 |
|
Concurrent Serious Bacterial Infections in 2396 Infants and Children Hospitalized With Respiratory Syncytial Virus Lower Respiratory Tract Infections
Kevin Purcell, MD, PharmD, RPh;
Jaime Fergie, MD
Arch Pediatr Adolesc Med. 2002;156:322-324.
ABSTRACT
| |
Background At Driscoll Children's Hospital (Corpus Christi, Tex), we observed that
most infants and children hospitalized for treatment of respiratory syncytial
virus (RSV) bronchiolitis and/or pneumonia received broad-spectrum intravenous
antibiotics despite having typical RSV signs and symptoms and positive RSV–rapid-antigen
tests on admission. Physicians were concerned about the possibility of concurrent
serious bacterial infections, especially in infants younger than 3 months
and in those with infiltrates present on the chest x-ray films.
Objective To report the frequency of concurrent serious bacterial infections in
infants and children hospitalized for treatment of RSV lower respiratory tract
infections.
Methods The medical records of 2396 infants and children admitted to Driscoll
Children's Hospital with RSV bronchiolitis and/or pneumonia during 7 RSV seasons
from July 1, 1991, through June 30, 1998, were reviewed.
Results There were positive cultures obtained from initial sepsis/meningitis
workups on admission in 39 infants and children (1.6%). Of these, 12 (31%)
were positive blood cultures and 27 (69%) were positive urine cultures. There
were no positive cerebrospinal fluid cultures. All of the positive blood cultures
contained either Staphylococcus epidermidis, Staphylococcus
warneri, or Bacillus species, which are common
contaminants. None of the patients received a standard 10-day course of intravenous
antibiotic therapy. All of the positive urine cultures were typical urinary
tract pathogens. All of the patients were treated.
Conclusions Concurrent serious bacterial infections are rare in infants and children
hospitalized with RSV lower respiratory tract infections and the empiric use
of broad-spectrum intravenous antibiotics is unnecessary in children with
typical signs and symptoms of RSV bronchiolitis.
INTRODUCTION
AT DRISCOLL Children's Hospital, a tertiary care pediatric teaching
hospital in Corpus Christi, Tex, we observed that infants and children hospitalized
for treatment of respiratory syncytial virus (RSV) bronchiolitis and/or pneumonia
usually received broad-spectrum intravenous (IV) antibiotics despite having
typical signs and symptoms of RSV and positive RSV rapid antigen tests on
admission. Once started, antibiotics were almost always continued until discharge.
Since many infants and children had fever at admission in addition to a several-day
history of rhinorrhea, congestion, and wheezing, physicians were concerned
about the possibility of concurrent bacterial infections, especially in infants
younger than 3 months and in those with infiltrates present on chest x-ray
films.
Based on our experience and the literature,1-5
we believed that concurrent serious bacterial infections on admission were
rare in infants and children hospitalized with RSV lower respiratory tract
infections. We also thought that the empiric use of broad-spectrum IV antibiotics
was unnecessary in infants and children with typical signs and symptoms of
RSV bronchiolitis and possibly even detrimental. Hall et al5
showed in a large, prospective study that the treatment of RSV lower respiratory
tract infections with broad-spectrum IV antibiotics actually increased the
risk for bacterial superinfection. These investigators also found that 2.0%
of infants and children hospitalized for treatment of RSV infections had concurrent
serious bacterial infections on admission (types of infections not reported).
Simultaneous infection with RSV and other respiratory pathogens has been documented
by Tristan et al6 and 2 cases of bacterial
pneumonia7-8 have been reported
in infants with bronchiolitis based on positive blood cultures for Streptococcus pneumoniae. Additionally, a case of concomitant Klebsiella pneumoniae sepsis and meningitis has been reported.9 The objective of this study was to report the frequency
of concurrent serious bacterial infections on admission in infants and children
hospitalized for treatment of RSV bronchiolitis and/or pneumonia.
SUBJECTS AND METHODS
As part of a study assessing the effectiveness of a multifaceted academic
detailing program on physician-prescribing of ribavirin and antibiotics, the
medical records of 2396 infants and children admitted to Driscoll Children's
Hospital with RSV lower respiratory tract infections during 7 RSV seasons
from July 1, 1991, through June 30, 1998, were reviewed. Subjects were identified
via a medical records search for International Classification
of Diseases, Ninth Edition (ICD-9) discharge
diagnoses of RSV bronchiolitis or RSV pneumonia. Only medical records of infants
and children with positive RSV rapid antigen tests or nasopharyngeal viral
cultures positive for RSV as recorded in the microbiology section of the laboratory
results were reviewed. Data were collected on age, sex, dates of admission,
lengths of stay, pediatric intensive care unit admissions, ribavirin use,
antibiotic use, initial sepsis/meningitis workup culture results, and presence
of risk factors associated with increased morbidity and mortality as defined
in the 1993 American Academy of Pediatrics guidelines for ribavirin use.
