Does this Febrile Wheezer Does this Febrile Wheezer Need a Full Septic Work-Need a Full Septic Work-Up? Up?

An evidence-based approach to evaluation of acute febrile bronchiolitis in the ED

Jeff Matte PGY-3 CCFP(EM)

ObjectivesObjectivesReview 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 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 PresentationCase 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? Any Ideas? InfectiousFB AspirationStructural AnomaliesCardiovascular DiseaseMediastinal MassFunctional CausesGenetic CausesAcquired

So What Would You Do? 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?

BronchiolitisBronchiolitis 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? 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

ResultsResults448 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 So How Does This Impact Practice? 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 Methods Blood and Urine C&S – All PatientsCXR - Respiratory SymptomsLP 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 Enrolled Patients 1125 febrile infants aged < 3 months948 (84.3%) with bronchiolitis177 (15.7%) without bronchiolitis

Results 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 So How Does This Impact Practice? 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 management3) SBI frequency◦ In febrile infants with clinically diagnosed

bronchiolitis

Methods – prospective cohort study◦3066 febrile infants < 3 months in 220

practices across USA

Patient Patient CharacteristicCharacteristicss

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 So How Does This Impact Practice? Practice? ConclusionPractioners 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)

LimitationsMay 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 PopulationPatient Population

Mean age 35.5 days33% were < 28 days55% male156 had clinical bronchiolitis

despite RSV status

ResultsResults 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 So How Does This Impact Practice? Practice? ConclusionFebrile 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+

RecommendationsUrine 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

ResultsResultsRadiological 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 So How Does This Impact Practice? Practice? Conclusions/RecommendationsPrev healthy infants with typical

bronchiolitis do not need imagingRisk 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!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.

ReferencesReferences 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

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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: 947-954

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?Questions?