1. Does this Febrile Wheezer Need a Full Septic Work-Up?
An evidence-based approach to evaluation of acute febrile bronchiolitis in the ED
Jeff Matte PGY-3 CCFP(EM)

2. Objectives
Review a case presentation on child with wheeze and discuss ddx and investigations YOU would do
Discuss the incidence of SBI in the febrile child with bronchiolitis
Review the evidence regarding full septic work-up for these infants
Discuss evidence surrounding CXR in children with clinical bronchiolitis

3. Case Presentation 45d M to ED with fever, cough x 48hr.
Progressively worsening, noted to be “working to breathe” today according to mom. More ‘lethargic’ today, difficulty with po intake. Began as rhinorrhea, cough and fever started afterwards.
Breastfeeding q3hr but amount less then normal. 6 wet diapers since yesterday.
Previously healthy, born at 39 wks GA via SVD with no complications pre- or post- natal. Was discharged home with mom after 48h observation period, no respiratory interventions needed
Adequate feeding and weight gain to date, followed by family MD . No immunizations yet. NKDA. No medications.

4. Case Presentation VS: HR 145, RR 62, O2 96% RA, T38.5C
GEN: moderate indrawing, nasal flaring, no tracheal tug, some abdominal breathing, no obvious cyanosis, smiling at you, active, good skin turgor.
HEENT: MMM, post pharynx and TMs mildly erythematous, small ant cervical LNs bilat, no neck stiffness, supple fontanelle.
RESP: moderate bilat expiratory wheeze, no crackles, no rhales, no focal decreases in A/E
CVS: NS1S2 no mm
GI: soft and non-tender, BS present
EXT: cap refill < 2 secs, no edema, warm to touch.
OTHER: No new rash, not mottled, no meningismus.

5. Any Ideas? Infectious FB Aspiration Structural Anomalies
Cardiovascular Disease
Mediastinal Mass
Functional Causes
Genetic Causes
Acquired
Infectious
Viral URTI
bronchiolitis
Asthma/RAD
Laryngotracheobronchitis
Bacterial tracheitis
FB aspiration
- Esophageal or tracheal/bronchial
Structural Anomalies
- trachoebronchial tree (tracheomalacia and bronchomalacia)
-larygneal clefts
-fistulas b/w tracheobronchial tree
-tracheal stenosis/webs
-cystic mass/lesions
CV Disease
-Vascular rings -LV failure or pulmonary venous outflow obstructions
-conditions resulting in pulmonary artery dilation and/or L arterial enlargement
Mediastinal Mass
tumors, thymic lesions, bronchogenic cysts, angiomatous lesions, enlarged lymph nodes
Functional Conditions
-GERD chronic microaspiration significant mucosal edema and inflammation
-swallowing disorder related to neurologic or muscular dysfunction of the pharynx and or larynx can result in weakness and impaired swallowing
Genetic
-CF
Acquired
-BPD respiratory illness in preterm newborns
-BOOP

6. So What Would You Do? A) FSW, Empiric Abx, Admit
B) FSW, -LP, Empiric Abx, Admit
C) CBC, UA & C/S, CXR, +/- Abx
D) CXR only, +/- Abx, Treat and Assess
E) UA & C/S only, Treat and Assess
F) No Investigations, Treat and Assess
G) Other?
Fever without a source SBIs in this age group:
UTI 15%
Bacteremia 1%
Meningitis %
**all recommended workup to include CBC, cath UA and urine culture
Rochester:
-Hx: term, no perinatal abx, no underlying disease, no hospitalize longer then mother
-Exam: well appearing, no evidence of ear, soft tissue or bone infection
-Lab: WBC 5-15, Bands < 1,500, Urine WBC < 10/hpf
Philly:
-Hx: immunocompetent
-Exam: well appearing, normal exam
-Labs: WBC < 15, Band:N ratio < 0.2, urine wbc < 10, CSF < 8, CXR nil
Boston:
-Hx, no imms within last 48h, no abx within last 48h, no dehydration
-Lab: WBC < 20,000, Urine WBC < 10, CSF < 10, CXR nil

