Underuse of Antivirals for Hospitalized Children With Influenza

Source: Antoon JW, Amarin JZ, Hamdan O, et al. Antiviral use among children hospitalized with laboratory-confirmed influenza illness: a prospective, multicenter surveillance studys. Clin Infect Dis. 2025;81(3):623-633; doi: 10.1093/cid/ciae573.Investigators from multiple institutions conducted a study to estimate the proportion of children hospitalized with influenza who received influenza-specific antiviral treatment and identify factors associated with receipt of these medications. For the study, they reviewed data in the New Vaccine Surveillance Network (NSVN). NSVN is a prospective program, funded by CDC and conducted at 7 pediatric medical centers in the US. At these centers, nasal or oropharyngeal samples are obtained for research purposes on patients <18 years old admitted with acute respiratory illness to detect pathogens. The results are not provided to clinicians who may also order viral pathogen testing as part of routine care. Participants in the current study were children enrolled in NSVN between December 2016 and March 2020 who had laboratory-confirmed influenza by either research or clinical testing. The primary study outcome was the proportion of participants who were prescribed an influenza antiviral, including oseltamivir, peramivir, baloxavir, or zanamivir, during their hospitalization. Demographic and clinical characteristics associated with receipt of antiviral medication were identified using multivariate logistic regression and focusing on children at increased risk of influenza because of a chronic condition.Among 17,051 children enrolled in NSVN during the study period in whom testing was performed, 1,213 (7.1%) had laboratory-confirmed influenza and were included in the analysis. The median age of study patients was 3.7 years. Overall, 63% were identified by clinical testing. Of the 1,213 children hospitalized with influenza, 652 (53.8%) received an antiviral, with 651 treated with oseltamivir. Among those who underwent clinical testing, 63.5% received an antiviral. Across the 7 NSVN sites, the proportion of patients who received antivirals ranged from 26.2% to 73.7%. The rate of antiviral treatment was higher among patients with symptoms ≤2 days than in those with a longer duration (40.2% vs 28.4%). Independent predictors of receipt of an influenza-specific antiviral included the presence of a hematologic condition (adjusted odds ratio [aOR], 1.76; 95% confidence interval [CI], 1.03, 3.02), oncologic or immunocompromising disorder (aOR, 2.41; 95% CI, 1.13, 5.11), clinical testing for influenza (aOR, 3.07; 95% CI, 2.28, 4.14), and ICU admission (aOR, 1.53; 95% CI, 1.02, 2.29). Patients treated with antivirals before hospital admission were more likely to receive this treatment during their hospitalization (aOR, 2.34; 95% CI, 1.49, 3.67), while those presenting >2 days after onset of symptoms were less likely to receive antivirals (aOR, 0.40; 95% CI, 0.30, 0.52).The authors conclude that a substantial proportion of children hospitalized with influenza did not receive antiviral treatment.Dr Loyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.In the current study, investigators reported that antiviral treatment targeting influenza in all hospitalized children and among children considered high risk, such as infants <6 months, was underutilized despite national recommendations. There was wide variation in antiviral use among the 7 hospitals included in the study. Some factors influenced treatment, such as hematologic disorders, immunocompromising conditions, ICU admission on presentation, and prior outpatient antiviral treatment.Why are clinicians hesitant to treat influenza with antivirals in the hospital setting despite recommendations? The problem lies in the paucity of high-quality studies in pediatrics.1,2 In a cross-sectional survey of pediatricians from 5 specialties across 7 US children’s hospitals in 2024, investigators also reported nonadherence to national recommendations and concluded that a randomized controlled trial of oseltamivir in hospitalized children is needed to help strengthen current recommendations.1 Major concerns from survey participants were around timing of antiviral use and adverse effects such as vomiting.Though imperfect, vaccination is another essential tool to prevent severe influenza-related illness. According to the CDC, there were 280 pediatric deaths in the 2024–25 flu season, the highest since national reporting began in 2004, excluding the 2009–10 H1N1 pandemic.3 Approximately 50% of children who died from influenza had an underlying medical condition, and 89% were not fully vaccinated.3 Unfortunately, influenza vaccination coverage among US children has declined from 55.5% (2022–23) to 49.2% (2024–25).4Influenza remains a formidable force, particularly in hospitalized children with severe illness. In addition to continued efforts to encourage vaccination, better evidence is needed to support pharmacotherapy to shift clinician attitudes toward treatment.Despite national recommendations, treatment of hospitalized children with influenza with antivirals is suboptimal. (See AAP Grand Rounds. 2022;47[1]:3.)5