Office-based treatment and outcomes for febrile infants with clinically diagnosed bronchiolitis

Omphalitis Hospitalizations at a US Children's Hospital

OBJECTIVES

To describe demographics, presentation, resource use, and outcomes of patients diagnosed with omphalitis.

METHODS

This was a retrospective descriptive study of infants with omphalitis at a children's hospital system between January 2006 and December 2020. Presentation, resource use, and outcomes (omphalitis complications [eg, necrotizing fasciitis], 30-day related cause revisit, and death) were described.

RESULTS

Ninety-one patients had a primary or secondary International Classification of Diseases, Ninth or 10th Revision, code for omphalitis. Seventy-eight patients were included in analysis (47 with omphalitis as primary reason for admission). Patients with omphalitis as the primary reason for admission presented with rash (44 of 47, 93.6%), fussiness/irritability (19 of 47, 40.4%), and fever (6 of 47, 12.8%). C-reactive protein was minimally elevated, with a median of 0.4 mg/dL (interquartile range 0.29-0.85).Among all patients, blood cultures were positive in 3 (3 of 78, 3.8%) and most had positive wound cultures (70 of 78, 89.7%), with primarily gram-positive organisms. Median duration of intravenous antibiotics was 5 days (interquartile range 3-7). No patients had complications of omphalitis or death. Five patients (5 of 78, 6.4%) had a 30-day revisit for a related cause.

CONCLUSIONS

We found variation in presentation and management of patients with omphalitis at our tertiary children's hospital system. Wound cultures, but not blood tests, were helpful in guiding management in the majority of cases. There were no complications of omphalitis or deaths.

Systematic Literature Review of Respiratory Syncytial Virus Laboratory Testing Practices and Incidence in United States Infants and Children <5 Years of Age

Background

Respiratory syncytial virus (RSV) can cause serious illness in those aged <5 years in the United States, but uncertainty remains around which populations receive RSV testing. We conducted a systematic literature review of RSV testing patterns in studies published from 2000 to 2021.

Methods

Studies of RSV, medically attended RSV lower respiratory tract infections (LRTIs), and bronchiolitis were identified using standard methodology. Outcomes were clinical decisions to test for RSV, testing frequency, and testing incidence proportions in inpatient (IP), emergency department (ED), outpatient (OP), and urgent care settings.

Results

Eighty good-/fair-quality studies, which reported data from the period 1988–2020, were identified. Twenty-seven described the clinical decision to test, which varied across and within settings. Two studies reported RSV testing frequency for multiple settings, with higher testing proportions in IP (n = 2, range: 83%–85%, 1996–2009) compared with ED (n = 1, 25%, 2006–2009) and OP (n = 2, 15%–25%, 1996–2009). Higher RSV testing incidence proportions were observed among LRTI infant populations in the ED (n = 1, 74%, 2007–2008) and OP (n = 2, 54%–69%, 1995–2008). Incidence proportions in LRTI populations were not consistently higher in the IP setting (n = 13). Across studies and time, there was heterogeneity in RSV testing patterns, which may reflect varying detection methods, populations, locations, time periods, and healthcare settings.

Conclusions

Not all infants and children with LRTI are tested for RSV, highlighting underestimation of RSV burden across all settings.

Urinary Tract Infection in Children With Bronchiolitis: Is It Worth Testing Everyone?

Objective The current study aims to determine the prevalence of urinary tract infection (UTI) and the need to perform urine analysis and cultures in children admitted with bronchiolitis in a large tertiary children's hospital in Riyadh, Saudi Arabia. Methods We conducted a retrospective chart review of pediatric patients 0-2 years of age who were admitted with bronchiolitis from November 2016 till April 2017. All charts were analyzed to identify the children investigated for UTI, and their results were then reviewed. Results There were 407 children admitted with bronchiolitis during the study period. Two-thirds of them were investigated for UTI. Only 2.6% of the patients tested positive for urine culture, and only 0.96% were found to have a true UTI. Conclusion The prevalence of UTI in children with bronchiolitis is too low to justify routine screening. Therefore, only children with a high risk of having UTI should be investigated.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

BACKGROUND AND OBJECTIVES

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics.

METHODS

We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).

