Utilization of viral molecular diagnostics among children hospitalized with community acquired pneumonia

Provider-ordered viral testing and antibiotic administration practices among children with acute respiratory infections across healthcare settings in Nashville, Tennessee

Objective

Evaluate the association between provider-ordered viral testing and antibiotic treatment practices among children discharged from an ED or hospitalized with an acute respiratory infection (ARI).

Design

Active, prospective ARI surveillance study from November 2017 to February 2020.

Setting

Pediatric hospital and emergency department in Nashville, Tennessee.

Participants

Children 30 days to 17 years old seeking medical care for fever and/or respiratory symptoms.

Methods

Antibiotics prescribed during the child's ED visit or administered during hospitalization were categorized into (1) None administered; (2) Narrow-spectrum; and (3) Broad-spectrum. Setting-specific models were built using unconditional polytomous logistic regression with robust sandwich estimators to estimate the adjusted odds ratios and 95% confidence intervals between provider-ordered viral testing (ie, tested versus not tested) and viral test result (ie, positive test versus not tested and negative test versus not tested) and three-level antibiotic administration.

Results

4,107 children were enrolled and tested, of which 2,616 (64%) were seen in the ED and 1,491 (36%) were hospitalized. In the ED, children who received a provider-ordered viral test had 25% decreased odds (aOR: 0.75; 95% CI: 0.54, 0.98) of receiving a narrow-spectrum antibiotic during their visit than those without testing. In the inpatient setting, children with a negative provider-ordered viral test had 57% increased odds (aOR: 1.57; 95% CI: 1.01, 2.44) of being administered a broad-spectrum antibiotic compared to children without testing.

Conclusions

In our study, the impact of provider-ordered viral testing on antibiotic practices differed by setting. Additional studies evaluating the influence of viral testing on antibiotic stewardship and antibiotic prescribing practices are needed.

Antibiotic Use and Respiratory Viral PCR Testing Among Pediatric Patients With Nosocomial Fever

Objective Pediatric patients admitted to the hospital often develop fevers during their inpatient stay, and many children are empirically started on antibiotics. The utility of respiratory viral panel (RVP) polymerase chain reaction (PCR) testing in the evaluation of nosocomial fevers in admitted patients is unclear. We sought to evaluate whether RVP testing is associated with the use of antibiotics among inpatient pediatric patients. Patients and methods We conducted a retrospective chart review of children admitted from November 2015 to June 2018. We included all patients who developed fever 48 hours or more after admission to the hospital and who were not already receiving treatment for a presumed infection (on antibiotics). Results Among 671 patients, there were 833 inpatient febrile episodes. The mean age of children was 6.3 years old, and 57.1% were boys. Out of 99 RVP samples analyzed, 22 were positive (22.2%). Antibiotics were started in 27.8% while 33.5% of patients were already on antibiotics. On multivariate logistic regression, having an RVP sent was significantly associated with increased initiation of antibiotics (aOR 95% CI 1.18-14.18, p=0.03). Furthermore, those with a positive RVP had a shorter course of antibiotics compared to those with a negative RVP (mean 6.8 vs 11.3 days, p=0.019). Conclusions Children with positive RVP had decreased antibiotic exposure compared to those with negative RVP results. RVP testing may be used to promote antibiotic stewardship among hospitalized children.

Use and Cost Analysis of Comprehensive Respiratory Panel Testing in a Pediatric Emergency Department

OBJECTIVES

Fever and respiratory infections are among the leading causes of pediatric emergency department visits and hospitalizations. Although typically self-resolving, clinicians may perform diagnostic tests to determine microbial etiologies of these illnesses. Although comprehensive respiratory viral panels can quickly identify causative organisms, cost to the hospital and patient may be significant. The objective of this study was to analyze the financial impact of comprehensive respiratory viral panel use in relation to associated clinical outcomes.

METHODS

This study was a single-center, retrospective chart review of pediatric emergency department patients who were evaluated between October 1, 2016, and April 30, 2018, with International Classification of Diseases, Tenth Revision (ICD-10) code diagnoses of acute upper respiratory infection, fever unspecified, and/or bronchiolitis. Our primary outcome was the effect of comprehensive respiratory viral panel testing and results on the total health care charge to patients. Secondary outcomes were the effect of comprehensive respiratory viral panel testing and results on emergency department length of stay and antimicrobial use.