7. Bronchiolitis
Most common LRTI in infants. Most common reason for pediatric hospital admission in North America.
Diagnosis CLINICAL!!!
When fever occurs in this setting, clinicians have difficulty determining etiology and subsequent work up.
Concern for concomitant SBI complicating factor. Unclear if clinical evidence of viral infection significantly reduces risk of SBIs?
The rate of CXR is variable and performed in 20-89% of bronchiolitis cases.
Despite high prevalence, little consensus exists in use of testing and treatment!
Affects 20-30% of all infants
Viral bronchiolitis most common reason for pediatric hospital admission in the US (20% of all cause infant hospitalization)
RSV and rhinovirus are most common
-Peak season is Nov to Mar
-Infants typically b/w 2mo to 2 yrs old

8. Recommendations?
Practice guidelines recommend lab testing and empiric abx for selected febrile infants < 3 mo with no identifiable focus
Guidelines for febrile bronchiolitis are less clear, stating “antibacterial medications should be used only in children who have specific indications of the co-existence of a bacterial infection”.
Sepsis evaluation prolongs stay and increases costs and is not without complications.
2008 Pediatrics – Office Setting
-practice guidelines have recommended lab testing and empiric abx tx for selected febrile infants < 3 months of age with no identifiable focus of infection
-guidelines for lab testing and abx tx for infants with bronchilitis are less clear, stating that “antibacterial medications should be used only in children with bronchiolitis who have specific indications of the coexistence of a bacterial infection”
-sepsis evaluation prolongs stay and significantly increases costs for infants hospitalized with bronchiolitis (4)

9. Objective – assess prospectively the frequency of concurrent SBI in febrile infants < 3 months of age with or without bronchiolitis
Methods – CBC, blood/urine cultures, CXR obtained on all patients, CSF on selected
The Pediatric Infectious Disease Journal 2008
Schneider Children's Medical Centre and Sackler Faculty of Medicine in Israel
Prospective study looking at all febrile infants aged < 90d who were hospitalized in general pediatric department over 3 year period
Methods
-included all febrile infants 90d or less who were hospitalized from an ED
-excluded infants with chronic disease (heart, lung, renal), preterm < 32 weeks, abx within 48h of presentation and infants without documented fever (ie by hx only)
-eligible divided into 2 groups (with or without bronchiolitis)
-dx bronchiolitis based on findings of acute wheeze or chest retractions associated with URTI
-NP swabs obtained but not necessary
SBI = Dx UTI, meningitis, or bacteremia based on growth of known pathogen in culture
-all infants got complete lab and radiologic evaluation including blood urine and CXR, abN WBC > 15 or neuts > 10
-LP done if infant was sick, age < 6wks without bronchiolitis, age < 4 wks with bronchiolitis

10. Results 448 infants enrolled
136 (30.4%) had bronchiolitis
312 (69.6%) no bronchiolitis
RSV+ in 82 (60.3%) of the bronchiolitis group
SBI detected in 30/312 (9.6%) without bronchiolitis
UTI in 25, Urosepsis in 4
Meningitis in 1
SBI detected in 3/136 (2.2%) with bronchiolitis
UTI in all 3
Results – SBI detected in 30 of 312 (9.6%) infants without bronchiolitis compared with 3 of 136 (2.2%) infants with bronchiolitis
Conclusion – risk of SBI in febrile infants is significantly lower in the presence of bronchiolitis

