Bacteraemia and antibiotic use in respiratory syncytial virus infections

Interactions between respiratory syncytial virus and Streptococcus pneumoniae in the pathogenesis of childhood respiratory infections: a systematic review

Lower respiratory tract infections, commonly caused by respiratory syncytial virus (RSV) or Streptococcus pneumoniae (pneumococcus), pose a substantial global health burden, especially in children younger than 5 years of age. A deeper understanding of the relationship between RSV and pneumococcus would aid the development of health-care approaches to disease prevention and management. We completed a systematic review to identify and assess evidence pertaining to the relationship between RSV and pneumococcus in the pathogenesis of childhood respiratory infections. We found mechanistic evidence for direct pathogen-pathogen interactions and for indirect interactions involving host modulation. We found a strong seasonal epidemiological association between these two pathogens, which was recently confirmed by a parallel decrease and a subsequent resurgence of both RSV and pneumococcus-associated disease during the COVID-19 pandemic. Importantly, we found that pneumococcal vaccination was associated with reduced RSV hospitalisations in infants, further supporting the relevance of their interaction in modulating severe disease. Overall evidence supports a broad biological and clinical interaction between pneumococcus and RSV in the pathogenesis of childhood respiratory infections. We hypothesise that the implementation of next-generation pneumococcal and RSV vaccines and monoclonal antibodies targeting RSV will act synergistically to reduce global morbidity and mortality related to childhood respiratory infections.

Epidemiology and Outcomes of Bacterial Coinfection in Hospitalized Children With Respiratory Viral Infections: A Single Center Retrospective Chart Review

OBJECTIVE

Children with viral respiratory illness are often suspected of having bacterial coinfection. This study was designed to determine the impact of bacterial coinfection on hospital course and outcomes and the rate of antimicrobial misuse.

METHODS

Single-center retrospective chart review, including all hospitalized children who had a respiratory viral panel sent within 48 hours of admission from January 2015 to December 2019. Patients who had a positive respiratory, urine, blood culture within 24 hours of admission were identified. Demographics, resource utilization, and outcomes were compared between the 2 groups.

RESULTS

This study included 2192 patients. Of those, 269 patients had positive bacterial cultures. Out of these cultures from 192 patients were identified as contaminants. True bacterial coinfection was 3.5% (77/2192). Almost 1/3 of admitted patients were prescribed empiric antimicrobials. Children with bacterial coinfection tended to be younger (median age 8.4 months vs 16.3 months, p < 0.01) and had higher proportion of prematurity (23.3% vs 12.1%, p < 0.01). Children with bacterial coinfection were more likely to require ICU admission (37.6% vs 23.9%, p < 0.01) and intubation (28.5% vs 5.3 %, p < 0.01). They had higher ICU (5.7 days vs 1.9 days, p < 0.01) and hospital length of stay (4.0 days vs 2.0 days, p < 0.01), higher mortality (2.6% vs 0.2%, p = 0.02), and a higher median cost of hospital care ($3774.44 vs $2424.49.90, p < 0.01).

CONCLUSIONS

The rate of bacterial coinfection in hospitalized children with viral infections is very low, which contradicts the routine administration of empiric antimicrobials. Patients with coinfection require more hospital resources and have worse clinical outcomes.

Risk factors for disease severity and increased medical resource utilization in respiratory syncytial virus (+) hospitalized children: A descriptive study conducted in four Belgian hospitals

Background

We aimed to provide regional data on clinical symptoms, medical resource utilization (MRU), and risk factors for increased MRU in hospitalized respiratory syncytial virus (RSV)-infected Belgian pediatric population.

Methods

This prospective, multicenter study enrolled RSV (+) hospitalized children (aged ≤5y) during the 2013–2015 RSV seasons. RSV was diagnosed within 24h of hospitalization. Disease severity of RSV (+) patients was assessed until discharge or up to maximum six days using a Physical Examination Score (PES) and a derived score based on ability to feed, dyspnea and respiratory effort (PES3). MRU (concomitant medications, length of hospitalization [LOH], and oxygen supplementation) was evaluated. Kaplan-Meier survival analysis was performed to compare MRU by age and presence of risk factors for severe disease. Association between baseline covariates and MRU was analyzed using Cox regression models.

Results

In total, 75 children were included, Median (range) age was 4 (0–41) months, risk factors were present in 18.7%, and early hospitalization (≤3 days of symptom onset) was observed in 57.3% of patients. Cough (100%), feeding problems (82.2%), nasal discharge (87.8%), and rales and rhonchi (82.2%) were frequently observed. Median (range) LOH and oxygen supplementation was 5 (2–7) and 3 (1–7) days. Oxygen supplementation, bronchodilators, and antibiotics were administered to 58.7%, 64.0%, and 41.3% of the patients, respectively. Age <3 months and baseline total PES3 score were associated with probability and the duration of receiving oxygen supplementation. LOH was not associated with any covariate.

Conclusion

RSV is associated with high disease burden and MRU in hospitalized children. Oxygen supplementation but not length of hospitalization was associated with very young age and the PES3 score. These results warrant further assessment of the PES3 score as a predictor for the probability of receiving and length of oxygen supplementation in RSV hospitalized children.

Registration

NCT02133092

Antibiotic use for respiratory syncytial virus in the Middle East: A surveillance study in hospitalized Jordanian children

Introduction

In developing countries where point-of-care testing is limited, providers rely on clinical judgement to discriminate between viral and bacterial respiratory infections. We performed a cross-sectional cohort study of hospitalized Jordanian children to evaluate antibiotic use for respiratory syncytial virus (RSV) infections.

Materials and methods

Admitting diagnoses from a prior viral surveillance cohort of hospitalized Jordanian children were dichotomized into suspected viral-like, non-pulmonary bacterial-like, and pulmonary bacterial-like infection. Stratifying by sex, we performed a polytomous logistic regression adjusting for age, underlying medical condition, maternal education, and region of residence to estimate prevalence odds ratios (PORs) for antibiotic use during hospitalization. Sensitivity and specificity of admission diagnoses and research laboratory results were compared.

Results

Children with a suspected viral-like admission diagnosis, compared to those with suspected non-pulmonary bacterial-like, were 88% and 86% less likely to be administered an empiric/first-line antibiotic (male, aPOR: 0.12; female, aPOR: 0.14; p-value = <0.001). There were slight differences by sex with males having a lower prevalence than females in being administered an expanded coverage antibiotic; but they had a higher prevalence of macrolide administration than males with non-pulmonary bacterial-like infection. Overall, children with RSV had a 34% probability (sensitivity) of being assigned to a suspected viral-like diagnosis; whereas RSV-negative children had a 76% probability (specificity) of being assigned to a suspected pulmonary bacterial-like diagnosis.

Conclusions

Hospitalized children with a suspected viral-like admission diagnosis were less likely to receive an empiric/first-line and expanded coverage antibiotic compared to suspected non-pulmonary and pulmonary infections; however, when evaluating the accuracy of admission diagnosis to RSV-laboratory results there were considerable misclassifications. These results highlight the need for developing antibiotic interventions for Jordan and the rest of the Middle East.

Unnecessary antibiotic treatment of children hospitalised with respiratory syncytial virus (RSV) bronchiolitis: risk factors and prescription patterns

OBJECTIVES

Respiratory syncytial virus (RSV) is a leading cause of respiratory tract infections, especially in young children. Antibiotics are often unnecessarily prescribed for the treatment of RSV. Such treatments affect antibiotic resistance in future bacterial infections of treated patients and the general population. This study aimed to understand risk factors for and patterns of unnecessary antibiotic prescription in children with RSV.

