If you haven’t read parts I, II, III, IV or V what are you waiting for? Today’s post will focus on testing in bronchiolitis. And no, I won’t be testing you… Let’s get straight to the content.
Question: Do you need to get a chest X-Ray?
Answer: No
Consider the findings of Schuch et al in Pediatrics, 2007. The authors looked at 265 infants 2 to 23 months with bronchiolitis. They noted that 0.75% (2/265) had an X-Ray inconsistent w/ bronchiolitis. This means that when you’re clinically sure the X-Ray basically ALWAYS looks like bronchiolitis. In addition, they noted that antibiotic use increased from 2.6% to 14.7% in those that had a chest X-Ray done. This is likely do to all of the atelectasis that can be seen on these films. I do not obtain chest X-Rays in patients with clinically obvious bronchiolitis, as this can save money without compromising my diagnostic accuracy.
[divider scroll_text=””]Question: Do you need to do viral testing (PCR, culture, rapid antigen)?
Answer: Not usually
There are some benefits to viral testing in that it can obviate the need for further diagnostic testing (more on this later), help with better defining the disease course (RSV versus human metapneumovirus), assist with cohorting (if your facility does this), and in epidemiological/research initiatives. That being said, viral testing generally does not alter management. In addition the utility of the test varies with disease prevalence As you’d expect, the more bronchiolitis in the community, and the more likely you think a child has it, the more likely your test will be positive. Finally, many of these tests come with a $$$ price tag.
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Question: Do you need to do additional testing on the neonate (<60 or 90 days) with fever?
Answer: Yes, but less than you would if the child didn’t have bronchiolitis
Kuppermann et al from Archives of Pediatrics and Adolescent Medicine, 1997 examined a prospective cohort of 417 patients under 2 years (156 cases with bronchiolitis and fever and 261 controls with fever, but not bronchiolitis). They got blood cultures on all patients, urine cultures on all females, and urine cultures on males less than six months. They found that in the bronchiolitis group there were no cases of bacteremia and a 2% prevalence of UTI. In the control group they noted 2.7% with bacteremia and 13.6% with UTI.
A larger follow up study from Levine et al, Pediatrics, 2004 looked at 1248 febrile infants <60 days of age. They compared the RSV positive with negative groups and noted the following;
RSV + vs RSV –
UTI 5.4% vs 10.1%
Bacteremia 1.1% vs. 2.3%
Meningitis 0% vs. 0.9%
Any SBI 7% vs 12.5%
[divider scroll_text=””]So what do I do?
Serious bacterial infection is less common in febrile infants with bronchiolitis than in those without bronchiolitis. Only the rate of UTI remains high, especially in those less than 2 months of age. In those under 60 days with bronchiolitis and fever I only get a urinalysis and culture (by cath specimen of course). For those over two months I strongly consider testing their urine as well – basing my decision on age, gender, race and height/duration of fever.
See you all next time. Thanks again to Todd Florin, MD, MSCE – I should send him a gift basket.
