SEVERE INFECTIONS: Edited by Michael S. NiedermanSevere influenza: overview in critically ill patientsSarda, Cristinaa; Palma, Pedrob,c; Rello, JordidAuthor Information aInfectious Diseases Department, Fondazione I.R.C.C.S Policlinico San Matteo Pavia, Italy bInfectious Diseases Department, São João University Hospital Center cFaculty of Medicine of University of Porto, Porto, Portugal dCRIPS, Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain Correspondence to Pedro Palma, Serviço de Doenças Infecciosas, Centro Hospitalar Universitário de São João, Alameda do Professor Hernâni Monteiro, 4200-319 Porto, Portugal. Tel: +351 225 512 100; fax: +351 225 512 329; e-mail: [email protected]; [email protected] Current Opinion in Critical Care: October 2019 - Volume 25 - Issue 5 - p 449-457 doi: 10.1097/MCC.0000000000000638 Buy Metrics Abstract Purpose of review Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity. Recent findings Pandemic influenza A (H1N1) virus circulates seasonally and remains the predominant subtype among intensive care patients. Mortality in acute respiratory failure (ARF) is around 20%, independent of influenza subtypes. During severe infection, the imbalance between pro-inflammatory and anti-inflammatory molecules, such as Th1 and Th17 cytokines, is associated with complicated infections and mortality. Primary viral pneumonia presents in more than 70% of ICU influenza patients and more than 50% develop acute respiratory distress syndrome. Bacterial secondary infection occurs in 20% of severe cases and Streptococcus pneumoniae and Staphylococcus aureus remain the prevalent pathogens. Myocarditis and late-onset cardiovascular complications are associated with mortality. Antiviral therapy within 48 h after onset, avoidance of corticosteroids and rescue therapies for ARF or myocarditis, such as extracorporeal membrane oxygenation, improve survival. Summary The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.