11. So How Does This Impact Practice?
Summary
Young febrile infants with clinical bronchiolitis are less likely to have SBI than febrile infants without bronchiolitis
Those < 3 months of age, clinical findings of bronchiolitis associated with significantly lower risk of SBI
No cases of meningitis or bacteremia in bronchiolitis group
UTI found in 3 (2.2%) in bronchiolitis group and 25 (8%) FUO group
Found rates similar b/w RSV+ and RSV- bronchiolitis for SBI
Did not differentiate results based on major age groups!
Discussion
-young febrile infants with clinical bronchiolitis are less likely to have SBI than febrile infants without bronchiolitis (P=0.005)
-the previous studies on SBI in children with bronchiolitis show rates ranging form 1.1% to 7% and in all studies but one, the rate was 3.7% or lower
-results indicate in those < 3 months of age, clinical findings of bronchiolitis are associated with a significant lower risk of a SBI
-no cases of meningitis or bacteremia in the bronchiolitic infants compared with 1 case of meningitis and 4 cases of bacteremia in the infants without bronchiolitis
-UTI was found in 3 (2.2%) infants in bronchiolitis group and 25 (8%) in the nonbronchiolitis group
-the ability oto observe hospitalized infants for clinical deterioration further lowers the risk of missing SBI, even without sepsis evaluation at the time of admission
-together, these findings suggest that routine FSW and abx treatment may not be justified in nontoxic febrile infant < 3 months of age with acute bronchiolitis
-recommend obtaining blood and urine cultures, without empiric abx tx
-paucity of data prior on febrile infants with RSV-negative bronchiolitis; they included patients with RSV neg and RSV unknown bronchiolitis and found that rates were similar to those who were RSV positive, suggesting that a limited evaluation for SBI in febrile infants with “clinical” bronchiolitis may be sufficient
-for the infant < 4 weeks of age, the optimal approach is less clear.
-a prior study demonstrated no difference in the rate of SBI b/w RSV+ and RSV- infants < 28 d old
-this study reported a low overall rate of SBI among a group of patients that included these youngest infants however, it is impossible to make any firm recommendations in management of children < 28 days old b/c of the modest number of patients with bronchiolitis enrolled
AAP Commentary
-growing body of research defining the rate of SBI in infants with bronchiolitis should help limit our patients’ exposure to unneeded procedures and medications
-2006 AAP bronchiolitis CPG recommended antibiotics be used only when specific indications of bacterial co-infection
OVERALL: This study presents evidence that convinced the AAP to withhold antibiotics in febrile patients with RSV bronchiolitis and a normal urinalysis who do not have specific findings for a concurrent bacterial infection

12. Objective
prospectively assess risk of SBI in each of the first 3 months in hospitalized febrile infants with bronchiolitis
Methods
compared the risk of SBI b/w hospitalized infants with or without bronchiolitis by age in months
-Journal of Clinical Pediatrics 2011
-Schneider Children's Medical Centre in Israel
-Study group composed of all febrile infants aged 90 or less who were hospitalized in 2 general pediatric departments of tertiary care pediatric hospitals over a 3 year period
Objective –prospectively assess risk of SBI in each of the first 3 months in hospitalized febrile infants with bronchiolitis
Methods – compared the risk of SBI between hospitalized infants with OR without bronchiolitis by age in months
-prospective observational design
-excluded infants with chronic disease (heart, lung, renal), preterm infants < 32 weeks, and infants who had received antibiotics within 48hours prior to hospitalization
-diagnosis of bronchiolitis based on findings of acute wheezing or chest retractions in association with an URTI
-testing for RSV was done on all, but not necessary for inclusion in the study

13. Methods Blood and Urine C&S – All Patients CXR - Respiratory Symptoms
LP only if:
ill appearing
age < 6 weeks without bronchiolitis
age < 4 weeks with bronchiolitis
WBC > 15 or Total Neutrophils > 10
Dx SBI based on growth of cultures in CSF, blood or urine, or diagnosed with pneumonia on CXR
-all received blood and urine cultures
-CXR done in presence of respiratory symptoms
-LP if ill-appearing , age < 6 weeks without bronchiolitis, , age < 4 weeks with bronchiolitis, abN WBC > 15 or total neutrophiles >10
-Dx SBI based on growth of cultures in CSF, blood or urine, or diagnosis of pneumonia based by radiography

14. Enrolled Patients 1125 febrile infants aged < 3 months
948 (84.3%) with bronchiolitis
177 (15.7%) without bronchiolitis
Table 1 shows the background characteristics in infants according to age and the presence or absence of bronchiolitis
None of the variables were found to be significantly different between the groups

