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. 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Evaluation of the utility of radiography in acute bronchiolitis. J of Pediatr. 2007; 150: 429-433 Questions?