Does this Febrile Wheezer

Need a Full Septic WorkUp?

An evidence-based approach to
evaluation of acute febrile
bronchiolitis in the ED
Jeff Matte PGY-3

Objectives
Review

a case presentation on child with

wheeze and discuss ddx and
investigations YOU would do

Discuss

the incidence of SBI in the febrile

child with bronchiolitis

Review

the evidence regarding full septic

work-up for these infants

Discuss

evidence surrounding CXR in

children with clinical bronchiolitis

Case Presentation
45d

M to ED with fever, cough x 48hr.

Progressively

worsening, noted to be working to

breathe today according to mom. More
lethargic today, difficulty with po intake. Began
as rhinorrhea, cough and fever started afterwards.

Breastfeeding

q3hr but amount less then normal.

6 wet diapers since yesterday.

Previously

healthy, born at 39 wks GA via SVD

with no complications pre- or post- natal. Was
discharged home with mom after 48h observation
period, no respiratory interventions needed

Adequate

feeding and weight gain to date,

followed by family MD . No immunizations yet.
NKDA. No medications.

Case Presentation

VS: HR 145, RR 62, O2 96% RA, T38.5C

GEN: moderate indrawing, nasal flaring, no tracheal

tug, some abdominal breathing, no obvious cyanosis,
smiling at you, active, good skin turgor.

HEENT: MMM, post pharynx and TMs mildly

erythematous, small ant cervical LNs bilat, no neck
stiffness, supple fontanelle.

RESP: moderate bilat expiratory wheeze, no crackles,

no rhales, no focal decreases in A/E

CVS: NS1S2 no mm

GI: soft and non-tender, BS present

EXT: cap refill < 2 secs, no edema, warm to touch.

OTHER: No new rash, not mottled, no meningismus.

Any Ideas?
Infectious
FB

Aspiration
Structural Anomalies
Cardiovascular Disease
Mediastinal Mass
Functional Causes
Genetic Causes
Acquired

So What Would You Do?

A)

FSW, Empiric Abx, Admit

B)

FSW, -LP, Empiric Abx, Admit

C)

CBC, UA & C/S, CXR, +/- Abx

D)

CXR only, +/- Abx, Treat and Assess

E)

UA & C/S only, Treat and Assess

F)

No Investigations, Treat and Assess

G)

Other?

Bronchiolitis

Most common LRTI in infants. Most common reason for

pediatric hospital admission in North America.

Diagnosis CLINICAL!!!

When fever occurs in this setting, clinicians have

difficulty determining etiology and subsequent work up.

Concern for concomitant SBI complicating factor.

Unclear if clinical evidence of viral infection
significantly reduces risk of SBIs?

The rate of CXR is variable and performed in 20-89% of

bronchiolitis cases.

Despite high prevalence, little consensus exists in use

of testing and treatment!

Recommendations?
Practice

guidelines recommend lab testing

and empiric abx for selected febrile infants
< 3 mo with no identifiable focus

Guidelines

for febrile bronchiolitis are less

clear, stating antibacterial medications
should be used only in children who have
specific indications of the co-existence of
a bacterial infection.

Sepsis

evaluation prolongs stay and

increases costs and is not without
complications.

Objective

assess prospectively the

frequency of concurrent SBI in febrile infants
< 3 months of age with or without
bronchiolitis

Methods

CBC, blood/urine cultures, CXR

obtained on all patients, CSF on selected

Results
448

infants enrolled

136 (30.4%) had bronchiolitis

312 (69.6%) no bronchiolitis
RSV+ in 82 (60.3%) of the bronchiolitis group

SBI

detected in 30/312 (9.6%) without

bronchiolitis
UTI in 25, Urosepsis in 4
Meningitis in 1

SBI

detected in 3/136 (2.2%) with

bronchiolitis
UTI in all 3

So How Does This Impact

Practice?

Summary
Young febrile infants with clinical bronchiolitis are
less likely to have SBI than febrile infants without
bronchiolitis
Those < 3 months of age, clinical findings of
bronchiolitis associated with significantly lower
risk of SBI
No cases of meningitis or bacteremia in
bronchiolitis group
UTI found in 3 (2.2%) in bronchiolitis group and
25 (8%) FUO group
Found rates similar b/w RSV+ and RSVbronchiolitis for SBI
Did not differentiate results based on major
age groups!

