Similarly in cases associated with H1N1v (‘Swine flu’) treatment has often been prescribed regardless of symptom duration. Oseltamivir 75 mg bd po for 5 days is currently the preferred neuraminidase inhibitor [134,135]. Inhaled zanamivir 10 mg (two puffs) bid by inhalation device for 5 days is an alternative [136] and has even been suggested as the preferred agent for HIV-seropositive adults with significant immunosuppression in some guidelines on the basis of increased rates of oseltamivir resistance

in this group [137]. Most pandemic IAV strains in 2009–2010 retained susceptibility to neuraminidase inhibitors, but strains with reduced susceptibility to oseltamivir have been reported PARP inhibitor occasionally in individuals living with HIV [138]. In addition, seasonal IAV strains in 2008–2009 were frequently oseltamivir-resistant [139] and the selection of the most appropriate neuraminidase inhibitor must be made in light of the prevailing susceptibility of the strain(s) circulating in a given ‘flu season’ in consultation with local virologists. While many of these strains remain susceptible to zanamivir at present, multi-resistant strains have been reported

in other immunocompromised groups [140]. Some authorities have suggested combination therapy will be required, particularly for immunocompromised patients, in the future and clinical trials are exploring this possibility in patients (not specifically HIV-seropositive individuals) MG-132 cell line with severe infection [141,142]. For critically ill individuals parenteral formulations ROS1 of neuraminidase inhibitors, currently available for compassionate use or through expanded access programmes, include iv peramivir and zanamivir but there are currently no data on their use in HIV-seropositive individuals. Neuraminidase inhibitors have proven efficacy against IAV in individuals considered at high risk of IAV complications [143]. It is recommended that immunocompromised patients also receive doxycycline 200 mg stat then 100 mg od or co-amoxiclav 625 mg tid

po with clarithromycin 500 mg bd po as an alternative, all for 7 days during an episode of IAV but again no specific data are available for HIV-seropositive populations [144]. If pneumonia develops, coverage should be as per the guidelines above for community-acquired pneumonia but if patients fail to respond promptly, there are epidemiological concerns that methicillin-sensitive or -resistant Staphylococcus aureus (MSSA/MRSA) may be causing bacterial super-infection or there is a significant incidence of bacterial super-infection with MSSA/MRSA, then antibacterial therapy should also target these organisms. IAV vaccination should be offered to all HIV-seropositive individuals every ‘flu season (category Ib recommendation) [97,99,145].