RESULTS

A total of 5766 visits were included for primary analysis, with 229 (4%) undergoing comprehensive respiratory viral panel testing. Of these, 163 had a positive result (71%) for at least 1 organism. The total cost was significantly higher in the group that underwent comprehensive respiratory viral panel testing ($643.39 [$534.18-$741.15] vs $295.15 [$249.72-$353.92]; P < 0.001). There was no decrease in emergency department length of stay or significant change in antimicrobial use associated with comprehensive respiratory viral panel use.

CONCLUSIONS

This study demonstrates that the utilization of comprehensive respiratory viral panels in pediatric emergency department patients with bronchiolitis, unspecified fever, and/or acute upper respiratory infection adds significant cost to patient care without a decrease in their length of stay or antimicrobial use. Further studies are needed to determine the appropriate targeted use of comprehensive respiratory viral panels.

Analysis of the impact of diagnostic virology tests on the use of antibiotics in paediatric inpatients with community-acquired pneumonia

Introduction

Viruses are one of the most common causes of community-acquired pneumonia (CAP) in children. Early identification of respiratory viruses could result in a decrease in the use of antibiotics.

Methods

Observational, retrospective study from January 2014 to June 2018, that included paediatric patients admitted with a diagnosis of CAP in a tertiary hospital, in which antigenic tests and/or viral PCR on a respiratory sample was performed.

Results

A total of 105 CAP episodes were included, with identification of a respiratory virus in 93 (88.6%) cases. Patients with respiratory syncytial virus (RSV) detection had a lower onset of empirical antibiotic therapy (35.1% vs. 55.9%, p-value = .042). In addition, cases with RSV or influenza identification required shorter duration of antibiotic therapy (receiving 45.6% ≥2 days vs. 68.8% of those not identified, p = .017).

Conclusion

The use of respiratory virus diagnostic techniques in our setting can optimise antibiotic use in children admitted with CAP.

Analysis of the impact of diagnostic virology tests on the use of antibiotics in paediatric inpatients with community-acquired pneumonia

Introducción

Los virus son una de las causas más frecuentes de neumonía adquirida en la comunidad (NAC) en niños. La identificación precoz de virus respiratorios podría suponer una disminución en el consumo de antibióticos.

Métodos

Estudio observacional, retrospectivo, desde enero del 2014 hasta junio del 2018, que incluyó a los pacientes pediátricos ingresados en un hospital terciario con diagnóstico de NAC, a los que se realizó test antigénico o PCR viral en muestra respiratoria.

Resultados

Se incluyeron 105 episodios de NAC, identificándose algún virus respiratorio en 93 (88,6%) casos. Los pacientes con detección de virus respiratorio sincitial (VRS) presentaron menor inicio de antibioterapia empírica (35,1% vs. 55,9%, p valor: 0,042). Además, los casos con identificación de VRS o influenza precisaron menor duración de antibioterapia (recibiendo el 45,6% ≥ 2 días frente al 68,8% de los que no se identificó, p = 0,017).

Conclusión

El uso de técnicas diagnósticas de virus respiratorios en nuestro medio puede optimizar el consumo de antibióticos en niños ingresados con NAC.

The Clinical Utility of Respiratory Viral Testing in Hospitalized Children: A Meta-analysis

CONTEXT

Respiratory virus (RV) detection tests are commonly used in hospitalized children to diagnose viral acute respiratory infection (ARI), but their clinical utility is uncertain.

OBJECTIVES

To systematically review and meta-analyze the impact of RV test results on antibiotic consumption, ancillary testing, hospital length of stay, and antiviral use in children hospitalized with severe ARI.

DATA SOURCES

Seven medical literature databases from 1985 through January 2018 were analyzed.

STUDY SELECTION

Studies in children <18 years old hospitalized for severe ARI in which the clinical impact of a positive versus negative RV test result or RV testing versus no testing are compared.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts, and full texts; extracted data; and assessed study quality.

RESULTS

We included 23 studies. High heterogeneity did not permit an overall meta-analysis. Subgroup analyses by age, RV test type, and viral target showed no difference in the proportion of patients receiving antibiotics between those with positive versus negative test results. Stratification by study design revealed that RV testing decreased antibiotic use in prospective cohort studies (odds ratio = 0.58; 95% confidence interval: 0.45-0.75). Pooled results revealed no conclusive impact on chest radiograph use (odds ratio = 0.71; 95% confidence interval: 0.48-1.04). Results of most studies found that positive RV test results did not impact median hospital length of stay, but they may decrease antibiotic duration. Nineteen (83%) studies were at serious risk of bias.

