title: Early use of glucocorticoids was a risk factor for critical disease and death from pH1N1 infection.
abstract: BACKGROUND
  Glucocorticoids increase the risk of developing critical disease from viral infections. However, primary care practitioners in China use them as antipyretics, potentially exposing hundreds of millions to this risk.
  
  
  METHODS
  We enrolled all patients with confirmed pandemic influenza A (pH1N1) virus infection aged ≥3 years with available medical records at 4 Shenyang City hospitals from 20 October to 30 November 2009. A critical patient was any confirmed, hospitalized pH1N1 patient who developed ≥1 of the following: death, respiratory failure, septic shock, failure or insufficiency of ≥2 nonpulmonary organs, mechanical ventilation, or ICU admission. In a retrospective cohort study, we evaluated the risk of developing critical illness in relation to early (≤72 hours of influenza-like illness [ILI] onset) glucocorticoids treatment.
  
  
  RESULTS
  Of the 83 hospitalized case-patients, 46% developed critical illness, 17% died, and 37% recovered and were discharged. Critically ill and other patients did not differ by underlying conditions and severity, median temperature at first clinic visit, and other measured risk factors. Of 17 patients who received early glucocorticoid treatment, 71% subsequently developed critical disease compared with 39% of 66 patients who received late (>72 hours) or no glucocorticoid treatment (RR(M-H) = 1.8, 95% CI = 1.2-2.8, after adjusting for 2 summary variables; ie, presence of underlying diseases and presence of underlying risk factors). Proportional hazards modeling showed that use of glucocorticoids tripled the hazard of developing critical disease (hazard ratio [HR] = 2.9, 95% CI = 1.3-6.2, after adjusting for the same summary variables).
  
  
  CONCLUSIONS
  Early use of parenteral glucocorticoids therapy for fever reduction and pneumonia prevention increases the risk for critical disease or death from pH1N1 infection. We recommend that guidelines on glucocorticoid use be established and enforced.
authors.affiliation: Institute of Immunization Program, Guangdong Center for Disease Control and Prevention, Guangdong, China.
authors.forename: Ke
authors.initials: K
authors.lastname: Han
authors.forename: Huilai
authors.initials: H
authors.lastname: Ma
authors.forename: Xiangdong
authors.initials: X
authors.lastname: An
authors.forename: Yang
authors.initials: Y
authors.lastname: Su
authors.forename: Jing
authors.initials: J
authors.lastname: Chen
authors.forename: Zhiyong
authors.initials: Z
authors.lastname: Lian
authors.forename: JinHui
authors.initials: J
authors.lastname: Zhao
authors.forename: Bao-Ping
authors.initials: BP
authors.lastname: Zhu
authors.forename: Robert E
authors.initials: RE
authors.lastname: Fontaine
authors.forename: Zijian
authors.initials: Z
authors.lastname: Feng
authors.forename: Guang
authors.initials: G
authors.lastname: Zeng
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D003907:Dexamethasone / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D005334:Fever / Q000188:drug therapy; D005938:Glucocorticoids / Q000008:administration & dosage* / Q000009:adverse effects; D006760:Hospitalization; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000453:epidemiology* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D058873:Pandemics / Q000706:statistics & numerical data*; D011024:Pneumonia, Viral / Q000188:drug therapy; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D005938:Glucocorticoids; D003907:Dexamethasone; D008775:Methylprednisolone