Audit and cost of treatment modalities provided for respiratory syncytial virus bronchiolitis in a Malaysian teaching hospital.

Abstract

3 August 2001 Dear Editor AUDIT AND COST OF TREATMENT MODALITIES PROVIDED FOR RESPIRATORY SYNCYTIAL VIRUS BRONCHIOLITIS IN A MALAYSIAN TEACHING HOSPITAL Respiratory syncytial virus (RSV) bronchiolitis is an important cause for hospital admission in young children. Very young infants, especially those who had premature births (less than 36 weeks gestation), with chronic lung disease or congenital heart disease are at greatest risk of developing severe RSV disease.1 Despite the extensive amount of research and literature dedicated to RSV, availability of effective therapeutic measures for RSV infection remains elusive. Treatment modalities such as nebulized bronchodilators, antibiotics and corticosteroid therapy are commonly prescribed for RSV bronchiolitis. We determined the treatment modalities provided to 216 children aged younger than 24 months who were admitted consecutively to our unit with a diagnosis of RSV-proven bronchiolitis. An audit was performed by reviewing the clinical profile and treatment modalities provided for these children. Costs incurred for the execution of the treatment modalities were calculated based on the Malaysian ringgit (RM) and expressed in Australian dollars (AU$) [RM 1 = AU$ 0.50]. Treatment and investigations performed were essentially determined at the discretion of the individual attending physician. Nebulized bronchodilators followed by antibiotic therapy were the most commonly prescribed treatment modalities. Children with an underlying illness or who had premature births were more likely to require oxygen supplementation and paediatric intensive care unit (PICU) care than their healthy term counterparts (Table 1); this situation is most likely due to an increased risk of more severe RSV disease in this category of children. None of the children received ribavarin or corticosteroid therapy. The frequent use of nebulized bronchodilator therapy and antibiotics for RSV bronchiolitis in our institution is not an uncommon occurrance.2 It is understandable that clinicians are keen to prescribe nebulized bronchodilator therapy when confronted with a wheezing child, not unlike that seen in bronchial asthma. Antibiotic therapy was empirically prescribed for approximately half of the patients; the deterioration in clinical condition being attributed to a bacterial infection. However, both these treatment modalities are not without potential adverse effects. Nebulized bronchodilator therapy may cause further deterioration and hypoxaemia in acute bronchiolitis,3 and it has been well established that inappropriate use of antibiotics can promote the development of bacterial resistance.4 Furthermore, ineffective and unnecessary treatment modalities are clearly not cost-effective and increase the substantial financial burden that RSV disease poses; an implication that is especially important in developing nations where local socio-economic constraints towards the national health programme remains a primary consideration. There is a need for evidence-based management guidelines in the provision of treatment modalities for RSV bronchiolitis. Children with RSV bronchiolitis should receive treatment that is at least effective and clearly not potentially detrimental. In addition, the implementation of clinical practice guidelines has been shown to be successful in reducing overall treatment costs.5 However, convincing evidence that supports commonly prescribed treatment for RSV bronchiolitis is still lacking, and the debate on the usefulness of nebulized bronchodilator and corticosteroid therapy continues. These factors remain significant obstacles to the development of satisfactory management guidelines for RSV bronchiolitis.