Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. 890-892 (doi:10.1542/peds.2007-1305)
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COMMENTARY

Health Care Epidemiology Perspective on the October 2006 Recommendations of the Subcommittee on Diagnosis and Management of Bronchiolitis

Jo-Ann S. Harris, MDa, W. Charles Huskins, MDb, Joanne M. Langley, MDc, Jane D. Siegel, MDd for the Pediatric Special Interest Group of the Society for Healthcare Epidemiology of America

a Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas
b Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
c Canadian Center for Vaccinology, IWK Health Center, Halifax, Nova Scotia, Canada
d Department of Pediatrics, University of Texas Southwestern, Dallas, Texas

Abbreviations: PSIG, Pediatric Special Interest Group • RSV, respiratory syncytial virus

The recent evidence-based clinical practice guideline "Diagnosis and Management of Bronchiolitis,"1 developed by the American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis and published in the October 2006 issue of Pediatrics, is a welcome comprehensive and practical tool for assisting clinicians in managing bronchiolitis in young children. In this commentary we present the views of the Pediatric Special Interest Group (PSIG) of the Society for Healthcare Epidemiology of America on several aspects of the guideline related to the management of children who are hospitalized with bronchiolitis. Established in October 2006, the PSIG comprises pediatric infectious-disease physicians and infection-control professionals who have expertise in pediatric health care epidemiology and infection control. The PSIG requests that the American Academy of Pediatrics subcommittee clarify and reconsider its recommendations regarding the target population for the guideline, viral diagnostic testing, and interventions for preventing transmission of respiratory syncytial virus (RSV) and other viral agents that are associated with bronchiolitis, especially in inpatient settings.


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Although it was stated that the guideline applies to the management of bronchiolitis in healthy children, it is important to note that the absence of an identified underlying condition does not necessarily imply that hospitalized children with bronchiolitis are otherwise healthy. Severe bronchiolitis may be an early manifestation of primary immunodeficiency or HIV infection. Therefore, some infants who are presumed to be otherwise "normal" may have a previously undiagnosed medical condition and require additional diagnostic and management interventions (eg, prolonged shedding of RSV or other viruses, which requires an extended period of contact precautions2).


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We agree that bronchiolitis is a clinical diagnosis that is based on history (rhinorrhea, difficulty breathing, cough) and physical examination (tachypnea, crackles, retractions, wheeze). Neither diagnostic imaging nor laboratory tests are needed to recognize this common syndrome. As noted in the guideline, RSV accounts for 50% to 80% of lower respiratory tract illness during the peak of RSV season, but other agents (eg, influenza, human metapneumovirus, adenovirus, parainfluenza virus, bocavirus) can produce an identical clinical pattern, or coinfection may exist.3,4 Although the guideline stated that the need for viral diagnostic testing is not supported by evidence (recommendation 1a), the PSIG offers additional considerations and evidence to support the use of viral diagnostic testing, especially for hospitalized children, for the following purposes:

  1. facilitating appropriate patient placement and cohorting of patients and staff to minimize the risk of transmission of viral agents to other vulnerable patients, which are acknowledged in the guideline as effective control measures;
  2. reducing unnecessary treatment with antibiotics5,6 as recommended in the 12-step Campaign to Reduce Antimicrobial Resistance in Hospitalized Children (www.cdc.gov/drugresistance/healthcare/children/12steps_children.htm), which was developed by the Centers for Disease Control and Prevention, and reducing hospital costs7;
  3. identifying viral agents (influenza) for which effective antiviral therapy is available8;
  4. collecting and reporting of health care–associated (nosocomial) RSV-infection rates, which has been proposed as a quality-of-care performance indicator for inpatient pediatric units and may be required in public reporting systems in the future9;
  5. identifying emerging agents that may cause bronchiolitis and pneumonia in children (eg, human metapneumovirus, bocavirus)3,4;
  6. defining and tracking of epidemiologic trends, including the beginning and end of RSV season during which palivizumab is administered to infants with defined high-risk conditions (note that because the onset of RSV activity can vary among regions and communities and knowledge of RSV activity has implications for management of persons with lower respiratory tract illness in health care settings, including chronic care facilities, the Centers for Disease Control and Prevention recommends that physicians and facilities consult their local laboratory for the latest data on RSV activity10); and
  7. assessing the effectiveness of preventive measures, including administration of palivizumab to patients at high risk, infection-control precautions to prevent transmission within health care facilities, and, in the case of influenza, influenza vaccine and postexposure management of people at high risk.

Although these justifications are particularly relevant for hospitalized children, viral diagnostic testing of children in outpatient settings may be indicated for many of the same reasons, particularly those related to defining and tracking epidemiologic trends.


   INTERVENTIONS FOR PREVENTING TRANSMISSION OF RSV AND OTHER RESPIRATORY VIRUSES IN INPATIENT SETTINGS
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The guideline highlighted appropriately the importance of hand hygiene and the education of health care personnel and family members in preventing patient-to-patient transmission of respiratory viruses. However, it is important to also include in their recommendation 9 the following measures:

  1. In addition to standard precautions, implement contact precautions: wear gowns and gloves for entry into the patient's room.
  2. Implement droplet precautions: wear masks for entry into the patient's room until influenza virus and adenovirus have been ruled out as etiologic agents and as recommended for standard precautions during contact with all patients when splashes or sprays of respiratory secretions may occur.
  3. Monitor adherence of health care personnel to the measures listed above.
  4. Screen visitors and restrict those who show signs and symptoms of respiratory tract infection from contact with patients.
  5. Use single patient rooms when available and cohort patients and/or staff.