15. Results
Incidence of SBI significantly lower with bronchiolitis (4%) versus those without (12.2%)
Subgroup of neonates aged < 28 days, incidence was 9.7% and not significantly lower then neonates without
Table 2 shows the incidence of SBI in the febrile infant with or without bronchiolitis by age in months
Results Overall:
SBIs detected in 116/948 infants without bronchiolitis (12.2%; UTI in 92, bacteremia with UTI in 7, isolated bacteremia in 8, pneumonia in 9)
SBIs detected in 7/177 infants with bronchilitis (4%; all UTI)
Statistically significant difference P>0.001
NP RSV + in 139/177 (78.5%) of bronchiolitis neonates
Among the 7 children in the bronchiolitis group with UTI, 6 were RSV+ and 1 RSV-
Neonatal Group < 28 days:
-no statistically sig diff was noted b/w infants with or without bronchiolitis in the neonatal age group (9.7 vs 15.7%), P=0.6
29-60 days:
-Those with bronchiolitis had sig lower rate of SBI than those without bronchiolitis (3.2 vs 10%, P=0.03)
61-90 days:
-a trend to less SBI in those with bronchiolitis was noted also for the age group of 61 to 90 days (1.9 vs 11.1%); however, b/c of the low numbers of hospitalized infants in this age group, this difference did not reach significance (P=0.066)
****noteworthy that the only type of SBI identified in infants with bronchiolitis in all age groups was UTI; none had the more invasive types of bacterial infection

16. So How Does This Impact Practice?
Summary
Findings suggest viral illness as likely the source of fever in ages > 28 days
Concomitant UTI described in 2-10%, depending on age group; lower but not negligible!
Recommendations
Routine FSW with empiric abx treatment may not be justified in nontoxic febrile infants < 90 days with bronchiolitis
In < 28 days, recommend obtaining blood and urine cultures
Those days, obtaining only urine cultures is more appropriate
Conclusion
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 UTI was relatively high (9.7%)
Conclusion
-although the findings of clinical bronchiolitis suggest that it is the source of febrile illness, concomitant UTI are described in 2-10%, depending on the age group
-since UTI in neonates can potentially progress to bacteremia, we believe that in hospitalized febrile neonates aged < 28 days with bronchiolitis (in whom according to these results approx 10% will have UTI), a more careful approach is warranted, including obtaining blood and urine cultures with close monitoring
-on the other hand, in older infants with bronchiolitis, considering the fact that the risk of SBI is 2-4% and as invasive SBI are rare, obtaining only urine cultures with careful monitoring, may be sufficient
Keep in mind that while adopting a more permissive approach to infants with bronchiolitis, one should remember that although the risk for UTI is lower then in those with out bronchiolitis, a rate of 2-4% is not negligible, and also there are scarce case reports of infants with bronchiolitis and meningitis or sepsis
Findings suggest:
Routine full-fever evaluation with empiric abx treatment may not be justified in nontoxic febrile infants aged < 90 days with acute bronchiolitis
In the group of neonates aged < 28 days, we recommend obtaining blood and urinary cultures
Those days obtaining only urine cultures is more appropriate
Discussion
-main finding of study is febrile infants age < 3 months with clinical bronchiolitis are significantly less likely to have SBI than febrile infants without bronchiolitis
-however this did not hold true for the youngest group of infants aged < 28 days, as the risk for SBI was relatively high and not stat different (9.7 vs 15.7%)
-the overall rate of SBIs in the infants with bronchiolitis in this study 4% was in agreement with other studies
-also yielded the relatively high incidence of UTI in neonates aged < 28 d with clinical bronchiolitis
-also showed that UTI was the only SBI identified in infants with bronchiolitis, with none having more sever types of infection

17. Objectives – goals to describe:
1) frequency of sepsis evaluation and empiric abx tx
2) clinical predictors of management
3) SBI frequency
In febrile infants with clinically diagnosed bronchiolitis
Methods – prospective cohort study
3066 febrile infants < 3 months in 220 practices across USA
2008 Journal of Pediatrics
Question – among febrile bronchiolitic infants with fever seen in the outpatient office setting, how common is SBI
Outcomes –compared the frequency of sepsis evaluation, parenteral abx tx and SBI in infants with and without clinically diagnosed bronchiolitis
-Predictors of sepsis evaluation and parenteral antibiotic treatment in infants with bronchiolitis were also identified
Conclusion
In office settings, SBI in young infants with fever and clinically diagnosed bronchiolitis is uncommon
-limited testing for bacterial infection seems to be an appropriate management strategy
Translating Best Evidence into Best Care (Pediatrics)
-Notably infants with bronchiolitis were more ill appearing than those wihtout, yet they were only half as likely to be evaluated for sepsis and receive IV abx suggesting that the clincial diagnosis of a viral infection primary predicts the physicians management and comfort level
-in contrast, infants hospitalized with bronchiolitis infection still frequently receive antibiotics and therapies not recommended for bonchiolitis, despite lab confirmation of RSV+
-this difference in management of bronchiolitis in the hospital and office setting may have important implicaitons clinically and economoically
-infants with bronchiolitis in this stuy compared with thosse without bronchiolitis were significally more likely to undergo CXR, O2 measurements, RSV testing and to become hospitalized and require more f/up visits