METHODS

In a single-centre, retrospective study in Israel, we obtained data for children aged ≤2 years (n = 1016) hospitalised for RSV bronchiolitis during 2008-2018 and ascertained not to have bacterial co-infections. Antibiotic misuse was defined as prescription of antibiotics during hospitalisation of the study population. Demographic and clinical variables were assessed as predictors of unnecessary antibiotic treatment in a multivariable logistic regression model.

RESULTS

The unnecessary antibiotic treatment rate of children infected with RSV and ascertained not to have a bacterial co-infection was estimated at 33.4% (95% CI 30.5-36.4%). An increased likelihood of antibiotic misuse was associated with drawing bacterial cultures and with variables indicative of a severe patient status such as lower oxygen saturation, higher body temperature, tachypnoea and prior recent emergency room visit. Older age and female sex were also associated with an increased likelihood of unnecessary antibiotic treatment.

CONCLUSIONS

Unnecessary antibiotic treatment in RSV patients was very common and may be largely attributed to physicians' perception of patients' severity. Improving prescription guidelines, implementing antibiotic stewardship programmes and utilising decision support systems may help achieve a better balance between prescribing and withholding antibiotic treatment.

Co-seasonality and co-detection of respiratory viruses and bacteraemia in children: a retrospective analysis

Objectives

The aim of this study was to assess the co-seasonality and co-detection of respiratory viral infections and bacteraemia in children since the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13).

Methods

Children <18 years old were eligible for inclusion if they had a respiratory infection and a positive PCR-based assay for respiratory viruses as well as a positive blood culture between 2010 and 2018 at a single referral centre in the United States, regardless of their underlying medical condition or antibiotic treatment history. Monthly incidence rates of respiratory viruses and bacteraemia were analysed with a seasonal-trend decomposition procedure based on loess (STL) and cross-correlation functions using time series regression modelling.

Results

We identified 7415 unique positive respiratory virus tests, including 2278 respiratory syncytial virus (RSV) (31%), 1825 influenza viruses (24%), 1036 parainfluenza viruses (14%), 1017 human metapneumovirus (hMPV) (14%), 677 seasonal coronaviruses (9%), and 582 adenoviruses (8%), together with a total of 11 827 episodes of bacteraemia. Significant co-seasonality was found between all-cause bacteraemia and RSV (OR = 1.76, 95%CI 1.50–2.06, p < 0.001), influenza viruses (OR = 1.38, 95%CI 1.13–1.68, p 0.002), and seasonal coronaviruses (OR = 1.18, 95%CI 1.09–1.28, p < 0.001), respectively. Analysis of linked viral–bacterial infections in individual children indicated that the rate ratio (RR) of bacteraemia associated with hMPV (RR = 2.73, 95%CI 1.12–6.85, p 0.019) and influenza (RR = 2.61, 95%CI 1.21–6.11, p 0.013) were more than double that of RSV. Staphylococcus aureus and Streptococcus pneumoniae were the most commonly identified pathogens causing bacteraemia.

Conclusions

There is a significant association between hMPV and influenza viruses and bacteraemia of all causes in hospitalized children at a single paediatric centre in the United States. Large multicentre studies are needed to confirm these findings and to elucidate the mechanisms by which hMPV potentiates the virulence and invasive capacity of diverse bacteria.

Bacteremia in Children Hospitalized Due to Respiratory Syncytial Virus Infection

The frequency of bacteremia in children hospitalized due to respiratory syncytial virus infection (RSV) rarely exceeds 1%, but a recent study reported a 10% risk of bacteremia. In this study, we set out to verify the frequency, usefulness, and costs of blood cultures in RSV infections. We addressed the issue by reviewing medical files of 512 children, aged 8 days-121 months, who were hospitalized during January 2010 and June 2017. The RSV-related diagnoses included bronchiolitis (390 patients), RSV pneumonia (65 patients), and bronchitis (57 patients). There were 212 blood cultures performed in 185 patients (36%). In 10 cultures (5.4%), the following pathogens were identified: Staphylococcus haemolyticus, 4; Staphylococcus epidermidis, 1; Staphylococcus hominis, 1; Corynebacterium, 1 Streptococcus parasanguinis, 1; Rothia mucilaginosa, 1; Micrococcus luteus, 1; and Streptococcus hominis, 1 case. However, all of these pathogens were identified as a contamination of samples only. Therefore, both positive blood cultures turned out in fact negative, and the patients having either result of blood culturing showed no clinically relevant differences. The total cost of blood cultures in the pediatric ward amounted to €1980. If performed in each and every patient, the costs would have reached €5490. In conclusion, the frank frequency of bacteremia in children with RSV infection, with no sepsis, seems exceedingly low, which confirms the earlier findings. Thus, blood culturing, generating high costs, is of negligible clinical value. The study provides no evidence supporting a routine blood culture in case of children hospitalized due to RSV infection.

Bacterial co-infection of the respiratory tract in ventilated children with bronchiolitis; a retrospective cohort study

Background

Viral bronchiolitis is the most common cause of respiratory failure requiring invasive ventilation in young children. Bacterial co-infections may complicate and prolong paediatric intensive care unit (PICU) stay. Data on prevalence, type of pathogens and its association with disease severity are limited though. These data are especially important as bacterial co-infections may be treated using antibiotics and could reduce disease severity and duration of PICU stay. We investigated prevalence of bacterial co-infection and its association with disease severity and PICU stay.

Methods

Retrospective cohort study of the prevalence and type of bacterial co-infections in ventilated children performed in a 14-bed tertiary care PICU in The Netherlands. Children less than 2 years of age admitted between December 2006 and November 2014 with a diagnosis of bronchiolitis and requiring invasive mechanical ventilation were included. Tracheal aspirates (TA) and broncho-alveolar lavages (BAL) were cultured and scored based on the quantity of bacteria colony forming units (CFU) as: co-infection (TA > 10^{^5}/BAL > 10^{^4} CFU), low bacterial growth (TA < 10^{^5}/BAL < 10^{^4} CFU), or negative (no growth). Duration of mechanical ventilation and PICU stay were collected using medical records and compared against the presence of co-infection using univariate and multivariate analysis.

Results

Of 167 included children 63 (37.7%) had a bacterial co-infection and 67 (40.1%) low bacterial growth. Co-infections occurred within 48 h from intubation in 52 out 63 (82.5%) co-infections. H.influenza (40.0%), S.pneumoniae (27.1%), M.catarrhalis (22.4%), and S.aureus (7.1%) were the most common pathogens. PICU stay and mechanical ventilation lasted longer in children with co-infections than children with negative cultures (9.1 vs 7.7 days, p = 0.04 and 8.1vs 6.5 days, p = 0.02).

Conclusions

In this large study, bacterial co-infections occurred in more than a third of children requiring invasive ventilation for bronchiolitis and were associated with longer PICU stay and mechanical ventilation. These findings support a clinical trial of antibiotics to test whether antibiotics can reduce duration of PICU stay.

Antibiotic Overuse in Children with Respiratory Syncytial Virus Lower Respiratory Tract Infection

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections (LRTI) during the first year of life. Antibiotic treatment is recommended in cases suspected of bacterial coinfection. The aim of this prospective study was to estimate the incidence of bacterial coinfections and the amount of antibiotic overuse in children infected with RSV using expert panel diagnosis.

METHODS

Children 1 month of age and over with LRTI or fever without source were prospectively recruited in hospitals in the Netherlands and Israel. Children with confirmed RSV infection by Polymerase Chain Reaction (PCR) on nasal swabs were evaluated by an expert panel as reference standard diagnosis. Three experienced pediatricians distinguished bacterial coinfection from simple viral infection using all available clinical information, including all microbiologic evaluations and a 28-day follow-up evaluation.