RESULTS

In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

CONCLUSIONS

The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Association of Cough Status With Bacterial Infections in Febrile Infants

OBJECTIVES

To examine the association between cough status and bacterial infections (BIs) to more accurately stratify risk and predict BIs in febrile infants.

METHODS

A retrospective cohort study was performed by identifying all infants ≤60 days old with temperature ≥38°C at an urban pediatric emergency department from 2014 to 2016. The Rochester Risk model was used to stratify risk. Cough status (with or without) was the main covariate of interest. The primary outcome was a BI, including urinary tract infection, bacteremia, or meningitis. Analyses consisted of descriptive statistics, simple and multiple regression to compare the odds of BI on the basis of cough status, as well as χ² statistics to compare the BI rates among high-risk infants with and without cough.

RESULTS

Of 508 febrile infants ≤60 days old, 46 (9.1%) had a BI, 13 of which were either bacteremia or meningitis. There were no BIs among low-risk infants with a cough. The odds of BI increased progressively, peaking at 14.6 (95% confidence interval: 4.3-49.7) for high-risk infants without a cough. The adjusted odds of BI among infants with cough was 0.47 (95% confidence interval: 0.22-0.99).

CONCLUSIONS

In our findings, an inverse relationship is demonstrated between presence of cough and odds of BI, suggesting that cough status may be a useful marker of viral infections in febrile infants. Considering that detecting cough status is noninvasive, inexpensive, and immediately available, it represents an attractive value-based risk factor to enhance current BI prediction models.

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.

Why Are Children With Bronchiolitis At Risk Of Urinary Tract Infections?

Viral respiratory infections are frequently eliminated from human bodies without any sequelae. Secondary serious bacterial infection (SBI) in children with acute bronchiolitis has been an apprehension expressed by health care providers. Several published studies have shown an association between acute bronchiolitis and secondary bacterial infection, including urinary tract infections (UTI). However, the proposed mechanism by which a virus can induce UTIs is not yet known. The aim of this commentary is to update the current evidence of risk of UTI in children with bronchiolitis. We present several clinical studies related to the topic as well as a brief review of the potential pathophysiology of secondary infections that could present with viral respiratory illness.

Antibiotic Treatment in Patients with Bronchiolitis

This study seeks to define the indications and the economic impact of the use of antibiotics in infants hospitalized due to bronchiolitis during 2010-2017. There were 459 children with bronchiolitis, median age of 2.2 months, 390 infections with respiratory syncytial virus (RSV), and 69 were non-RSV. Twenty two percent of all these children (102/459) required a workup toward urinary tract co-infections (UTI). A control group, consisting of 8,456 children without bronchiolitis, was created to assess UTI frequency in the general population. We found that 16.0% (73/459) children with bronchiolitis received antibiotics; 63 (13.7%) due to respiratory infection and 9 due to UTI. A time-trend analysis showed a decreasing use of antibiotics, from 57.0% in 2010 to 13.7% in 2017, with the lowest value of 6.4% noticed in 2014. Children treated with antibiotics required a 4-day longer hospitalization than those untreated (p < 0.01), but there were no other clinically relevant differences. After excluding the first 2 years with the highest antibiotic ordering, antibiotics, on average, were used in 9.8% of children with bronchiolitis. Frequency of UTI accompanying bronchiolitis was comparable to that in the control group (8.9% vs. 10.9%, respectively). Specificity of urine culture was 71%, with 100% sensitivity assumed, while the positive predicted value of only 41%. The unnecessary costs of urine cultures, if performed in each patient, would have been €2,236, and with additional laboratory tests in each case of a false positive result it would have reached €5,448. We conclude that antibiotics should be used for bronchiolitis only in justified cases, and their use should not exceed 10% of patients. Since UTI is no more frequent in bronchiolitis than in the general children's population, urine cultures should not be performed routinely.

Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis

IMPORTANCE

Concomitant urinary tract infection (UTI) is a frequent concern in febrile infants with bronchiolitis, with a prior meta-analysis suggesting a prevalence of 3.3%. However, the definition of UTI in these studies has generally not incorporated urinalysis (UA) results.

OBJECTIVE

To conduct a systematic review and meta-analysis examining the prevalence of UTI in infants with bronchiolitis when positive UA results are incorporated into the UTI definition.