18. Patient Characteristics
Those with bronchiolitis were significantly older (mean age 8.1 weeks vs 6.9 weeks)
Physical exam findings associated with bronchiolitis included:
fewer w high fever (< 39)
more who appeared ‘moderately ill or very ill’
trend toward increased signs of infant distress
Table 1 – shows pt characteristics and clinical presentation of febrile infants with and without bronchiolitis
-doctors made initial clinical dx of bronchiolitis for 218/3066 infants (7%) and 2848/3066 (93%) without
-182/218 (83.5%) had resp distress, chest findings (wheeze, retractions, rhonchi, rhales, decrease bs, prolonged expiration) or a cough, compared with 337/2848 (12%) without dx of bronchiolitis, which suggests that clinicians appropriately followed the study manual guidelines in making the dx

19. Infants with Bronchiolitis
Less likely to have:
Urine tested (35% vs 56%)
CSF cultures (16% vs 32%)
FSWU (14% vs 28%)
More likely to have:
CXR (55% vs 20%)
RSV (47% vs 6%)
O2 sat monitor (45% vs 7%)
Hospitalization (50% vs 34%)
Table 2 shows the freq and results of lab testing for patients with and without clinically diagnosed bronchiolitis
Pts with bronchiolitis were significantly less likely to have urine testing, CSF fluid cultures and complete sepsis evaluations
-they were sig more likely to have CXR, abN CXR findings, RSV testing, RSV+, o2 sat testing
-there were no differences in rates of CBC, CBC results or rates of Blood Cultures
Table 3 describes the care of febrile infants with and without bronchiolitis
-with bronchiolitis were sig less likely to undergo complete septic eval (14% vs 28%) but more likely to be hospitalized (50% vs 34%)
-abx admin rate did not vary significantly, however bronchiolitis were less likely to receive IV abx (33% vs 45%)

20. Risk difference only significant for:
No cases of UTI, bacteremia, meningitis in any of the febrile infants with cultures in clinically dx bronchiolitis group
Risk difference only significant for:
UTI (P = 0.001)
Combined endpoint of bacteremia and bacterial meningitis combined (P = 0.031)
Any SBI (P < 0.001)
Table 6 outlines the prevalence of SBI in febrile infants with and without bronchiolitis
-there were no cases of UTI, bacteremia or meningitis in any of the infants with cultures in the clinically diagnosed bronchiolitis group (0 of 125 patients)
-risk differences were statistically significant for UTI (P=0.001), bacteremia and bacterial meningitis combined (P=0.031) and any SBI (P < 0.001)
Studies suggest may show an increased incidence of UTIs if all were cultured in the bronchiolitis group

21. URTI and AOM frequently occur with bronchiolitis and not unexpected
Initial clinical impression consistent with final dx of bronchiolitis in 78%
Infiltrates in bronchiolitis commonly seen, thus, not surprising pneumonia was final dx in 11%
URTI and AOM frequently occur with bronchiolitis and not unexpected
Table 7 shows the final primary diagnoses for patients with clinically diagnosed bronchiolitis
-despite the reported low risk of bacterial infections, no consensus exists regarding the care of febrile infants with bronchiolitis who are < 3 months of age
-the AAP guidelines for managmeent of bronchiolitis acknowledge low rates of bacterial infx and recommend limiting abx tx to documented cases of bacterial co-infection, but make no clear recommendations regarding indications for lab testing
-this study shows more likely to tet infants < 28 days, with fever of > 38.5 (high risk groups)

22. So How Does This Impact Practice?
Conclusion
Practioners less likely to perform FSWU, urine testing and CSF cultures in clinical bronchiolitis
Among infants with clinical bronchiolitis, none had SBI
Diagnoses among 2848 infants with fever and no bronchiolitis included:
Bacterial meningitis (n = 14)
Bacteremia (n = 49)
UTI (n = 167)
Limitations
May have missed cases of SBI in patients with clinically dx bronchiolitis, as the majority did not undergo FSWU