RESULTS

A total of 188 children (24% of all 784 recruited patients) were positive for RSV. From these, 92 (49%) were treated with antibiotics. All 27 children (29%) with bacterial coinfection were treated with antibiotics. Fifty-seven patients (62%) were treated with antibiotics without a diagnosis of bacterial coinfection. In 8 of the 92 (9%), the expert panel could not distinguish simple viral infection from bacterial coinfection.

CONCLUSION

This is the first prospective international multicenter RSV study using an expert panel as reference standard to identify children with and without bacterial coinfection. All cases of bacterial coinfections are treated, whereas as many as one-third of all children with RSV LRTI are treated unnecessarily with antibiotics.

Healthcare resource use and economic burden attributable to respiratory syncytial virus in the United States: a claims database analysis

Background

Despite several studies that have estimated the economic impact of Respiratory Syncytial Virus (RSV) in infants, limited data are available on healthcare resource use and costs attributable to RSV across age groups. The aim of this study was to quantify age-specific RSV-related healthcare resource use and costs on the US healthcare system.

Methods

This retrospective case-control study identified patients aged ≥1 year with an RSV event in the Truven Health Marketscan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases between August 31, 2012 and August 1, 2013. RSV patients were matched 1:1 with non-RSV controls for age, gender, region, healthcare plan and index date (n = 11,432 in each group). Stratified analyses for healthcare resource use and costs were conducted by age groups. RSV-attributable resource use and costs were assessed based on the incremental differences between RSV cases and controls using multivariate analysis.

Results

RSV patients had a higher healthcare resource use (hospital stays, emergency room/urgent care visits, ambulatory visits and outpatient visits) than non-RSV matched controls for all age groups (all p < 0.0001), particularly in the elderly age groups with RSV (1.9 to 3 days length of stay, 0.4 to 0.5 more ER/UC visits, 0.7 to 2.7 more ambulatory visits, 12.1 to 18.6 more outpatient visits and 9.5 to 14.6 more prescriptions than elderly in the control groups). The incremental difference in adjusted mean annual costs between RSV and non-RSV controls was higher in elderly (≥65; $12,030 to $23,194) than in those aged < 65 years ($2251 to $5391). Among children, adjusted costs attributable to RSV were higher in children aged 5–17 years ($3192), than those 1–4 years ($2251 to $2521).

Conclusions

Our findings showed a substantial annual RSV-attributable healthcare resource use and costs in the US across age groups, with the highest burden in those aged ≥65 years. These data can be used in cost-effectiveness analyses, and may be useful for policymakers to guide future RSV vaccination and other prevention programs.

Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis

BACKGROUND

An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%-23% of cases. Despite national guidelines stating "current evidence does not support routine radiography in children with bronchiolitis"; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia.

OBJECTIVES

We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis.

METHODS

We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, "What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?": Patients-pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention-H&P and VS; Comparator-a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome-operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR-). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test-treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection.

RESULTS

We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR- to significantly decrease the pretest probability of finding a +CXR. Our test-treatment threshold model showed that hypoxia (O₂ Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O₂ Sat < 95%) and respiratory failure requiring ventilatory support.

CONCLUSION

No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.

Paramyxovirus Infection: Mortality and Morbidity in a Pediatric Intensive Care Unit

OBJECTIVES

We investigated mortality and morbidity of patients admitted to a pediatric intensive care unit (PICU) with paramyxovirus infection.

METHODS

A retrospective study between October 2002 and March 2015 of children with a laboratory-confirmed paramyxovirus infection was included.

RESULTS

In all, 98 (5%) PICU admissions were tested positive to have paramyxovirus infection (respiratory syncytial virus =  66, parainfluenza  =  27 and metapneumovirus  =  5). The majority of admissions were young patients (median age 1.05 years). Bacteremia and bacterial isolation in any site were present in 10% and 28%, respectively; 41% were mechanically ventilated, and 20% received inotropes. The three respiratory viruses caused similar mortality and morbidity in the PICU. Fatality (seven patients) was associated with malignancy, positive bacterial culture in blood, the use of mechanical ventilation, inotrope use, lower blood white cell count and higher C reactive protein (p  =  0.02-0.0005). Backward binary logistic regression for these variables showed bacteremia (odds ratio [OR]: 31.7; 95% CI: 2.3-427.8; p  =  0.009), malignancy (OR: 45.5; 95% CI: 1.4-1467.7; p  =  0.031) and use of inotropes (OR: 15.0; 95% CI: 1.1-196.1; p  =  0.039) were independently associated with non-survival. March and July appeared to be the two peak months for PICU hospitalizations with paramyxovirus infection.

CONCLUSIONS

Infections with paramyxoviruses account for 5% of PICU admissions and significant morbidity. Patient with premorbid history of malignancy and co-morbidity of bacteremia are associated with non-survival. March and July appeared to be the two peak months for PICU admissions with paramyxoviruses.

Incidence, Morbidity, and Costs of Human Metapneumovirus Infection in Hospitalized Children

BACKGROUND

Human metapneumovirus (HMPV) causes acute respiratory tract infections in infants and children. We sought to measure the clinical and economic burden of HMPV infection in hospitalized children.

METHODS

We conducted a retrospective cohort study from 2007 to 2013 at Primary Children's Hospital in Salt Lake City, Utah. Children <18 years of age with laboratory-confirmed HMPV infection were included. Demographic, clinical, and financial data were abstracted from the electronic medical record.

RESULTS

During the study period, 815 children were hospitalized with laboratory-confirmed HMPV infection: 16% <6 months, 50% 6-23 months, 23% 2-4 years, and 11% 5-17 years of age. A complex chronic condition was identified in 453 (56%) children hospitalized with HMPV infection; this proportion increased with increasing age (P < .001). There was marked variation in annual HMPV hospitalization rates, ranging from 9 of 100 000 person-years in 2012-2013 to 79 of 100 000 in 2009-2010. Hospitalization rates were highest among children <2 years (200 of 100 000 person-years) and lowest among children 5-17 years of age (5 of 100 000). Of hospitalized children, 18% were treated in the intensive care unit and 6% required mechanical ventilation. The median length of stay was 2.8 days (interquartile range [IQR], 1.8-4.6) and did not vary by age. The median total hospital cost per patient was $5513 (IQR, $3850-$9946) with significantly higher costs for patients with chronic medical conditions (P < .001).

CONCLUSIONS

Human metapneumovirus infection results in a large number of hospitalizations with substantial morbidity, resource utilization, and costs. The development of a safe and effective vaccine could reduce the clinical and economic burden of HMPV.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing bacterial complications in children aged two months to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August week 1, 2015) and EMBASE (1974 to August 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotic prescriptions with placebo or no treatment in children aged two months to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated, so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.We found no studies assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Bacteremia in Children Hospitalized with Respiratory Syncytial Virus Infection

BACKGROUND

The risk of bacteremia is considered low in children with acute bronchiolitis. However the rate of occult bacteremia in infants with RSV infection is not well established. The aim was to determine the actual rate and predictive factors of bacteremia in children admitted to hospital due to confirmed RSV acute respiratory illness (ARI), using both conventional culture and molecular techniques.

METHODS

A prospective multicenter study (GENDRES-network) was conducted between 2011-2013 in children under the age of two admitted to hospital because of an ARI. Among those RSV-positive, bacterial presence in blood was assessed using PCR for Meningococcus, Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, and Staphylococcus aureus, in addition to conventional cultures.

