PEDIATRICS Vol. 99 No. 3 March 1997,
p. e7
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Does Ribavirin Impact on the Hospital Course of Children With
Respiratory Syncytial Virus (RSV) Infection? An Analysis Using the
Pediatric Investigators Collaborative Network on Infections in Canada
(PICNIC) RSV Database
Received Feb 23, 1996; accepted May 10, 1996.
,
,,
From the * Winnipeg Children's Hospital and University of
Manitoba, Winnipeg, Manitoba; the Hospital for Sick Children and
University of Toronto, Toronto, Ontario; the § Children's Hospital of
Eastern Ontario and University of Ottawa, Ottawa, Ontario; the
Montreal Children's Hospital, and McGill University, Montreal,
Quebec; ¶ British Columbia Children's Hos- pital and University of
British Columbia, Vancouver, British Columbia; # Centre Hospitalier de
l'Universite Laval, Quebec City, Quebec; ** Izaak Walton Killam
Hospital and Dalhousie University, Halifax, Nova Scotia;
Children's Health Centre and the University of Alberta,
Edmonton, Alberta; and §§ Alberta Children's Hospital, and University
of Calgary, Calgary, Alberta.
Objectives. To determine the relationship between receipt of aerosolized ribavirin and the hospital course of high-risk infants and children with respiratory syncytial virus (RSV) lower respiratory infection (LRI).
Methods. The 1993-1994 Pediatric Investigators
Collaborative Network on Infections in Canada (PICNIC) RSV database
consists of prospectively enrolled children with acute RSV LRI,
admitted to nine Canadian pediatric tertiary care centers. After
excluding cases with compromised immunity and/or nosocomial infection,
subsets with any congenital heart disease (CHD), chronic lung disease (CLD), age 
6 weeks (INFANT), gestation 36 weeks (PREM), or severe disease within 48 hours of admission as shown by an oxygen saturation 90% or an FiO2 requirement of >.35 (EARLY HYPOXIA) were
studied in two ways. First, each risk group subset was analyzed
separately to assess the association between ribavirin receipt and
measures of disease severity including duration of intensive care,
mechanical ventilation, hy- poxia and RSV-attributable hospital
stay. Secondly, ribavirin was added as an independent variable to a
previously described multiple regression model for RSV-attributable
length of hospital stay and two mutually exclusive subsets were
analyzed: 1) previously healthy patients with 
1 of: INFANT, PREM, or
EARLY HY- POXIA; 2) patients with CHD and/or CLD.
Results. Between January 1993 and June 1994, 1425 community-acquired hospitalized cases of RSV LRI were entered into the RSV database. Among these 750 (52.6%) fit into one or more of the defined subsets including 97 CHD, 134 CLD, 213 INFANT, 211 PREM, and 463 EARLY HYPOXIA. The proportion ventilated in each group was 20.6%, 20.9%, 15.5%, 15.2%, and 13.3%, respectively. Across the subsets ribavirin use ranged from 36% to 57% of ventilated patients and 6% to 39% of nonventilated patients. For nonventilated patients in each subset the median RSV-attributable hospital length of stay (RSV-LOS) was 2 to 3 days longer for ribavirin recipients and the duration of hypoxia was significantly increased. Duration of intensive care unit (ICU) stay was also increased for all ribavirin-treated subgroups except those with CHD. In contrast, for ventilated patients, ribavirin therapy was not significantly associated with any of the outcome measures regardless of risk group. In the multiple regression model, ribavirin was significantly associated with a prolonged RSV-LOS both for children with CHD and/or CLD as well as for those whose only risk factors included INFANT, PREM, and/or EARLY HY- POXIA.
Conclusions. These data raise further doubts about the clinical effectiveness of ribavirin in infants and children with risk factors for severe disease. Selection bias, with ribavirin used for sicker children, may have influenced outcome. Nevertheless the long durations of hospitalization, ICU, ventilation, and oxygen supplementation in nonventilated ribavirin recipients stress the need for further randomized trials to assess its efficacy. ribavirin, respiratory syncytial virus, pneumonia, bronchiolitis.
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