DATA SOURCES

Medline (1946-2017) and Ovid EMBASE (1976-2017) through August 2017 and bibliographies of retrieved articles.

STUDY SELECTION

Studies reporting UTI prevalence in bronchiolitis.

DATA EXTRACTION

Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines via independent abstraction by multiple investigators. Random-effects models generated a weighted pooled event rate with corresponding 95% confidence intervals.

MAIN OUTCOMES AND MEASURES

Prevalence of UTI.

RESULTS

We screened 477 unique articles by abstract, with full-text review of 30 studies. Eighteen bronchiolitis studies reported a UTI prevalence and 7 of these reported UA data for inclusion in the meta-analysis. The overall reported prevalence of UTI in bronchiolitis from these 18 studies was 3.1% (95% CI, 1.8%-4.6%). With the addition of positive UA results (defined as the presence of pyuria or nitrites) as a diagnostic criterion, the prevalence of UTI as reported in the 7 studies in bronchiolitis was 0.8% (95% CI, 0.3%-1.4%). Sensitivity analyses yielded similar results, including for infants younger than 90 days. Heterogeneous definitions of UTI and UA criteria introduced uncertainty into prevalence estimates.

CONCLUSIONS AND RELEVANCE

When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for bronchiolitis.

Associations of Neighborhood-Level Social Determinants of Health with Bacterial Infections in Young, Febrile Infants

OBJECTIVE

To examine the sociodemographic characteristics of one population of young, febrile infants and identify associations between neighborhood-level social determinants of health (SDHs) with bacterial infections.

STUDY DESIGN

This was a retrospective cross sectional study of all infants ≤90 days old with a temperature of ≥38°C who presented in 2014 to the emergency department of an urban children's hospital in a large east coast city. The primary outcome was the presence of a bacterial infection, defined as a positive urine, blood, or cerebrospinal fluid culture that was treated clinically as a pathogen. The home address of each infant was geocoded and linked to neighborhood data based on census tract. Neighborhood-level SDHs included deprivation index, median household income, poverty, childhood poverty, social capital, and crowded housing. Associations were estimated using generalized estimating equations and negative binomial regression analysis. Models were adjusted for age, prematurity, and race/ethnicity.

RESULTS

Of 232 febrile infants, the median age was 54 days, 58% were male, 49% were Hispanic, and 88% had public health insurance; 31 infants (13.4%) had a bacterial infection. In the adjusted analyses, the risk of bacterial infection among infants from neighborhoods with high rates of childhood poverty was >3 times higher (relative risk, 3.16; 95% CI, 1.04-9.6) compared with infants from neighborhoods with low rates of childhood poverty.

CONCLUSIONS

Our findings suggest that SDHs may be associated with bacterial infections in young, febrile infants. If confirmed in subsequent studies, the inclusion of SDHs in predictive tools may improve accuracy in detecting bacterial infections among young, febrile infants.

Overview of prevention and management of acute bronchiolitis due to respiratory syncytial virus

INTRODUCTION

Respiratory Syncytial Virus (RSV) is the most common cause of Acute Bronchiolitis (AVB) in infants. AVB causes significant morbidity and mortality worldwide, most deaths occurring in the developing world. AVB causes respiratory distress in infants, leading to respiratory failure in some cases. Disease is more severe in infants with risk factors, such as prematurity, chronic cardiac and lung disease and immunodeficiency. Areas covered: Despite major advances in supportive care in the developed world, which has led to a significant reduction in mortality, treatment remains symptomatic and supportive. No specific antiviral treatment has yet proven to be effective. Prevention of disease with monoclonal antibodies has proven to reduce illness severity in those with risk factors, however, this is prohibitively expensive, particularly for the developing world. Prospects for vaccine development are improving. However, because most disease is in young infants, maternal immunization is necessary. However, due to the transient nature of RSV immunity and the circulation of multiple subtypes, vaccines proven to be effective in adult challenge models have yet to be translated to protection in infants. Expert commentary: Despite advances in preventative treatments, adherence to evidence-based guidelines provides the best prospect for successful reduction in morbidity and mortality.

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.

Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months With Bronchiolitis

OBJECTIVES

The aims of the study were to investigate whether the prevalence of urinary tract infections (UTIs) in febrile infants aged 2 to 12 months with bronchiolitis is higher than the presumed prevalence of asymptomatic bacteriuria (1%) in similarly aged patients and thus to determine whether UTI testing is necessary for these patients.

METHODS

This was a prospective cohort study in which we enrolled a convenience sample of febrile infants aged 2 to 12 months with a clinical diagnosis of bronchiolitis. All patients were seen in the emergency department at a large children's hospital between November 1, 2011 and April 15, 2012, had reported or documented fever higher than 38°C, and had urine collected for determination of the presence of UTI. After the conclusion of enrollment, a chart review was conducted to assess missed cases.

RESULTS

Positive urine cultures were found in 6/90 (6.7%) patients (confidence interval, 2.5%-13.9%). The positive urine cultures and urinalysis results were found in 4/90 (4.5%) patients (confidence interval, 1.2%-11%).

CONCLUSIONS

In our patient population, a significant proportion of infants aged 2 to 12 months who present with bronchiolitis and fever have a concurrent UTI. Obtaining a urine specimen for UTI testing should be considered in infants aged 2 to 12 months with bronchiolitis and fever. A larger multicenter study is needed to further assess the risk factors for UTIs in this patient population.

Virus-induced secondary bacterial infection: a concise review

Respiratory diseases are a very common source of morbidity and mortality among children. Health care providers often face a dilemma when encountering a febrile infant or child with respiratory tract infection. The reason expressed by many clinicians is the trouble to confirm whether the fever is caused by a virus or a bacterium. The aim of this review is to update the current evidence on the virus-induced bacterial infection. We present several clinical as well in vitro studies that support the correlation between virus and secondary bacterial infections. In addition, we discuss the pathophysiology and prevention modes of the virus–bacterium coexistence. A search of the PubMed and MEDLINE databases was carried out for published articles covering bacterial infections associated with respiratory viruses. This review should provide clinicians with a comprehensive idea of the range of bacterial and viral coinfections or secondary infections that could present with viral respiratory illness.

Risk of urinary tract infection in infants and children with acute bronchiolitis

OBJECTIVES:

To estimate the prevalence of urinary tract infection in infants and children with bronchiolitis.

METHODS:

A retrospective cross-sectional study involving patients zero to 24 months of age who were hospitalized with acute bronchiolitis was conducted.

RESULTS:

A total of 835 paediatric patients with acute bronchiolitis were admitted to the paediatric ward between January 2010 and December 2012. The mean (± SD) age at diagnosis was 3.47±2.99 months. There were 325 (39%) girls and 510 (61%) boys. For the purpose of data analysis, the patient population was divided into three groups: group 1 included children hospitalized with respiratory syncytial virus (RSV) bronchiolitis; group 2 included children hospitalized with clinical bronchiolitis with no virus detected; and group 3 included children hospitalized with clinical bronchiolitis due to a respiratory virus other than RSV. Results revealed that urinary tract infection was present in 10% of patients, and was most common in group 3 (13.4%) followed by group 2 (9.7%), and was least common in group 1 (6%) (P=0.030).

CONCLUSIONS:

The possibility of a urinary tract infection should be considered in a febrile child with a diagnosis of bronchiolitis, particularly if the trigger is a respiratory virus other than RSV.

Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

BACKGROUND

Although supportive care is the mainstay management for acute bronchiolitis, non-evidence-based diagnostic testing and medications remain common in emergency departments (EDs).

OBJECTIVE

Our aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED.

METHODS

A cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group.

RESULTS

A total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77-2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33-2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38-2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33-2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21-4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12-10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15-3.26).

CONCLUSIONS

Both EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.

Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age

Bronchiolitis is the most common reason for admission to hospital in the first year of life. There is tremendous variation in the clinical management of this condition across Canada and around the world, including significant use of unnecessary tests and ineffective therapies. This statement pertains to generally healthy children ≤2 years of age with bronchiolitis. The diagnosis of bronchiolitis is based primarily on the history of illness and physical examination findings. Laboratory investigations are generally unhelpful. Bronchiolitis is a self-limiting disease, usually managed with supportive care at home. Groups at high risk for severe disease are described and guidelines for admission to hospital are presented. Evidence for the efficacy of various therapies is discussed and recommendations are made for management. Monitoring requirements and discharge readiness from hospital are also discussed.

