interval, 1.2-62.8).

Conclusion: Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.

MeSH terms

  • APACHE
  • Adolescent
  • Adult
  • Age Distribution
  • Aged
  • Aged, 80 and over
  • Antiviral Agents / therapeutic use
  • Child
  • Critical Illness
  • Female
  • Hospitalization
  • Humans
  • Hypoxia
  • Influenza A Virus, H1N1 Subtype*
  • Influenza, Human* / complications
  • Influenza, Human* / diagnosis
  • Influenza, Human* / mortality
  • Influenza, Human* / therapy
  • Kaplan-Meier Estimate
  • Male
  • Mexico / epidemiology
  • Middle Aged
  • Multiple Organ Failure / etiology
  • Multiple Organ Failure / mortality
  • Neuraminidase / antagonists & inhibitors
  • Respiration, Artificial
  • Respiratory Distress Syndrome, Adult / etiology
  • Respiratory Distress Syndrome, Adult / mortality
  • Retrospective Studies
  • Young Adult

Substances

  • Antiviral Agents
  • Neuraminidase