RESULTS

66 children with positive RSV respiratory illness were included. In 10.6% patients, bacterial presence was detected: H. influenzae (n = 4) and S. pneumoniae (n = 2). In those patients with bacteremia, there was a previous suspicion of bacterial superinfection and had received empirical antibiotic treatment 6 out of 7 (85.7%) patients. There were significant differences in terms of severity between children with positive bacterial PCR and those with negative results: PICU admission (100% vs. 50%, P-value = 0.015); respiratory support necessity (100% vs. 18.6%, P-value < 0.001); Wood-Downes score (mean = 8.7 vs. 4.8 points, P-value < 0.001); GENVIP scale (mean = 17 vs. 10.1, P-value < 0.001); and length of hospitalization (mean = 12.1 vs. 7.5 days, P-value = 0.007).

CONCLUSION

Bacteremia is not frequent in infants hospitalized with RSV respiratory infection, however, it should be considered in the most severe cases.

Systematic review and meta-analysis of respiratory syncytial virus infection epidemiology in Latin America

Respiratory syncytial virus (RSV) is a frequent cause of acute respiratory infection and the most common cause of bronchiolitis in infants. The aim of this systematic review and meta-analysis was to obtain a comprehensive epidemiological picture of the data available on disease burden, surveillance, and use of resources in Latin America. Pooled estimates are useful for cross-country comparisons. Data from published studies reporting patients with probable or confirmed RSV infection in medical databases and gray literature were included from 74 studies selected from the 291 initially identified. When considering all countries, the largest pooled percentage RSV in low respiratory tract infection patients was found in the group between 0 and 11 months old, 41.5% (95% CI 32.0–51.4). In all countries, percentages were increasingly lower as older children were included in the analyses. The pooled percentage of RSV in LRTIs in the elderly people was 12.6 (95% CI 4.2–24.6). The percentage of RSV infection in hospitalized newborns was 40.9% (95% CI 28.28–54.34). The pooled case fatality ratio for RSV infection was 1.74% (95% CI 1.2–2.4) in the first 2 years of life. The average length of stay excluding intensive care unit admissions among children with risk factors for severe disease was 12.8 (95% CI 8.9–16.7) days, whereas it averaged 7.3 (95% CI 6.1/8.5) days in otherwise healthy children.We could conclude that infants in their first year of age were the most vulnerable population. To our knowledge, this is the first systematic review on RSV disease burden and use of health resources in Latin America.

Antibiotics for bronchiolitis in children under two years of age

BACKGROUND

Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are often used.

OBJECTIVES

To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings.

DATA COLLECTION AND ANALYSIS

Two review authors independently analysed the search results.

MAIN RESULTS

We included seven studies with a total of 824 participants. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission.In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness.One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin.The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02).Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures.There were no deaths reported in any of the arms of the seven included studies. No other adverse effects were reported.

AUTHORS' CONCLUSIONS

This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics.

Factors associated with disease severity in children with bronchiolitis

OBJECTIVE

Bronchiolitis is one of the top causes of hospitalization of infants in the United States. Several clinical factors have been associated with hospitalization; however, few studies have examined factors related to severe disease. Our goal was to describe the clinical characteristics and hospital course of children admitted with bronchiolitis and to identify factors related to intensive care unit (ICU) admission in this population.

METHODS

We conducted a retrospective review of all children less than 2 years of age admitted to a children's hospital with bronchiolitis between July 2008 and July 2011. Demographic and clinical data were collected including information regarding hospital course, treatments received and respiratory pathogens.

RESULTS

During the study period, 734 children were admitted to the hospital with bronchiolitis, 22% of whom were admitted to the ICU and 10% of whom were intubated and mechanically ventilated. Admission to the ICU was associated with younger age [110 (45-210) days versus 69 (35-149) days, p < 0.001] and history of premature birth (OR 1.7, 95% CI 1.1-2.4, p = 0.01), but not with race or ethnicity. The use of respiratory treatments was common in the children admitted to the ICU but was not associated with shortened durations of hospitalization. In addition, neither prematurity nor young age were associated with either increased duration of hospitalization or with increased likelihood of mechanical ventilation.

CONCLUSIONS

During acute bronchiolitis infections, younger children and those with a history of prematurity were more likely to be admitted to the ICU with severe disease.

A systematic review of predictive modeling for bronchiolitis

PURPOSE

Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases.

METHODS

A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years).

RESULTS

The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain.

CONCLUSIONS

Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1950 to May week 2, 2013) and EMBASE (1974 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) or quasi-RCTs comparing antibiotic prescriptions with placebo or non-treatment in children up to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.No studies were found assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

The quality of evidence currently available does not provide strong support for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Epidemiology of respiratory syncytial virus-associated acute lower respiratory tract infection hospitalizations among HIV-infected and HIV-uninfected South African children, 2010-2011

BACKGROUND

There are limited data on respiratory syncytial virus (RSV) infection among children in settings with a high prevalence of human immunodeficiency virus (HIV). We studied the epidemiology of RSV-associated acute lower respiratory tract infection (ALRTI) hospitalizations among HIV-infected and HIV-uninfected children in South Africa.

METHODS

Children aged <5 years admitted to sentinel surveillance hospitals with physician-diagnosed neonatal sepsis or ALRTI were enrolled. Nasopharyngeal aspirates were tested by multiplex real-time polymerase chain reaction assays for RSV and other viruses. Associations between possible risk factors and severe outcomes for RSV infection among HIV-infected and uninfected children were examined. The relative risk of hospitalization in HIV-infected and HIV-uninfected children was calculated in 1 site with population denominators.

RESULTS

Of 4489 participants, 4293 (96%) were tested for RSV, of whom 1157 (27%) tested positive. With adjustment for age, HIV-infected children had a 3-5-fold increased risk of hospitalization with RSV-associated ALRTI (2010 relative risk, 5.6; [95% confidence interval (CI), 4.5-6.4]; 2011 relative risk, 3.1 [95% CI, 2.6-3.6]). On multivariable analysis, HIV-infected children with RSV-associated ALRTI had higher odds of death (adjusted odds ratio. 31.1; 95% CI, 5.4-179.8) and hospitalization for >5 days (adjusted odds ratio, 4.0; 95% CI, 1.5-10.6) than HIV-uninfected children.

CONCLUSION

HIV-infected children have a higher risk of hospitalization with RSV-associated ALRTI and a poorer outcome than HIV-uninfected children. These children should be targeted for interventions aimed at preventing severe RSV disease.

Pulmonary bacterial coinfection in infants and children with viral respiratory infection

The true incidence of pulmonary bacterial coinfection in infants and children hospitalized with a viral respiratory infection is difficult to ascertain but can vary widely from under 1 to 44%. For the same patient group admitted to pediatric intensive care units and/or requiring ventilatory support, the evidence is more convincing, with reported incidences of 17-39%. Studies covering influenza and respiratory syncytial virus infection dominate the recent literature. Whether treatment (or 'cover') with antibiotics is indicated/justified lies in the balance of risk of pulmonary bacterial coinfection (or risk of not diagnosing it), severity of disease and the patient setting. The balance between the overprescription of antibiotics and the possible sequelae associated with bacterial coinfection in infants and children continues to fuel debate.

Respiratory viral and pneumococcal coinfection of the respiratory tract: implications of pneumococcal vaccination

The interactions between Streptococcus pneumoniae and other respiratory pathogens have been studied in vitro, in animal models and in humans - including epidemiologic and vaccine probe studies. Interactions of pneumococcus with respiratory viruses are common, and many mechanisms have been suggested to explain this phenomenon. The aim of this review is to explore pneumococcal interactions with respiratory viruses and consider the potential role that the pneumococcal polysaccharide-protein conjugate vaccine may play in modifying pneumococcal-respiratory viral interactions.