Recent advances in the management of acute bronchiolitis

Acute bronchiolitis is characterized by acute wheezing in infants or children and is associated with signs or symptoms of respiratory infection; it is rarely symptomatic in adults and the most common etiologic agent is respiratory syncytial virus (RSV). Usually it does not require investigation, treatment is merely supportive and a conservative approach seems adequate in the majority of children, especially for the youngest ones (<3 months); however, clinical scoring systems have been proposed and admission in hospital should be arranged in case of severe disease or a very young age or important comorbidities. Apnea is a very important aspect of the management of young infants with bronchiolitis. This review focuses on the clinical, radiographic, and pathologic characteristics, as well as the recent advances in management of acute bronchiolitis.

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.

Overuse of bronchodilators and steroids in bronchiolitis of different severity: bronchiolitis-study of variability, appropriateness, and adequacy

BACKGROUND

In the management of acute bronchiolitis there is a generalised use of treatments that have not been shown to be useful or efficacious in clinical studies. The objective of this study was to determine the appropriateness in the treatment of acute bronchiolitis of different severity within different clinical care settings.

METHODS

This is a cross-sectional, descriptive study of 5647 cases of acute bronchiolitis in 91 Spanish hospitals and primary care centres. We classified the appropriateness of the treatments according to the recommendations of a consensus conference.

RESULTS

There was an inappropriate use of treatments in 58.3% of the cases during the acute phase and in 45.4% during the maintenance phase. There was a generalised use of inhaled beta 2 agonists, regardless of the severity of the patients (hospitalised patients 69.3%, emergency care 63.2% and ambulatory 64.1%). Adrenaline was used in 30.1% of hospitalised cases and in 80.2% of intensive care patients. Systemic corticosteroids were not only used in one-third of hospitalised patients but also in 25.8% of ambulatory cases.

CONCLUSIONS

In acute bronchiolitis in Spain there is a wide use of treatments that are not recommended by the available clinical practice guidelines. Beta 2 agonist bronchodilators and corticosteroids are widely used and maintained, regardless of the severity of the patients.

Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project)

Most patients with acute bronchiolitis have a mild course and only require outpatient care. However, some of them have to go to emergency departments, because they have respiratory distress or feeding problems. There, they frequently receive diagnostic and therapeutic procedures. We want to know the variability and appropriateness of these procedures. A cross-sectional study (October 2007 to March 2008) was carried out on 2,430 diagnosed cases of bronchiolitis in hospital emergency departments, which required no hospitalization. An analysis of the appropriateness of the treatments was made in 2,032 cases gathered in ten departments with at least 100 cases, using as criterion the recommendations of a consensus conference. We estimated the adjusted percentages of each department. Most of the bronchiolitis were mild, in spite that they underwent multiple diagnostic and therapeutic procedures. In the acute phase, different treatments were used: inhaled beta 2 agonists (61.4%), antipyretics (17.1%), oral steroids (11.3%), and nebulized adrenaline (9.3%). In the maintenance phase, the most common treatments were: inhaled beta 2 agonists (50.5%), oral steroids (17%), oral beta 2 agonists (14.9%), and antibiotics (6.1%). The 64% of the treatments used in the acute phase and the 55.9% in the maintenance phase were considered inappropriate in the appropriateness analysis; a great heterogeneity among centers was found.

CONCLUSIONS

There are discrepancies between clinical practice and evidence-based management of bronchiolitis in Spanish emergency departments. Inappropriate treatments were used in more than half of patients. The wide variation between centers shows the influence of local prescribing habits and reveals the scope for improvement.

Month-by-month age analysis of the risk for serious bacterial infections in febrile infants with bronchiolitis

OBJECTIVE

This study's aim was to assess the risk of serious bacterial infections (SBI) in each of the first 3 months in hospitalizes febrile infants with bronchiolitis.

PATIENTS AND METHODS

The risk of SBI was compared between hospitalized infant with or without bronchiolitis by age in months.

