Cochrane Review: Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department.

Abstract

BackgroundPediatric acute respiratory infections (ARIs) represent a significant burden on pediatric emergency departments (ED) and families. Most of these illnesses are due to viruses. However, investigations (radiography, blood and urine testing) to rule out bacterial infections and antibiotics are often ordered because of diagnostic uncertainties. This results in prolonged ED visits and unnecessary antibiotic use. The risk of concurrent bacterial infection has been reported to be negligible in children over three months of age with a confirmed viral infection. Rapid viral testing in the ED may alleviate the need for precautionary testing and antibiotic use.ObjectivesTo determine the effect of rapid viral testing in the ED on the rate of precautionary testing, antibiotic use and ED length of visit.Search strategyWe searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 1) which contains the ARI Group's Specialized Register, MEDLINE (1950 to April Week 3 2009), EMBASE (1988 to Week 16, 2009), MEDLINE In‐Process & Other Non‐Indexed Citations (April 27, 2009), HealthStar (1966 to 2009), BIOSIS Previews (1969 to 2009), CAB s (1973 to 2007), CBCA Reference (1970 to 2007), and Proquest Dissertations and Theses (1861 to 2009).Selection criteriaRandomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.Data collection and analysisTwo review authors used the inclusion criteria to select trials, evaluate their quality and extract data. Missing data were obtained from trial authors. Differences in rate of investigations and antibiotics use were expressed as risk ratios (RR) and difference in ED length of visits was expressed as mean difference, with 95% confidence interval (CI).Main resultsFour trials were included, three RCTs and one quazi‐RCT, with 759 children in the rapid viral testing and 829 in the control group. Rapid viral testing did not reduce antibiotic use in the ED significantly, neither clinically nor statistically. We found lower rates of chest radiography (RR 0.77, 95% CI 0.65 to 0.91) in the rapid viral testing group but no effect on length of ED visits, blood or urine testing in the ED.Authors' conclusionsCurrent evidence is insufficient, although promising, to support routine rapid viral testing as a means to reduce antibiotic use in pediatric EDs. Results suggest that rapid viral testing may be beneficial but are not statistically significant due to lack of power. A large trial addressing these outcome measures is needed.Plain Language Summary Does rapid viral testing in the Emergency Department affect the treatment of children with fever and respiratory problems? Children admitted to Emergency Departments (ED) with fever and respiratory symptoms represent a major burden to the health care system, as well as significant anxiety and expense to parents and caregivers. Physicians often order diagnostic tests and may prescribe antibiotics when they are unsure of the cause of the illness and are concerned about the possibility of serious bacterial infection. However, in most cases, fever and respiratory symptoms are caused by viruses. In addition, in children in whom a virus is found to be the cause of their illness, the risk of serious bacterial infection is very low. This review was conducted to assess whether a rapid viral test done in the ED changes what physicians do when treating these children. We found that in previously healthy children coming to the ED with fever and respiratory symptoms, a rapid viral test reduces the use of chest X‐rays and that there is a trend toward less antibiotic usage, and blood and urine investigations. The true impact of this intervention on the latter three outcomes requires trials with larger enrollment numbers.