Antibiotic use was defined as the prescribing of a broad-spectrum IV
antibiotic (second- or third-generation cephalosporin) in the admission orders.
Oral antibiotics were not considered. Subsequent physician orders were reviewed
to determine if the IV antibiotic was continued. A sepsis work-up included
blood and urine cultures while a meningitis workup included blood, urine,
and spinal fluid cultures. Only sepsis/meningitis workups done on admission
(the first day of hospitalization) were included. Bacterial infections were
considered to be concurrent if they were present along with RSV infections
at the time of admission and identified through the initial sepsis/meningitis
work-up. This is in distinction to secondary (subsequent) bacterial infections
as identified by Hall et al5 that arose during
hospitalization in association with the treatment of RSV infections with broad-spectrum
IV antibiotics.
Descriptive statistics were performed with Sigmastat statistical software
(SPSS Inc, Chicago, Ill). The institutional review board at Driscoll Children's
Hospital approved this research project.
RESULTS
The mean ± SD age of our patients was 237 ± 251 days.
Almost all of the patients (95.3%) were younger than 2 years, with 79.0% younger
than 1 year, 33.6% younger than 90 days, 11.9% younger than 6 weeks, and 6.1%
younger than 30 days. Most of the patients were boys (59%). The mean ±
SD length of stay was 5.2 ± 5.6 days and 8.3% of the patients were
admitted to the pediatric intensive care unit, with 7.3% requiring mechanical
ventilation. Although most of the patients were otherwise normal and healthy,
10.3% were premature and 17.0% had an underlying disease. The most common
underlying diseases were congenital heart disease (6.3%), bronchopulmonary
dysplasia (4.9%), neurological problems (3.2%), multiple congenital anomalies
(1.4%), and metabolic disorders (0.9%). Broad-spectrum IV antibiotics (second-
or third-generation cephalosporin) were prescribed on admission in 70.5% of
all patients. Once started, antibiotics were continued until discharge 97.0%
of the time. The overall RSV mortality rate was 0.25%.
Positive cultures from the initial sepsis/meningitis work-ups were obtained
on admission in 39 patients (1.6%). Of these, 12 (31%) were positive blood
cultures and 27 (69%) were positive urine cultures. There were no positive
cerebrospinal fluid cultures. All of the positive blood cultures were either Staphylococcus epidermidis, Staphylococcus warneri, or Bacillus species, which are common contaminants. Data were
not collected on whether these patients had clinical evidence of sepsis syndrome.
However, none of the patients received a standard 10-day course of IV antibiotic
therapy for sepsis. All of the positive urine cultures grew only one organism
and 74% (20) occurred in boys. The bacteria isolated were typical urinary
tract pathogens. All of the patients in this study were treated for urinary
tract infections.
COMMENT
In our study, very few infants and children hospitalized with RSV bronchiolitis
and/or pneumonia had concurrent serious bacterial infections. Our results
are consistent with the findings of one large prospective study and several
other smaller retrospective studies. Hall et al5
found that 13 (2%) of 635 infants and children hospitalized for treatment
of RSV lower respiratory tract infections had concurrent bacterial infections
on admission. The types of bacterial infections identified were not reported
for these patients. Liebelt et al1 found no
cases of concurrent serious bacterial infections in 211 infants younger than
90 days with bronchiolitis. Kuppermann et al2
also found no cases of bacteremia in 156 children younger than 2 years with
bronchiolitis. However, 1.9% of these patients had urinary tract infections.
Greenes and Harper3 found a 0.2% rate of bacteremia
in 411 children aged 3 to 36 months with bronchiolitis. One child had a positive
blood culture for S pneumoniae. Antonow et al4 found that 4 (1.5%) of 262 infants younger than 60
days with signs and symptoms typical of bronchiolitis had concurrent serious
bacterial infections. Three infants had urinary tract infections and 1 had
a blood culture positive for S pneumoniae.