RESULTS

A total of 1125 febrile infants aged ≤3 months were admitted during the study period, 948 without and 177 with bronchiolitis. The incidence of SBI was significantly lower among infants with bronchiolitis compared with those without (4% vs 12.2%, P < .001). However, within the subgroup of neonates with bronchiolitis aged ≤28 days, the incidence of SBI was 9.7% and was not significantly lower than in neonates without bronchiolitis.

CONCLUSION

The risk of SBI among febrile infants with bronchiolitis is significantly lower compared with febrile infants without bronchiolitis, but only after the neonatal period in which the risk for urinary tract infection was relatively high (9.7%).

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.

Fever

PURPOSE OF REVIEW

The present review presents novel infections and better evidence on current practices related to fever in children.

RECENT FINDINGS

Studies using more accurate diagnostic methods have provided evidence for prevalence of certain diseases, their clinical presentation and anticipated complications. Answers to certain clinical dilemmas related to febrile children in a pediatric office practice have been addressed recently. Some studies have explored current issues like immunization of pregnant women with influenza vaccine and the outbreak investigation of the swine H1N1 influenza.

SUMMARY

Fever still remains the most common reason for visits to the pediatrician or emergency room. Better diagnostic methods; appropriate therapeutic or preventive strategies; and continued surveillance for novel infections have improved outcomes from both an individual and public health perspective.

Bronchiolitis: recent evidence on diagnosis and management

Viral bronchiolitis is a leading cause of acute illness and hospitalization of young children. Research into the variation in treatment and outcomes for bronchiolitis across different settings has led to evidence-based clinical practice guidelines. Ongoing investigation continues to expand this body of evidence. Authors of recent surveillance studies have defined the presence of coinfections with multiple viruses in some cases of bronchiolitis. Underlying comorbidities and young age remain the most important predictors for severe bronchiolitis. Pulse oximetry plays an important role in driving use of health care resources. Evidence-based reviews have suggested a limited role for diagnostic laboratory or radiographic tests in typical cases of bronchiolitis. Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline.

Bronchiolitis

After completing this article, readers should be able to: 1. Recognize the clinical presentation of bronchiolitis. 2. Be aware of the recommendations made in the current American Academy of Pediatrics clinical practice guideline for diagnosis and management of bronchiolitis. 3. Describe the role of laboratory testing in the diagnosis of bronchiolitis. 4. Delineate the efficacy of current therapeutic interventions in the treatment of bronchiolitis. 5. Discuss the evaluation for serious bacterial infections in patients who have bronchiolitis. 6. Outline the prognosis and risk of recurrent wheezing in patients diagnosed with bronchiolitis.

Potential impact of accelerating the primary dose of pneumococcal conjugate vaccine in infants

OBJECTIVE

To estimate the potential effect of the acceleration of administration of the first dose of pneumococcal conjugate vaccine from 2 months to 6 weeks of age.

DESIGN

Prediction model using data from a retrospective cohort study.

SETTING

Published data from 8 states that participated in Active Bacterial Core Surveillance of the Emerging Infections Program Network for pneumococcus before pneumococcal conjugate vaccine introduction (July 1, 1997- June 30, 2000).

PARTICIPANTS

A total of 759 739 live births under surveillance. Intervention Estimating the potential benefit of administration of the first dose of the pneumococcal conjugate vaccine at 6 weeks of age instead of 2 months of age.

MAIN OUTCOME MEASURES

Estimation of reduction in the rate of invasive pneumococcal disease in infants 61 to 90 days of age.

RESULTS

The estimated direct effect of the acceleration of administration of the first dose of pneumococcal conjugate vaccine from 2 months to 6 weeks of age when this vaccine was first introduced could have reduced the burden of invasive pneumococcal disease in infants 61 to 90 days of age by 39.9%, 56.0%, and 72.1% for respective vaccine efficacies of 50%, 70%, and 90%. This translates into preventing an estimated 73, 103, and 133 cases of invasive pneumococcal disease per year among approximately 4 112 052 live births in the United States.

CONCLUSIONS

The acceleration of administration of the pneumococcal conjugate vaccine from 2 months to 6 weeks of age could reduce the burden of invasive pneumococcal disease among infants. This observation may be important when a new conjugate vaccine becomes available, particularly among populations with prevalent invasive pneumococcal disease from a serotype included in the new vaccine.