Source: Sarma V, Dowd MD, Slaughter AJ, et al. Effect of rapid diagnosis of influenzae virus type A on the emergency department management of febrile infants and toddlers. Arch Pediatr Adolesc Med. 2002;156:41–43.One aim of the evaluation of the febrile infant and young child is to distinguish between bacterial and viral illnesses. This is especially dif. cult in winter when rates of influenza infection may reach as high as 10–40% because the symptoms of influenza (fever, cough, and irritability) can raise concerns of bacterial pneumonia, bacteremia, or meningitis. These authors from Children’s Mercy Hospital, Kansas City, Missouri, sought to determine the effect of rapid diagnosis of influenza virus type A (IVTA) on the clinical management of febrile infants and toddlers in a pediatric emergency department (ED). An electronic medical record review over 2 consecutive winter seasons identified 2,772 children 2–24 months old with temperature greater than 39°C who presented to the ED. During the first season (1998–99) the rapid test for IVTA was only available 5 days/week, 8 hours/day, whereas in the 1999–2000 season it was available 24 hours/day, 7 days/week. Of 183 (6.6%) children tested for IVTA, 72 were positive. Two groups of children with positive results were compared: an early diagnosis group whose results were known before discharge from the ED (n=47) and a late group whose diagnosis became available only after discharge from the ED. The groups did not differ significantly for age, triage category, temperature, white blood cell count, chest radiograph performed, mean length of stay in the ED, mean charges, or admission to an inpatient unit. Fewer patients in the early diagnosis group received ceftriaxone (2% versus 24%, P=.006) when compared to those in the late diagnosis group and there were fewer urinalyses (2% versus 24%, P=.006) and complete blood counts performed (17% versus 44%, P=.02). The authors conclude that rapid confirmation of IVTA infection seems to decrease ancillary tests and antibiotic use in febrile infants and toddlers in the ED.While history and physical examination often suffice to differentiate viral from bacterial illness, the uncertainty of “non-specific viral illness” may lead to unnecessary testing and use of antibiotics. In fact, in a recent study 48% of pediatricians surveyed said that parents often pressure them to prescribe unnecessary antibiotics and 34% of them occasionally or more frequently comply with these requests.1 The study abstracted above suggests that if the underlying diagnosis is known early it can modify the patient’s evaluation and management. There are some important limitations to this study. Only a small subset of the 2,772 eligible febrile children were tested at the discretion of the managing physician and the results were analyzed retrospectively. The authors do not report the average time delay for influenza test results in either the early or late groups, or when the influenza test was done relative to other laboratory or radiologic testing. Furthermore, we do not know whether the positive influenza test led to fewer follow-up visits to the primary care provider or the ED, or if any of these patients were subsequently diagnosed with serious bacterial infections.To be sure, many influenza-like illnesses are not due to the influenza virus but, rather, to other respiratory pathogens such as rhinoviruses, respiratory syncytial viruses, parainfl uenza virus, or adenovirus. Moreover, bacterial illness can complicate the course of influenza. However, a rapid test, if positive, can focus further management as we have seen with the wide use and impact of rapid group A streptococcal testing. The availability of a rapid, specific test for influenza at a reasonable cost may eventually lead to less lab testing, radiography, empiric antibiotic use, and hospitalization. One caveat: since the study excluded infants less than 2 months of age, it remains unclear whether a positive IVTA in that age group should limit testing for bacterial illnesses.
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Jan 1, 2006
Aeron Hurt + 1
Open Access