LIMITATIONS

Low-quality studies and high clinical and statistical heterogeneity were among the limitations.

CONCLUSIONS

Higher-quality prospective studies are needed to determine the impact of RV testing on antibiotic use in children hospitalized with severe ARI.

Improving Influenza Testing and Treatment in Hospitalized Children

OBJECTIVES

National guidelines recommend influenza testing for children hospitalized with influenza-like illness (ILI) during influenza season and treatment of those with confirmed influenza. Using quality improvement methods, we sought to increase influenza testing and treatment of children admitted to our hospital medicine service with ILI from 65% to 90% during the 2014-2015 influenza season.

METHODS

We targeted several key drivers using multiple plan-do-study-act cycles. Interventions included awareness modules, biweekly flyers, and failure tracking. ILI admissions (fever plus respiratory symptoms) were reviewed weekly once surveillance data revealed elevated influenza activity. Appropriate testing and treatment of ILI was defined as influenza testing and/or treatment within 24 hours of admission unless a known cause other than influenza was present. We used statistical process control charts to track progress using established quality improvement methods. Appropriate testing and treatment was also assessed in the 2016-2017 influenza season by using similar methods, although no new interventions were introduced.

RESULTS

For the 2014-2015 season, appropriate testing and treatment increased from a baseline mean of 65% to 91% within 3 months. For the 2016-2017 season, appropriate testing and treatment remained at a mean of 80% throughout the influenza season.

CONCLUSIONS

Appropriate influenza testing and treatment increased to 90% in children with ILI during the 2014-2015 season. Improvements were sustained in a subsequent influenza season. Our initiative improved recognition of influenza and likely increased treatment opportunities. Future work should be focused on wider implementation and further reducing variation.

Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses

Background: Respiratory viral illnesses account for many hospitalizations and inappropriate antibiotic use. Respiratory viral panels by polymerase chain reaction (RVP-PCR) provide a reliable means of diagnosis. In 2015, the RVP-PCR assay at our institution was switched from respiratory viral panel (RVP) to rapid respiratory panel (rapid RP), which has a faster turnaround time (24 hours vs 12 hours, respectively). The purpose of this study was to evaluate the effect of RVP-PCR tests on duration of antibiotic use and length of stay (LOS) in hospitalized patients. Methods: We performed a retrospective chart review of patients who had a RVP-PCR ordered within a 1-year time period before and after the assay switch. Patients who were pregnant, had received antibiotics within 30 days prior to admission, were not discharged, or had not completed antibiotics by end of study period were excluded. Results: Data were obtained from a total of 140 patients (70 in each group). Of these, 25 (35.7%) in the RVP group and 28 (40.0%) in the rapid RP group had a positive result. The median LOS was 4.5 days (IQR, 3-9 days) in the RVP group and 5 days (IQR, 3-9 days) in the rapid RP group (P = .78). The median duration of antibiotic use was 4 days (IQR, 2-7 days) in the RVP group and 5 days (IQR, 1-7 days) in the rapid RP group (P = .8). Conclusion: Despite faster turnaround time, there was no significant difference in duration of antibiotic use, or LOS between the RVP and rapid RP groups.

Back to the Basics: Community-Acquired Pneumonia in Children

Community-acquired pneumonia (CAP) is a common childhood infection and often a reason for inpatient admission, especially when a child is hypoxic or in respiratory distress. Despite advances in technology and diagnostics, it remains difficult to accurately differentiate bacterial CAP from a viral process. Most of the laboratory tests routinely done in inpatient medicine, such as complete blood counts and acute phase reactants, do little to differentiate a viral pneumonia from a bacterial pneumonia. Clinicians must rely heavily on the clinical presentation and decide whether to treat empirically with antibiotics. Guidelines published by the Infectious Disease Society of America in 2011 have helped clinicians standardize the diagnosis and treatment of CAP. The guidelines recommend relatively narrow-spectrum antibiotics, such as ampicillin or penicillin, as empiric coverage for the fully immunized child older than age 3 months who requires hospitalization for CAP. [Pediatr Ann. 2017;46(7):e257-e261.].