Bronchiolitis outbreak caused by respiratory syncytial virus in southwest Bangladesh, 2010

BACKGROUND

During July 2010, newspapers reported a respiratory disease outbreak in southwestern Bangladesh resulting in the admission of children to a secondary care hospital. We investigated this outbreak to determine the etiology and explore possible risk factors.

METHODS

The hospital's physician diagnosed children aged <2 years with cough, tachypnea or dyspnea, and expiratory wheeze as having acute bronchiolitis. We reviewed the hospital records and listed case patients admitted between 26 June and 26 July 2010. We surveyed the case patients and collected nasal and throat swabs to test for respiratory viruses.

RESULTS

We identified 101 admitted acute bronchiolitis case patients. Fifty-nine (58%) of these were admitted between 16 and 20 July. Among the 29 case patients surveyed, the median age was 4 months and 65% were males. We identified respiratory syncytial virus (RSV) in 91% (21/23) of the samples, 43% of which had a dual viral infection. Most case patients (90%) were treated with broad-spectrum antibiotics. There were no reported deaths.

CONCLUSIONS

The sudden increase in admitted acute bronchiolitis case patients, their median age, and identification of RSV in the majority of samples suggest an outbreak of RSV bronchiolitis. Research to identify strategies to prevent respiratory infections including RSV in low-income settings should be prioritized. Factors that perpetuate antibiotic use in managing this viral syndrome should also be explored.

Treatment of acute viral bronchiolitis

Acute viral bronchiolitis represents the most common lower respiratory tract infection in infants and young children and is associated with substantial morbidity and mortality. Respiratory syncytial virus is the most frequently identified virus, but many other viruses may also cause acute bronchiolitis. There is no common definition of acute viral bronchiolitis used internationally, and this may explain part of the confusion in the literature. Most children with bronchiolitis have a self limiting mild disease and can be safely managed at home with careful attention to feeding and respiratory status. Criteria for referral and admission vary between hospitals as do clinical practice in the management of acute viral bronchiolitis, and there is confusion and lack of evidence over the best treatment for this condition. Supportive care, including administration of oxygen and fluids, is the cornerstone of current treatment. The majority of infants and children with bronchiolitis do not require specific measures. Bronchodilators should not be routinely used in the management of acute viral bronchiolitis, but may be effective in some patients. Most of the commonly used management modalities have not been shown to have a clear beneficial effect on the course of the disease. For example, inhaled and systemic corticosteroids, leukotriene receptor antagonists, immunoglobulins and monoclonal antibodies, antibiotics, antiviral therapy, and chest physiotherapy should not be used routinely in the management of bronchiolitis. The potential effect of hypertonic saline on the course of the acute disease is promising, but further studies are required. In critically ill children with bronchiolitis, today there is little justification for the use of surfactant and heliox. Nasal continuous positive airway pressure may be beneficial in children with severe bronchiolitis but a large trial is needed to determine its value. Finally, very little is known on the effect of the various interventions on the development of post-bronchiolitic wheeze.

Antibiotics for bronchiolitis in children

BACKGROUND

Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are used at rates of 34% to 99% in uncomplicated cases.

OBJECTIVES

To evaluate the effectiveness of antibiotics for bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2010, issue 4), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (January 1966 to November 2010), EMBASE (1990 to December 2010) and Current Contents (2001 to December 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, re-admissions, complications or adverse events and radiological findings.

DATA COLLECTION AND ANALYSIS

Two review authors independently analysed the search results.

MAIN RESULTS

Five studies (543 participants) met our inclusion criteria. One study randomised 52 children to either ampicillin or placebo and found no significant difference between the two groups for length of illness. A small study (21 children) with higher risk of potential bias randomised children with proven RSV infection to clarithromycin or placebo and found clarithromycin may reduce hospital re-admission (8% antibiotics versus 44% placebo; Fishers exact; P = 0.081). The two studies (267 children) providing adequate data for length of hospital stay showed no difference between antibiotics and control (pooled mean difference 0.34; 95% CI -0.71 to 1.38). Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures. None of the trials reported deaths.

AUTHORS' CONCLUSIONS

This review found minimal evidence to support the use of antibiotics for bronchiolitis. Research to identify a possible small subgroup of patients who have complications from bronchiolitis such as respiratory failure and who may benefit from antibiotics is justified.

Randomized placebo-controlled trial on azithromycin to reduce the morbidity of bronchiolitis in Indigenous Australian infants: rationale and protocol

BACKGROUND

Acute lower respiratory infections are the commonest cause of morbidity and potentially preventable mortality in Indigenous infants. Infancy is also a critical time for post-natal lung growth and development. Severe or repeated lower airway injury in very young children likely increases the likelihood of chronic pulmonary disorders later in life. Globally, bronchiolitis is the most common form of acute lower respiratory infections during infancy. Compared with non-Indigenous Australian infants, Indigenous infants have greater bacterial density in their upper airways and more severe bronchiolitis episodes. Our study tests the hypothesis that the anti-microbial and anti-inflammatory properties of azithromycin, improve the clinical outcomes of Indigenous Australian infants hospitalised with bronchiolitis.

METHODS

We are conducting a dual centre, randomised, double-blind, placebo-controlled, parallel group trial in northern Australia. Indigenous infants (aged ≤ 24-months, expected number = 200) admitted to one of two regional hospitals (Darwin, Northern Territory and Townsville, Queensland) with a clinical diagnosis of bronchiolitis and fulfilling inclusion criteria are randomised (allocation concealed) to either azithromycin (30 mg/kg/dose) or placebo administered once weekly for three doses. Clinical data are recorded twice daily and nasopharyngeal swab are collected at enrollment and at the time of discharge from hospital. Primary outcomes are 'length of oxygen requirement' and 'duration of stay,' the latter based upon being judged as 'ready for respiratory discharge'. The main secondary outcome is readmission for a respiratory illness within 6-months of leaving hospital. Descriptive virological and bacteriological (including development of antibiotic resistance) data from nasopharyngeal samples will also be reported.

DISCUSSION

Two published studies, both involving different patient populations and settings, as well as different macrolide antibiotics and treatment duration, have produced conflicting results. Our randomised, placebo-controlled trial of azithromycin in Indigenous infants hospitalised with bronchiolitis is designed to determine whether it can reduce short-term (and potentially long-term) morbidity from respiratory illness in Australian Indigenous infants who are at high risk of developing chronic respiratory illness. If azithromycin is efficacious in reducing the morbidly of Indigenous infants hospitalised with bronchiolitis, the intervention would lead to improved short term (and possibly long term) health benefits.

Acute lower respiratory tract infection due to respiratory syncytial virus in a group of Egyptian children under 5 years of age

BACKGROUND AND AIM

Respiratory syncytial virus (RSV) is one of the most important causes of acute lower respiratory tract infections (ALRTI) in infants and young children. This study was conducted to describe the epidemiology of ALRTI associated with RSV among children ≤ 5 years old in Egypt.

PATIENTS AND METHODS

We enrolled 427 children ≤ 5 years old diagnosed with ALRTI attending the outpatient clinic or Emergency Department (ED) of Children Hospital, Cairo University during a one- year period. Nasopharyngeal aspirates were obtained from the patients, kept on ice and processed within 2 hours of collection. Immunoflourescent assay (IFA) for RSV was performed.

RESULTS

91 cases (21.3%) had viral etiology with RSV antigens detected in 70 cases (16.4%). The RSV positive cases were significantly younger than other non-RSV cases (mean age 8.2 months versus 14.2 months, p <0.001). RSV cases had significantly higher respiratory rate in the age group between 2-11 months (mean 58.4 versus 52.7/minute, p < 0.001) and no significant difference in the mean respiratory rate in the age group between 12-59 months. More RSV cases required supplemental oxygen (46% versus 23.5%, p < 0.001) with higher rate of hospitalization (37.1% versus 11.2%, p < 0.001) than the non-RSV cases. 97% of RSV cases occurred in winter season (p < 0.001).