23. Objective
compare SBI risk in febrile RSV+ versus RSV- < 60d
Methods
3 year multicentre prospective cross-sectional study
All febrile infants < 60d presenting to 8 PEM
RSV determined by NPS
Bronchiolitis defined as wheezing alone or chest retractions + URTI
Evaluated with blood, urine CSF, stool culture
SBI was any UTI, bacteremia, meningitis or enteritis
Pediatrics 2004
Results – enrolled 1248 pts including 269 (22%) with RSV infection
-overal SBI status could be determined in 1169 (94%) of the 1248 patietns
-rate of BI was 11.4% (133/1169)
-rate of SBIs in RSV+ infants was 7% compared with 12.5% in RSV-
-RSV + had lower rates of bacteremia (1.1%) than RSV – (2.3%)
-No RSV + infants had bacterial meningitis , however, the difference bw the 2 groups with regard to bacteremia and bacterial meningitis did no achieve stat significance
Conclusion
-febrile infants who are < 60 days of age and have RSV infections are at significatly lower risk of SBI than febrile infants without RSV infection
-neverthless, the rate of SBIs particularly as a result of UTI remains appreciable in febrile RSV+ infants

24. Patient Population Mean age 35.5 days 33% were < 28 days 55% male
156 had clinical bronchiolitis despite RSV status
Patient Population
1868 patients eligible, 1248 (67%) of whom were enrolled
Mean age was 35.5d
-33% were 28d or younger, and 55% were male

25. Results All 3 evaluations performed in 1164/1248 (91%)
Overall rate of SBI 11.4%
Meningitis 0.7%
Bacteremia 2%
UTI 9.1%
Pneumonia (not considered SBI) 5.7%
Of the 1248 enrolled infants, LPs were performed in 1164 (93%), blood cultures in1235 (99%) and urine cultures in 1227 (98%)
RSV + infants were less likely to have an SBI compared to the RSV – infants (7% vs 12.5%)
RSV + infants had an appreciable rate of UTI (5.4%) although this rate was sig less than that of RSV-negative infants
RSV + patients had a lower rate of bacteremia than RSV- patients and had no cases of meningitis
However there was no statistical difference bw the 2 groups
The 156 infants with clinical bronchiolitis regardless of RSV status had a 7.1% rate of SBIs (and no bacteremia or meningitis events) versus a 12.5% rate in the 1035 infants without bronchiolitis (not stat sig P=0.07)
In a subgroup analysis comparing SBI rates stratified by age, we found no overall stat difference in rate of SBI or RSV + b/w the younger and older infants
Infants who were < 28 d had an overall SBI rate of 13.3% regardless of RSV status
The overall rate of SBI in the 187 RSV+ patients who were 29-60d was 5.5% all of whom had UTIs and one had bacteremia or meningitis
RSV+ less likely to have SBI (7% vs 12.5%) overall, but subgroup analysis shows SBI rate similar despite RSV status in < 28d age group
Appreciable rates of UTI (5.4% vs 10.1%)
Infants with clinical bronchiolitis (156) had 7.1% rate of SBIs with NO bacteremia or meningitis events versus 12.5% without bronchiolitis (1035)

26. So How Does This Impact Practice?
Conclusion
Febrile infants < 60d and RSV+ lower risk for SBI then RSV-
SBI risk remains appreciable in RSV+ mostly due to UTIs
< 28d risk of SBI is substantial and not altered by RSV+
Recommendations
Urine testing cannot be omitted by the presence of RSV+ in febrile infants
Discussion and Conclusion
Young febrile infants with RSV infections are less liely to have SBIs than who test negative for RSV
The febrile infants with RSV infection however had clinically important rates of Utis and to a lesser extent bacteremia
Thus it seems that one cannot necessariy obviate urine and blood testing in these febrile infants on the basis of RSV status alone
In thiscurrent study, 11.4% of febrile infants overall had SBIs which is consisten with the SBI rate of 5.4% to 12.6% in febrile infants reported in the literature
In older infants, those 29 to 60d of age, RSV-infected patients continue to have a clinically important rate of UTIs
Therefore, urine testing cannot be omitted by the presence of RSV infection in these febrile infants
Additional study of an even larger cohort ineeded