These measures are supported by evidence11–16 and are recommended for any patient who presents with a clinical diagnosis of bronchiolitis in the 2007 revision of the Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 200717 and in the 2003 HICPAC guidelines for preventing health care–associated pneumonia.18 These are particularly important preventive interventions, given the considerable medical costs,19 child morbidity,20 and family disruption21 that are associated with RSV and other viral respiratory infections, the substantial mortality rates in immunocompromised patients, higher death rates associated with health care–associated (nosocomial) RSV compared with community-acquired illness,22 and evidence that the rate of hospitalizations for bronchiolitis is increasing.23

In summary, we recommend that this guideline be adopted by health care facilities in collaboration with each facility's health care epidemiologist/infection-control team to ensure patient safety by including the appropriate measures to minimize the risk of health care–associated transmission of RSV and other viral agents associated with bronchiolitis and to address related public health concerns.


   FOOTNOTES
 
Accepted May 2, 2007.

Address correspondence to Jo-Ann S. Harris, MD, Division of Infectious Disease, Pediatric Special Interest Group of the Society for Healthcare Epidemiology of America, Department of Pediatrics, MS 4004, 3901 Rainbow Blvd, Kansas City, KS 66160. E-mail: jharris7{at}kumc.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.


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  1. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118 :1774 –1793[Abstract/Free Full Text]
  2. Hall CB, Powell KR, MacDonald NE, et al. Respiratory syncytial viral infection in children with compromised immune function. N Engl J Med. 1986;315 :77 –81[Abstract]
  3. Nicholson KG, McNally T, Silverman M, Simons P, Stockton JD, Zambon MC. Rates of hospitalization for influenza, respiratory syncytial virus and human metapneumovirus among infants and young children. Vaccine. 2006;24 :102 –108[CrossRef][Web of Science][Medline]
  4. Iwane MK, Edwards KM, Szilagyi PG, et al. Population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children. Pediatrics. 2004;113 :1758 –1764[Abstract/Free Full Text]
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  7. Barenfanger J, Drake C, Leon N, Mueller T, Troutt T. Clinical and financial benefits of rapid detection of respiratory viruses: an outcomes study. J Clin Microbiol. 2000;38 :2824 –2828[Abstract/Free Full Text]
  8. Rothberg MB, Fisher D, Kelly B, Rose DN. Management of influenza symptoms in healthy children: cost-effectiveness of rapid testing and antiviral therapy. Arch Pediatr Adolesc Med. 2005;159 :1055 –1062[Abstract/Free Full Text]
  9. Weinstein RA, Siegel JD, Brennan PJ. Infection-control report cards: securing patient safety. N Engl J Med. 2005;353 :225[Free Full Text]
  10. Centers for Disease Control and Prevention. Brief report: respiratory syncytial virus activity—United States, 2005–2006. MMWR Morb Mortal Wkly Rep. 2006;55 :1277 –1279[Medline]
  11. Hall CB. Nosocomial respiratory syncytial virus infections: the "cold war" has not ended. Clin Infect Dis. 2000;31 :590 –596[CrossRef][Web of Science][Medline]
  12. LeClair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med. 1987;317 :329 –334[Abstract]
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  14. Thorburn K, Kerr S, Taylor N, van Saene HK. RSV outbreak in a pediatric intensive care unit. J Hosp Infect. 2004;57 :194 –201[CrossRef][Web of Science][Medline]
  15. Doherty JA, Brookfield DS, Gray J, McEwan RA. Cohorting of infants with respiratory syncytial virus. J Hosp Infect. 1998;38 :203 –206[CrossRef][Web of Science][Medline]
  16. Madge P, Paton JY, McColl JH, Mackie PL. Prospective controlled study of four infection-control procedures to prevent nosocomial infection with respiratory syncytial virus. Lancet. 1992;340 :1079 –1083[CrossRef][Web of Science][Medline]
  17. Siegel JD, Rhinehart E, Jackson M, Chlarello L; Healthcare Infection Control Practices Advisory Committee. Guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Available at: www.cdc.gov/ncidod/dhqp/gl_isolation.html. Accessed August 21, 2007
  18. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3) :1 –36
  19. Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis hospitalizations in the United States. Pediatrics. 2006;118 :2418 –2423[Abstract/Free Full Text]
  20. Leader S, Kohlhase K. Recent trends in severe respiratory syncytial virus (RSV) among US infants, 1997 to 2000. J Pediatr. 2003;143(5 suppl) :S127 –S132
  21. Leidy NK, Margolis MK, Marcin JP, et al. The impact of severe respiratory syncytial virus on the child, caregiver, and family during hospitalization and recovery. Pediatrics. 2005;115 :1536 –1546[Abstract/Free Full Text]
  22. Langley JM, LeBlanc JC, Wang EE, et al. Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada study. Pediatrics. 1997;100 :943 –946[Abstract/Free Full Text]
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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C. B. Hall and A. S. Lieberthal
Viral Testing and Isolation of Patients With Bronchiolitis
Pediatrics, October 1, 2007; 120(4): 893 - 894.
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