Impact of a Transition from Respiratory Virus Shell Vial to Multiplex PCR on Clinical Outcomes and Cost in Hospitalized Children

While respiratory virus PCR panel (RVPP) is more expensive than shell vial (SV) cell culture, it has been shown to reduce unnecessary diagnostic procedures, decrease the inappropriate use of antimicrobials, and shorten the hospital length of stay (LOS). We therefore hypothesized that, for hospitalized children, RVPP would be associated with improved clinical outcomes but higher hospital charges than SV cell culture. We performed a retrospective cohort study of hospitalized children. Multivariate analysis was performed, and p-values were calculated. Respiratory virus testing was collected in a total of 1625 inpatient encounters, of which 156 were tested positive by RVPP (57.7%) and 112 were tested positive by SV (11.1%, p < 0.05). Excluding human rhinovirus (HRV) and human metapneumovirus (hMPV) from the analysis, patients with a positive test from SV had more comorbidities (p = 0.04) and higher mortality (p = 0.008). Patients with a positive test from RVPP had shorter LOS (p = 0.0503). Hospital charges for patients with a positive test from RVPP were lower, but not significantly so. When a multivariate analysis was performed, there were no statistically significant differences in comorbidities, mortality, LOS, or median hospital charges between those patients with a positive SV and those with a positive RVPP. Although testing with RVPP significantly increased the detection of respiratory viruses, clinical outcomes remained comparable to those tested with SV, however RVPP was found to not be associated with higher long-term hospital costs.

Impact of Multiplex Polymerase Chain Reaction Testing for Respiratory Pathogens on Healthcare Resource Utilization for Pediatric Inpatients

OBJECTIVE

To assess whether multiplex polymerase chain reaction (mPCR) vs non-mPCR testing impacts the use of antibiotics, chest radiographs, and isolation precautions.

STUDY DESIGN

We retrospectively compared use of antibiotics, chest radiographs, and isolation precautions for patients <18 years old (excluding neonates) hospitalized at a tertiary referral center tested for respiratory pathogens in the emergency department or during the first 2 hospital days, during 2 periods: June 2010-June 2012 (non-mPCR group) vs October 2012-May 2014 (mPCR group).

RESULTS

Subjects (n = 2430) in the mPCR group were older, had more complex chronic conditions, and were admitted to the pediatric intensive care unit more often compared with the non-mPCR (n = 2349) group. Subjects in the mPCR group had more positive tests (42.4% vs 14.4%, P < .01), received fewer days of antibiotics (4 vs 5 median antibiotic days, P < .01), fewer chest radiographs performed, (59% vs 78%, P < .01), and were placed in isolation longer (20 vs 0 median isolation-hours, P < .01) compared with the non-mPCR group. In multivariable regression, patients tested with mPCR were less likely to receive antibiotics for ≥2 days (OR 0.5, 95% CI 0.5-0.6), chest radiographs at admission (OR 0.4, 95% CI 0.3-0.4), and more likely to be in isolation for ≥2 days (OR 2.4, 95% CI 2.1-2.8) compared with the non-mPCR group.

CONCLUSIONS

Use of mPCR testing for respiratory viruses among hospitalized patients was significantly associated with decreased healthcare resource utilization, including decreased use of antibiotics and chest radiographs, and increased use of isolation precautions.

Recent Developments in Pediatric Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is the most common acute infectious cause of death in children worldwide. Consequently, research into the epidemiology, diagnosis, treatment, and prevention of pediatric CAP spans the translational research spectrum. Herein, we aim to review the most significant findings reported by investigators focused on pediatric CAP research that has been reported in 2014 and 2015. Our review focuses on several key areas relevant to the clinical management of CAP. First, we will review recent advances in the understanding of CAP epidemiology worldwide, including the role of vaccination in the prevention of pediatric CAP. We also report on the expanding role of existing and emerging diagnostic technologies in CAP classification and management, as well as advances in optimizing antimicrobial use. Finally, we will review CAP management from the policy and future endeavors standpoint, including the influence of clinical practice guidelines on clinician management and patient outcomes, and future potential research directions that are in the early stages of investigation.

Association of respiratory viruses with outcomes of severe childhood pneumonia in Botswana

BACKGROUND

The highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings.

METHODS

We conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes.

RESULTS

Between April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia.

CONCLUSIONS

Respiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.