CONCLUSION

RSV is the most common viral etiology of ALRTI in children below 5 years of age, especially in young infants below 6 months of age. It is more prevalent in winter and tends to cause severe infection.

Influenza and parainfluenza associated pediatric ICU morbidity

OBJECTIVES

To investigate if morbidity in young children admitted to a pediatric intensive care unit (PICU with a laboratory proven diagnosis of influenza and parainfluenza infection) had increased.

METHODS

Retrospective study from January 2003 through December 2009 was carried out. Every child in the PICU with a laboratory-confirmed influenza or parainfluenza infection was included.

RESULTS

18 influenza (influenza A =13 and influenza B = 5) and 17 parainfluenza admissions were identified over the 7-year period. Parainfluenza type 3 (n = 9) was the commonest subtype of parainfluenza infection. The median age of children admitted with influenza was higher than parainfluenza (4.5 vs 1.7 years, p = 0.044). Admissions associated with proven influenza and parainfluenza infections accounted for 2% of PICU annual admissions. There was only one death in 2003. 51% of these patients required ventilatory support, 45% received systemic corticosteroids, and 91% received initial broad spectrum antibiotic coverage. Bacterial co-infections were identified in 25% of these patients. The incidence of influenza admissions had not increased significantly in 2009 (H1N1 pandemic) when compared with 2003 (SARS epidemic) (p = 0.3). There were only two PICU cases of pandemic H1N1 in 2009 and both survived. The annual incidence of severe PICU cases of influenza and parainfluenza were 0.94 and 0.88 per 100,000 children per annum, respectively.

CONCLUSIONS

Pandemic H1N1, influenza and parainfluenza viruses may be associated with significant childhood morbidity and PICU admissions.

Incidence of bacterial coinfection with respiratory syncytial virus bronchopulmonary infection in pediatric inpatients

Bacterial coinfection occurs in pediatric bronchopulmonary infections caused by respiratory syncytial virus (RSV), but the incidence is uncertain. Our subjects are 188 pediatric inpatients having RSV bronchopulmonary infection in two hospitals in Chiba Prefecture between 2005 and 2007. On admission, antigen detection kits using nasopharyngeal aspirate were performed to detect RSV infection and washed sputum bacterial culture was performed to detect bacterial infection. Of the 188 pediatric inpatients with RSV bronchopulmonary infection, 95 (50.5%) patients were aged less than 1 year, 57 (30.3%) were aged 1-2 years, and 36 (19.1%) were aged 2 years or more. Thirty-six (19.1%) patients were associated with bronchial asthma attacks. Pathogenic bacteria were predominantly isolated from 43.6% of the patients. The three most frequently isolated bacteria were Haemophilus influenzae (43.9%), Streptococcus pneumoniae (36.6%), and Moraxella catarrhalis (29.3%). We found that 38.9% of H. influenzae strains were β-lactamase-nonproducing ampicillin-resistant strains. All S. pneumoniae strains were penicillin G (PcG) sensitive. However, 21.9% of S. pneumoniae strains showed PcG minimum inhibitory concentration values of 2 μg/ml. RSV bronchopulmonary infections in hospitalized children are often associated with antimicrobial-resistant bacterial infection in their lower airways. These results indicate that we should be aware of bacterial coinfections in the management of pediatric inpatients with RSV bronchopulmonary infection.

Lower respiratory tract infections

Acute lower respiratory infections (ALRI) are the major cause of morbidity and mortality in young children worldwide. ALRIs are important indicators of the health disparities that persist between Indigenous and non-Indigenous children in developed countries. Bronchiolitis and pneumonia account for the majority of the ALRI burden. The epidemiology, diagnosis, and management of these diseases in Indigenous children are discussed. In comparison with non-Indigenous children in developing countries they have higher rates of disease, more complications, and their management is influenced by several unique factors including the epidemiology of disease and, in some remote regions, constraints on hospital referral and access to highly trained staff. The prevention of repeat infections and the early detection and management of chronic lung disease is critical to the long-term respiratory and overall health of these children.

Management of bronchiolitis without antibiotics: a multicentre randomized control trial in Bangladesh

OBJECTIVE

To ascertain that antibiotics have no role in the management of bronchiolitis.

DESIGN

Multicentre randomized control trial (RCT).

SETTING

Five purposively selected teaching hospitals in Bangladesh.

PATIENT

Children under 24 months old with bronchiolitis.

INTERVENTIONS

Children were randomized into three groups of therapeutic interventions: parenteral ampicillin (P-Ab), oral erythromycin (O-Ab) and no antibiotic (N-Ab) in adjunct to supportive measures.

MAIN OUTCOME MEASURES

Clinical improvement was assessed using 18 symptoms/signs which were graded on a two-point recovery scale of 'rapid' and 'gradual', indicating improvement within 'four days' and 'beyond four days', respectively.

RESULTS

Each intervention group consisted of 98 +/- 1 children having comparable clinico-epidemiological characteristics at the baseline. The trial revealed that most chesty features (features appearing to arise from chest, i.e. cough, breathing difficulty, wheeze, chest indrawing, tachypnoea, tachycardia, rhonchi and crepitation) demonstrated a gradual recovery, beyond 4th admission day and, not differing among the three intervention groups (p > 0.23, p < 0.62, p = 0.54, p < 0.27, p = 0.75, p = 0.76, p = 0.81, p > 0.98, respectively). Most non-chesty features (features appearing to arise away from chest, i.e. feeding/sleeping difficulties, social smile, restlessness, inconsolable crying, nasal flaring, fever and hypoxaemia) demonstrated a rapid recovery, within 4 days, remaining comparable among the three intervention groups (p < 0.07, p = 0.65, p = 0.24, p < 0.61, p = 0.22, p = 0.84, p = 0.29 and p = 0.96, respectively). However, nasal symptoms (runny nose and nasal blockage) also showed no difference among groups (p = 0.36 and p = 0.66, respectively). Thus, the dynamics of clinical outcome obviates that children not receiving antibiotics had similar clinical outcome than those who did.

CONCLUSION

In hospital settings, managing bronchiolitis with only supportive measures but without antibiotics remains preferable.

Influenza virus infection and the risk of serious bacterial infections in young febrile infants

OBJECTIVE

We aimed to determine the risk of SBIs in febrile infants with influenza virus infections and compare this risk with that of febrile infants without influenza infections.

PATIENTS AND METHODS

We conducted a multicenter, prospective, cross-sectional study during 3 consecutive influenza seasons. All febrile infants <or=60 days of age evaluated at any of 5 participating pediatric EDs between October and March of 1998 through 2001 were eligible. We determined influenza virus status by rapid antigen detection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single-pathogen growth of either >or=5 x 10(4) colony-forming units per mL or >or=10(4) colony-forming units per mL in association with a positive urinalysis. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the 4 above-mentioned bacterial infections.

RESULTS

During the 3-year study period, 1091 infants were enrolled. A total of 844 (77.4%) infants were tested for the influenza virus, of whom 123 (14.3%) tested positive. SBI status was determined in 809 (95.9%) of the 844 infants. Overall, 95 (11.7%) of the 809 infants tested for influenza virus had an SBI. Infants with influenza infections had a significantly lower prevalence of SBI (2.5%) and UTI (2.4%) when compared with infants who tested negative for the influenza virus. Although there were no cases of bacteremia, meningitis, or enteritis in the influenza-positive group, the differences between the 2 groups for these individual infections were not statistically significant.

