Download Bronchiolitis

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)
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
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.
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.
Any Ideas?
Infectious
 FB Aspiration
 Structural Anomalies
 Cardiovascular Disease
 Mediastinal Mass
 Functional Causes
 Genetic Causes
 Acquired

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?
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!
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.

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
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
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!
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
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
Enrolled Patients



1125 febrile infants aged < 3 months
948 (84.3%) with bronchiolitis
177 (15.7%) without bronchiolitis
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

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 29-90 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%)
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
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
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%)

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)
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

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

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
Patient Population




Mean age 35.5 days
33% were < 28 days
55% male
156 had clinical bronchiolitis despite RSV
status
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%

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)


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
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
Results

Radiological Interpretations
◦
◦
◦
◦
◦

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%)
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
Take Home Messages!

SBI Risk?
◦ 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.
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: 269-270

Yarden-Bilavsky H, Ashkenazi-Hoffnung L, Livini G, Amir J, Bilavsky E. Month-by-month age
analysis of the risk for serious bacterial infections in febrile infants with bronchiolitis. J of
Clinical Pediatr. 2011; 50(11):1052-1056

Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90
days with bronchiolitis. Ach Pediatr Adolesc Med. 2011; 165(10): 951-956

Luginbuhl L, Newman T, Pantell R, Finch S, Wasserman R. Office-based treatment and
outcomes for febrile infants with clinically diagnosed bronchiolitis. J of Pediatr. 2008; 122: 947954

Levine D, Platt S, Dayan P, Macias C, Zorc J, Krief W, Schor J, Bank D, Fefferman N, Shaw K,
Kupperman N. Risk of serious bacterial infection in young febrile infants with respiratory
syncytial virus infections. J of Pediatr. 2004; 113; 1728-1734

Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D, MacPhee S, Mokanski M, Shaikin S,
Dick P. Evaluation of the utility of radiography in acute bronchiolitis. J of Pediatr. 2007; 150:
429-433
Questions?