The positive blood cultures obtained from the patients in this study
were due to contaminants. This underscores the principle that in a population
with a low incidence of disease, a positive result has an extremely low positive
predictive value. Thus, only 1.1% of the patients in our study may have had
actual concurrent serious bacterial infections on admission. All of the patients
had urine cultures positive for organisms. However, a 1.1% frequency of positive
urine cultures may be explained by asymptomatic bacteriuria and does not necessarily
represent cases of true concomitant urinary tract infections. Wettergren et
al10 found a 0.9% frequency in girls and a
2.5% frequency in boys of bacteriuria during the first year of life. The 1.1%
frequency of bacteriuria in our study patients is consistent with these data.
Hoberman et al11 reported a 3.5% prevalence
of urinary tract infections in febrile infants among those with a possible
source of fever (eg, bronchiolitis, otitis media, etc). The authors concluded
that asymptomatic bacteriuria was an unlikely explanation for all of the positive
urine cultures since the frequency of 3.5% observed was substantially greater
than the mean value reported in symptom-free infants by Wettergren et al.
Although there is a practice guideline for the treatment of infants
and children aged 0 to 36 months with fever without a source,12
there is no guideline that specifically addresses the treatment of febrile
infants and young children with clinical evidence of viral infections. Fever
occurs in 45% to 65% of infants and children hospitalized with RSV lower respiratory
tract infections.13 The cost of performing
sepsis/meningitis work-ups in all of these infants and children, as well as
the discomfort to the child (and stress to the family), is significant. Antonow
et al4 found that 49.6% of infants younger
than 60 days admitted with bronchiolitis underwent sepsis workups. The infants
who underwent sepsis workups had an average total charge of $4507 and a length
of stay of 3.4 days compared with $2998 and 2.8 days for those not undergoing
workups.4 Additionally, the cost of continuing
broad-spectrum IV antibiotics until discharge 97.0% of the time in infants
and children with RSV lower respiratory tract infections, as observed in our
study, can be significant in terms of dollars spent and the potential development
of antibiotic resistance.
This retrospective study has several limitations. The database was assembled
as part of an academic detailing study. Only general patient demographics
and specific data that were needed to assess the outcomes of a multifaceted
academic detailing program were collected. No data were obtained on temperature,
white blood cell count with differential cell count, or chest x-ray film.
Also, data were not collected on the number of infants and children who underwent
sepsis/meningitis workups, only on the number of patients with positive cultures.
However, even though not all of the patients had cultures obtained, it is
unlikely that any other patients had serious bacterial infections, although
some cases of asymptomatic bacteriuria may have been missed. All patients
were observed in the hospital for an average of 5.2 days and review of their
medical records did not reveal any subsequent readmissions for missed bacterial
infections.
Concurrent serious bacterial infections are rare in infants and children
hospitalized with RSV lower respiratory tract infections. Performing all of
these cultures (full sepsis/meningitis workups) on admission in infants and
children with typical signs and symptoms of RSV bronchiolitis and a positive
RSV rapid antigen test, even in the presence of fever, is unnecessary and
adds to the cost, discomfort, and stress of the hospitalization. However,
laboratory testing for bacterial infections should be considered in severely
ill-appearing infants and children with atypical signs and symptoms or clinical
courses due to the small but real possibility of concurrent serious bacterial
infections.
| What This Study Adds
This large study of 2396 children hospitalized during a 7-year period
for treatment of RSV bronchiolitis and/or pneumonia supports previous findings
that concurrent serious bacterial infections are very rare in infants and
children with typical signs and symptoms of RSV lower respiratory tract infections.
|
|
AUTHOR INFORMATION
Accepted for publication December 21, 2001.
This work was presented in part at the 2001 Annual Meeting of the Pediatric
Academic Societies, Baltimore, Md, April 29, 2001.
There was no source of funding for this research project.
Corresponding author and reprints: Jaime Fergie, MD, Driscoll Children's
Hospital, Corpus Christi, TX 78411 (e-mail: fergiej{at}driscollchildrens.org).
From Texas A&M University–Kingsville School of Pharmacy,
Kingsville, Tex (Dr Purcell); Texas A&M University College of Medicine,
College Station (Dr Fergie); and the Driscoll Children's Hospital, Corpus
Christi, Tex (Dr Fergie).
REFERENCES
| |
1. Liebelt EL, Qi K, Harvey K. Diagnostic testing for serious bacterial infections in infants aged
90 days or younger with bronchiolitis. Arch Pediatr Adolesc Med. 1999;153:525-530.
FREE FULL TEXT
2. Kuppermann N, Bank DE, Walton EA, Senac MO, McCaslin I. Risks for bacteremia and urinary tract infections in young febrile
children with bronchiolitis. Arch Pediatr Adolesc Med. 1997;151:1207-1214.