CONCLUSIONS

Febrile infants <or=60 days of age with influenza infections are at significantly lower risk of SBIs than febrile infants who are influenza-negative. Nevertheless, the rate of UTI remains appreciable in febrile, influenza-positive infants.

Respiratory syncytial virus: from primary care to critical care

Respiratory syncytial virus (RSV) is a common disease in pediatrics. Certain subpopulations of children are at greatest risk for serious disease. However, previously healthy children also may become critically ill. In the clinic or the intensive care unit, children with RSV pose the challenge of how to treat a disease when evidence to support therapeutic options is severely limited. Prophylaxis is an option for certain children, although many do not qualify. RSV has been implicated in continued wheezing and the subsequent development of asthma. While evidence for this implication is still being sought, researchers are working on finding new ways to treat and prevent RSV.

Respiratory syncytial virus infection in children admitted to hospital but ventilated mechanically for other reasons

One thousand five hundred sixty-eight RSV infections were documented prospectively in 1,541 pediatric patients. Of these, 20 (1.3%) had acquired the RSV infection while treated by mechanical ventilation for reasons other than the actual RSV infection (group ventilated mechanically). The clinical characteristics of children who were infected with respiratory syncytial virus (RSV) infection while ventilated mechanically for other reasons are described and compared with a matched control group. Sixty percent of the group ventilated mechanically had at least one additional risk factor for a severe course of infection (prematurity 50%, chronic lung disease 20%, congenital heart disease 35%, immunodeficiency 20%). The median age at diagnosis in the group ventilated mechanically was 4.2 months. The matched pairs analysis (group ventilated mechanically vs. control group) revealed a higher proportion of patients with hypoxemia and apnoea in the group ventilated mechanically; more patients in the control group showed symptoms of airway obstruction (wheezing). At least one chest radiography was performed in 95% of the patients (n = 19) in the group ventilated mechanically versus 45% (n = 9) in the control group (P = 0.001). The frequency of pneumonia was 40% in the group ventilated mechanically and 20% in the control group. Despite existing consensus recommendations, only two patients (10%) of the group ventilated mechanically had received palivizumab previously. Significantly more patients in the group ventilated mechanically received antibiotic treatment (85% vs. 45%, P = 0.008), and attributable mortality was higher in the group ventilated mechanically (15% [n = 3] vs. 0% in the control group, P = 0.231). Children treated by long term mechanical ventilation may acquire RSV infection by transmission by droplets or caregivers and face an increased risk of a severe course of RSV infection. The low rate of immunoprophylaxis in this particular risk group should be improved.

Premorbid factors and outcome associated with respiratory virus infections in a pediatric intensive care unit

OBJECTIVES

The purpose of this study was to report the clinical features and outcome of all children with a laboratory proven diagnosis of respiratory virus infection admitted to a university Pediatric Intensive Care Unit (PICU).

METHODS

Retrospective study between January 2003 and April 2007 was carried out in the PICU. Every child with a laboratory-confirmed viral infection was included.

RESULTS

54 viruses were identified in 49 children (27 M, 22 F) over a 52-month period. The three respiratory virus species, respiratory syncytial virus (RSV) (n = 17), influenza (n = 13) and parainfluenza (n = 12), accounted for 86% of these 49 cases. PICU admissions due to influenza A (n = 10) were more common than influenza B (n = 3), whereas parainfluenza type 3 (n = 7) was the commonest subtype of parainfluenza infection. Comparing these three common viruses, the mean age of children admitted with RSV was lower than with influenza or parainfluenza (1.2 years vs. 5.6 years vs. 2.4 years, P = 0.003). Pre-existing conditions such as prematurity and chronic lung disease were only present in children with RSV infection. These respiratory viruses caused both upper (croup) and lower respiratory tract diseases (bronchiolitis, pneumonia). Extrapulmonary presentations were less prevalent and included encephalitis, seizures, cardiac arrest, coexisting diabetes ketoacidosis and acute lymphoblastic leukemia. One patient with RSV and another with influenza A died during their PICU stay. Nearly half of these patients required ventilatory support or received systemic corticosteroids, and 88% received initial broad spectrum antibiotic coverage. Approximately one in five of them had nebulised adrenaline, airway endoscopies or bacterial co-infections. Adenovirus was isolated in four patients and two (both with adenovirus type 3) died during the PICU stay.

CONCLUSIONS

In PICU, respiratory viral infections were associated with significant morbidity and life-threatening conditions.

Azithromycin does not improve disease course in hospitalized infants with respiratory syncytial virus (RSV) lower respiratory tract disease: a randomized equivalence trial

BACKGROUND

Nearly half of all hospitalized infants with respiratory syncytial virus (RSV) lower respiratory tract disease (LRTD) are treated with (parenteral) antibiotics. The present study was designed to test our hypothesis that the use of antibiotics would not lead to a reduced duration of hospitalization in mild to moderate RSV LRTD.

METHODS

Seventy-one patients < or =24 months of age with a virologically confirmed clinical diagnosis of RSV LRTD were randomized to azithromycin 10 mg/kg/day (n = 32) or placebo (n = 39) in a multicenter, randomized, double-blind, placebo-controlled equivalence trial during three RSV seasons (2002-2004 through 2005-2006). Primary endpoint was duration of hospitalization, secondary endpoints included duration of oxygen supplementation and nasogastric tube feeding, course of RSV symptom score, number of PICU referrals and number of patients who received additional antibiotic treatment. Data were analyzed according to the intention-to-treat principle using the Mann-Whitney U-test or chi2 test considering P < 0.05 as statistically significant.

RESULTS

Included patients were comparable with respect to baseline demographics, clinical characteristics, laboratory and roentgenologic investigations. The mean duration of hospitalization was not significantly different between patients treated with azithromycin or placebo (132.0 +/- 10.8 vs. 139.6 +/- 7.7 hr, P = 0.328). Azithromycin was not associated with a stronger resolution of clinical symptoms represented by the RSV symptom score. Four patients were treated with antibiotics after 72 hr, three of them were assigned to placebo (P = 0.406).

CONCLUSIONS

Infants and young children with RSV LRTD do not benefit from routine treatment with antibiotics (ISRCTN number 86554663).

Lack of usefulness of an abnormal white blood cell count for predicting a concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection

BACKGROUND

There continues to be controversy on the most appropriate way to manage infants and young children with fever and documented RSV lower respiratory tract infection (LRTI). The objective of this study was to determine the usefulness of an abnormal white blood cell (WBC) count for predicting a concurrent serious bacterial infection in patients admitted with RSV LRTI.

METHODS

The medical records were reviewed of patients discharged with RSV LRTI during the 5 RSV seasons from July 1, 2000 through June 30, 2005. Data were collected on age and gender as well as temperature, complete blood count with manual differential and bacterial cultures obtained at admission.

RESULTS

The inclusion criteria was met by 1920 patients. There were 672 febrile patients who had a complete blood count and a bacterial culture. One (5.0%) of 20 patients with a WBC <5000 had a positive culture, 23 (4.7%) of 492 patients with a WBC 5000-14,999 had a positive culture, 5 (4.8%) of 105 patients with a WBC 15,000-19,999 had a positive culture, 2 (5.7%) of 35 patients with a WBC 20,000-24,999 had a positive culture, none of 11 patients with a WBC 25,000-29,999 had a positive culture and 3 (33%) of 9 patients with a WBC >30,000 had a positive culture. Overall, cultures were positive in 34 (5.1%; 95% CI: 3.4-6.8%) of the febrile patients tested and almost all (32; 94%) showed positive urine cultures.

CONCLUSION

The probability of an abnormal WBC count <5000 and 15,000-30,000 being associated with a concurrent serious bacterial infection was very low and no different from that of a normal WBC count in febrile patients admitted with RSV LRTI.

Risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus infection

OBJECTIVE

To evaluate the risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus (RSV) disease.

PATIENTS AND METHODS

Retrospective cohort analysis of all infants hospitalized due to RSV infection between January 1, 2001 and July 31, 2005. Patients were identified by ICD-10 diagnosis of RSV infection including codes J21.0, J21.9, J12.1, J20.5 and B97.4. Medical charts were reviewed and RSV infection had to be confirmed by positive antigen detection test on nasopharyngeal aspirates.

RESULTS

A total of 464 infants had been hospitalized due to RSV infection and 42 (9.1%) were born<37 weeks of gestational age. Concurrent bacterial infections were diagnosed by either positive blood or urine cultures, stool culture, tracheal aspirates or smears in 4 of 42 preterm (9.5%) compared to 13 of 422 term (3.1%) infants (p=0.017, RR 3.092, CI 95% 1.251-7.641). Excluding the infants admitted to the intensive care unit (ICU) the total rate of bacterial co-infection was 1.9%. Ten of 42 preterm (23.8%) compared to 25 of 422 term (5.2%) infants were referred to ICU (p<0.001, RR 3.349, CI 95% 1.882-5.959). All preterm infants had pneumonia, and isolates were Streptococcus pneumoniae, Chlamydia pneumoniae and Streptococcus pneumoniae with Haemophilus influenzae. Mean length of stay in preterm infants with bacterial co-infection was 22.3 days compared to 10.3 days without bacterial co-infection (p<0.006).

CONCLUSION

The overall low risk of concurrent bacterial infection was significantly increased in preterm infants associated with prolonged hospitalization and ICU admission.

Effect of point of care information on inpatient management of bronchiolitis

BACKGROUND

We studied the effects of access to point-of-care medical evidence in a computerised physician order entry system (CPOE) on management and clinical outcome of children with bronchiolitis.

METHODS

This was a before-after study that took place in a Canadian tertiary care paediatric teaching hospital. The intervention was a clinical evidence module (CEM) for bronchiolitis management, adapted from Clinical Evidence (BMJ Publishing Group) and integrated into the hospital CPOE. CPOE users were medical trainees under the supervision of staff physicians working in the infant ward. Use of antibiotics, bronchodilators and corticosteroids; disease severity; length of hospital admission; and trainee use and perception of the CEM were measured before and after CEM introduction.

RESULTS

334 paediatric inpatients age 2 weeks to 2 years, with a clinical diagnosis of bronchiolitis; 147 children the year preceding and 187 children the year following introduction of a Clinical Evidence Module (CEM). The percentage of patients receiving antibiotics fell from 35% to 22% (relative decrease 37%) following the introduction of the CEM (p = 0.016). Bronchodilator use was high but following the CEM patients no longer received more than one variety. Steroid usage and length of hospitalisation were low and unaffected. Trainees found the CEM to be educational.

CONCLUSION

Readily accessible clinical evidence at the point of care was associated with a significant decrease in antibiotic use and an end to multiple bronchodilator use. The majority of physician trainees found the CEM to be a useful educational tool.

Antibiotics for bronchiolitis in children

BACKGROUND

Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting young babies. It is most often caused by Respiratory Syncytial Virus (RSV). The diagnosis is usually made on clinical grounds (especially tachypnoea and wheezing in a child less than two years of age). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. Despite this, they are used at rates of 34 to 99% in uncomplicated cases.

OBJECTIVES

To evaluate the use of antibiotics for bronchiolitis.

SEARCH STRATEGY

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) which includes the Acute Respiratory Infection Groups' specialised register, the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 3, 2006); MEDLINE (January 1966 to August Week 2, 2006); EMBASE (1990 to March 2006); and Current Contents (2001 to September 2006).

SELECTION CRITERIA

Types of studies: single or double blind randomised controlled trials comparing antibiotics to placebo in the treatment of bronchiolitis.

TYPES OF PARTICIPANTS

children under the age of two years diagnosed with bronchiolitis using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Types of interventions: oral, intravenous, intramuscular or inhaled antibiotics versus placebo. Types of outcome measures: primary clinical outcomes: time for the resolution of symptoms/signs (pulmonary markers: respiratory distress; wheeze; crepitations; oxygen saturation; and fever).

SECONDARY OUTCOMES

hospital admissions; time to discharge from hospital; re-admissions; complications/adverse events developed; and radiological findings.

DATA COLLECTION AND ANALYSIS

All data were analysed using Review Manager software, version 4.2.7.

MAIN RESULTS

One study met our inclusion criteria. It randomised children presenting clinically with bronchiolitis to either ampicillin or placebo. The main outcome measure was duration of illness and death. There was no significant difference between the two groups for length of illness and there were no deaths in either group.

AUTHORS' CONCLUSIONS

This review found no evidence to support the use of antibiotics for bronchiolitis. This results needs to be treated with caution given only one RCT justified inclusion. It is unlikely that simple RCTs of antibiotics against placebo for bronchiolitis will be undertaken in future. Research to identify a possible small subgroup of patients presenting with bronchiolitis-like symptoms who may benefit from antibiotics may be justified. Otherwise, research may be better focussed on determining the reasons for clinicians to use antibiotics so readily for bronchiolitis, and ways of reducing their anxiety, and therefore their use of antibiotics for bronchiolitis.

Antibiotics in childhood pneumonia

Pneumonia is one of the most common global childhood illnesses. The diagnosis relies on a combination of clinical judgement and radiological and laboratory investigations. Streptococcus pneumoniae remains the most important cause of childhood community-acquired pneumonia. In addition, viruses (including respiratory syncytial virus) and atypical bacteria (Mycoplasma and Chlamydia) are likely pathogens in younger and older children in developed countries. In the minority of cases only, the actual organism is isolated to guide treatment. Antibiotics effective against the expected bacterial pathogens should be instituted where necessary. The route and duration of antibiotic therapy, the role of emerging pathogens and the impact of pneumococcal resistance and conjugate pneumococcal vaccines are also discussed.

High incidence of pulmonary bacterial co-infection in children with severe respiratory syncytial virus (RSV) bronchiolitis

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of viral lower respiratory tract infections (LRTI). Viral LRTI is a risk factor for bacterial superinfection, having an escalating incidence with increasing severity of respiratory illness. A study was undertaken to determine the incidence of pulmonary bacterial co-infection in infants and children with severe RSV bronchiolitis, using paediatric intensive care unit (PICU) admission as a surrogate marker of severity, and to study the impact of the co-infection on morbidity and mortality.

METHODS

A prospective microbiological analysis was made of lower airways secretions on all RSV positive bronchiolitis patients on admission to the PICU during three consecutive RSV seasons.

RESULTS

One hundred and sixty five children (median age 1.6 months, IQR 0.5-4.6) admitted to the PICU with RSV bronchiolitis were enrolled in the study. Seventy (42.4%) had lower airway secretions positive for bacteria: 36 (21.8%) were co-infected and 34 (20.6%) had low bacterial growth/possible co-infection. All were mechanically ventilated (median 5.0 days, IQR 3.0-7.3). Those with bacterial co-infection required ventilatory support for longer than those with only RSV (p<0.01). White cell count, neutrophil count, and C-reactive protein did not differentiate between the groups. Seventy four children (45%) received antibiotics prior to intubation. Sex, co-morbidity, origin, prior antibiotics, time on preceding antibiotics, admission oxygen, and ventilation index were not predictive of positive bacterial cultures. There were 12 deaths (6.6%), five of which were related to RSV.

CONCLUSIONS

Up to 40% of children with severe RSV bronchiolitis requiring admission to the PICU were infected with bacteria in their lower airways and were at increased risk for bacterial pneumonia.