27. Objectives
Determine proportion of radiographs inconsistent with bronchiolitis in children with typical presentations
Compare rates of intended abx therapy before and after CXR in bronchiolitis
Methods
Prospective cohort of 265 infants 2-23 mo
All bronchiolitis and all got CXRs in ER
CXR interpreted as one of:
Simple Bronchiolitis – airspace dx only
Complex Bronchiolitis – airway and airspace dx
Inconsistent Diagnosis – lobar consolidation
2007 Journal of Pediatrics
Hospital for sick children in TO
Objectives – detemrine proportion of radiographs inconsisten with bronchiolitis in children with typical presentation of bronchiolitis and compare rates of intended abx therapy before radiography versus those given antibiotics after cxr
-the main potential benefit of radiography lies in the identification of diagnoses inconsisten with bronchiolitis such as lobar consolidation
Radiography is associated with numerous disadvantages and may be linked to an increased use of abx
-this study investigated the rate of radiographic altenate dx in infants with acute bronchiolitis (primary) and examined the impact of radiography on therapy (secondary)
Study Design – propsectiv cohort stuin PEM of 265 infants aged 2 to 23 months with radiographs showing either airway disease (simple bronchiolitis), airway and airspace disease (complex bronchiolitis) and inconsisten dx (e.g. lobar consolidation)
-all enrolled pts were tx with 2-3 consecutive nebs of 2.5mg/dose ventolin in 2mL NS
Thereafter, all children underwnet CXR

28. Results Radiological Interpretations Antibiotic Administration
Simple = 246/265 (92.8%)
Complex = 17/265 (6.9%)
Inconsistent = 2/265 (0.75%)
133 CXR needed to identify 1 inconsistent
15 CXR needed to identify 1 complex
Antibiotic Administration
7 (2.6%) identified for abx pre-radiography
39 (14.7%) received abx post-radiography
Intended Disposition
Same in pre- and post- radiography in 258/265 (97.4%)
Results – rate of inconsistent radiographs was 2/265 cases (0.75%)
-a total of 246 (92.8%) had simple radiographs and 17 (6.9%) were complex
-to identify 1 inconsistent and 1 complex radiograph requres imaing 133 and 15 children respectively
-of 148 infants with ox sat > 92% and a resp disease assessment score < 10/17, 143 (96.6%) had a simple cxr compared with 102/117 infants (87.2%) with higher scores or lower sats
-7 infants (2.6%) were identified for abx pre-radiograph; 39 infants (14.7%) received abx post-radiograph
-intended disposition (ie discharge vs admission ) was the same pre and post xr in 258/265 cases (97.4%)

29. Children with simple bronchiolitis were significantly less hypoxic and had a lower RDAI (resp distress assessment index) score.

30. So How Does This Impact Practice?
Conclusions/Recommendations
Prev healthy infants with typical bronchiolitis do not need imaging
Risk of airspace disease appears particularly low in children with sats > 92% and mild to moderate distress
More than 5x as many kids received abx therapy post-XR compared to pre-XR plan

31. Take Home Messages! SBI Risk? RSV Testing? Septic Work-Up? CXR?
significantly lower risk of SBI with febrile bronchiolitis (2-4%) vs fever without bronchiolitis (10-12%) especially in 29-90d group
Risk increased by UTI solely (2-10% depending on age group)
No reports (in these studies) of meningitis or bacteremia in bronchiolitis groups
RSV Testing?
RSV+ lower risk (7%) for SBI then RSV- (12%), but not negligible due to UTI risk
<28d risk of SBI is substantial and not altered by RSV+ vs RSV-
In clinical bronchiolitis, RSV status makes little difference in risk for SBI
Septic Work-Up?
< 28 days – FSWU (+/- LP) – risk of UTI approx 10%
29-90 days - obtaining urine culture is appropriate
CXR?
Prev healthy infants with typical bronchiolitis do not need imaging,
Consider if sats < 92% or severe respiratory distress.

32. References
Bilavsky E, Shouval DS, Yarden-Bilavsky H, Fisch N, Ashkenazi S, Amir J. Prospective study of the risk for serious bacterial infection in hospitalized febrile infants with or without bronchiolitis. Pediatr Infect Dis J. 2008; 27:
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33. Questions?