ABSTRACT
3. Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral
syndromes. Pediatr Infect Dis J. 1999;18:258-261.
FULL TEXT
|
ISI
| PUBMED
4. Antonow JA, Hansen K, McKinstry CA, Byington CL. Sepsis evaluations in hospitalized infants with bronchiolitis. Pediatr Infect Dis J. 1998;17:231-236.
FULL TEXT
|
ISI
| PUBMED
5. Hall CB, Powell KR, Schnabel KC, Gala CL, Pincus PH. Risk of secondary bacterial infection in infants hospitalized with
respiratory syncytial virus infection. J Pediatr. 1988;113:266-271.
FULL TEXT
|
ISI
| PUBMED
6. Tristram DA, Miller RW, McMillan JA, Weiner LB. Simultaneous infection with respiratory syncytial virus and other respiratory
pathogens. AJDC. 1988;142:834-836.
7. Baptist EC, Louthain L. Bacteremia in the infant with bronchiolitis. Arch Pediatr Adolesc Med. 1999;153:1309-1310.
FREE FULL TEXT
8. Timmons OD, Yamauchi T, Collins SR, Newbern DG, Sweatt JA, Jacobs RF. Association of respiratory syncytial virus and Streptococcus
pneumoniae infection in young infants. Pediatr Infect Dis J. 1987;6:1134-1135.
ISI
| PUBMED
9. St. Jacques DM, Barton LL, Rhee KH. Risk of serious bacterial infections in infants with bronchiolitis. Arch Pediatr Adolesc Med. 1998;152:819-820.
FREE FULL TEXT
10. Wettergren B, Jodal U, Jonasson G. Epidemiology of bacteriuria during the first year of life. Acta Paediatr Scand. 1985;74:925-933.
ISI
| PUBMED
11. Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr. 1993;123:17-23.
FULL TEXT
|
ISI
| PUBMED
12. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to
36 months of age with fever without source. Pediatrics. 1993;92:1-12.
FREE FULL TEXT
13. Hall CB. Respiratory syncytial virus. In: Feigin RD, Cherry JS, eds. Textbook of Pediatric
Infectious Diseases. 3rd ed. Philadelphia, Pa: Saunders; 1992:1633-1656.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Diagnosis and Management of Bronchiolitis
Subcommittee on Diagnosis and Management of Bronch
Pediatrics 2006;118:1774-1793.
ABSTRACT
| FULL TEXT
High incidence of pulmonary bacterial co-infection in children with severe respiratory syncytial virus (RSV) bronchiolitis
Thorburn et al.
Thorax 2006;61:611-615.
ABSTRACT
| FULL TEXT
Antibiotic treatment of wheezing in children with asthma: what is the practice?
Kozyrskyj et al.
Pediatrics 2006;117:e1104-e1110.
ABSTRACT
| FULL TEXT
Serious Bacterial Infections in Febrile Infants 1 to 90 Days Old With and Without Viral Infections
Byington et al.
Pediatrics 2004;113:1662-1666.
ABSTRACT
| FULL TEXT
Risk of Serious Bacterial Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections
Levine et al.
Pediatrics 2004;113:1728-1734.
ABSTRACT
| FULL TEXT
Bacteraemia and antibiotic use in respiratory syncytial virus infections
Bloomfield et al.
Arch. Dis. Child. 2004;89:363-367.
ABSTRACT
| FULL TEXT
Diagnosis and Testing in Bronchiolitis: A Systematic Review
Bordley et al.
Arch Pediatr Adolesc Med 2004;158:119-126.
ABSTRACT
| FULL TEXT
Prevalence of Serious Bacterial Infections in Febrile Infants With Respiratory Syncytial Virus Infection
Titus and Wright
Pediatrics 2003;112:282-284.
ABSTRACT
| FULL TEXT
The Effect of Rapid Respiratory Viral Diagnostic Testing on Antibiotic Use in a Children's Hospital
Byington et al.
Arch Pediatr Adolesc Med 2002;156:1230-1234.
ABSTRACT
| FULL TEXT
Concurrent Meningitis/Serious Bacterial Infection in an Infant Hospitalized With Respiratory Syncytial Virus
McGregor and Tung
Arch Pediatr Adolesc Med 2002;156:1055-1055.
FULL TEXT
Respiratory Syncytial Virus Infection and the Risk of Serious Bacterial Infections
Kuppermann et al.
Arch Pediatr Adolesc Med 2002;156:1055-1056.
FULL TEXT
|