Objective
prospectively assess risk of SBI in each of the
first 3 months in hospitalized febrile infants with
bronchiolitis

Methods
compared the risk of SBI b/w hospitalized infants
with or without bronchiolitis by age in months

Methods
Blood and Urine C&S All Patients
CXR - Respiratory Symptoms
LP only if:

ill appearing
age < 6 weeks without bronchiolitis
age < 4 weeks with bronchiolitis
WBC > 15 or Total Neutrophils > 10

Dx

SBI based on growth of cultures

in CSF, blood or urine, or diagnosed
with pneumonia on CXR

Enrolled Patients
1125 febrile infants aged < 3 months
948 (84.3%) with bronchiolitis
177 (15.7%) without bronchiolitis

Results
Incidence

of SBI significantly lower with bronchiolitis

(4%) versus those without (12.2%)
Subgroup of neonates aged < 28 days, incidence was
9.7% and not significantly lower then neonates without

So How Does This Impact

Practice?

Summary
Findings suggest viral illness as likely the source of fever in
ages > 28 days
Concomitant UTI described in 2-10%, depending on age
group; lower but not negligible!
Recommendations
Routine FSW with empiric abx treatment may not be justified
in nontoxic febrile infants < 90 days with bronchiolitis
In < 28 days, recommend obtaining blood and urine cultures
Those 29-90 days, obtaining only urine cultures is more
appropriate
Conclusion
risk of SBI among febrile infants with bronchiolitis is
significantly lower compared with febrile infants without
bronchiolitis, but only after the neonatal period in which the
risk for UTI was relatively high (9.7%)

Objectives goals to describe:

1) frequency of sepsis evaluation and empiric abx
tx
2) clinical predictors of management
3) SBI frequency
In febrile infants with clinically diagnosed
bronchiolitis

Methods prospective cohort study

3066 febrile infants < 3 months in 220 practices
across USA

Patient
Characteristic
s
Those with bronchiolitis
were significantly older
(mean age 8.1 weeks
vs 6.9 weeks)

Physical

exam findings
associated with
bronchiolitis included:
fewer w high fever (<
39)
more who appeared
moderately ill or very ill
trend toward increased
signs of infant distress

Infants with
Bronchiolitis
Less likely to have:

Urine tested (35% vs 56%)

CSF cultures (16% vs 32%)
FSWU (14% vs 28%)

More likely to have:

CXR (55% vs 20%)

RSV (47% vs 6%)
O2 sat monitor (45% vs 7%)
Hospitalization (50% vs
34%)

 No

cases of UTI, bacteremia, meningitis

in any of the febrile infants with cultures
in clinically dx bronchiolitis group

Risk

difference only significant for:

UTI (P = 0.001)
Combined endpoint of bacteremia and
bacterial meningitis combined (P = 0.031)
Any SBI (P < 0.001)

Initial

clinical impression consistent

with final dx of bronchiolitis in 78%
Infiltrates in bronchiolitis commonly
seen, thus, not surprising
pneumonia was final dx in 11%
URTI and AOM frequently occur with
bronchiolitis and not unexpected

So How Does This Impact

Practice?

Conclusion
Practioners less likely to perform FSWU, urine
testing and CSF cultures in clinical bronchiolitis
Among infants with clinical bronchiolitis, none
had SBI
Diagnoses among 2848 infants with fever and
no bronchiolitis included:
Bacterial meningitis (n = 14)
Bacteremia (n = 49)
UTI (n = 167)

Limitations
May have missed cases of SBI in patients with
clinically dx bronchiolitis, as the majority did
not undergo FSWU

Objective

compare SBI risk in febrile RSV+ versus RSV- < 60d

Methods

3 year multicentre prospective cross-sectional

study
All febrile infants < 60d presenting to 8 PEM
RSV determined by NPS
Bronchiolitis defined as wheezing alone or chest
retractions + URTI
Evaluated with blood, urine CSF, stool culture
SBI was any UTI, bacteremia, meningitis or enteritis

Patient Population

Mean age 35.5 days

33% were < 28 days
55% male
156 had clinical bronchiolitis

despite RSV status

Results

All 3 evaluations performed in 1164/1248 (91%)

Overall rate of SBI 11.4%
Meningitis 0.7%
Bacteremia 2%
UTI 9.1%

Pneumonia (not considered SBI) 5.7%

RSV+ less likely to have SBI (7% vs 12.5%) overall, but

subgroup analysis shows SBI rate similar despite RSV status
in < 28d age group
Appreciable rates of UTI (5.4% vs 10.1%)
Infants with clinical bronchiolitis (156) had 7.1% rate of SBIs

So How Does This Impact

Practice?

Conclusion
Febrile infants < 60d and RSV+ lower
risk for SBI then RSVSBI risk remains appreciable in RSV+
mostly due to UTIs
< 28d risk of SBI is substantial and not
altered by RSV+
Recommendations
Urine testing cannot be omitted by the
presence of RSV+ in febrile infants

Objectives

Determine proportion of radiographs

inconsistent with bronchiolitis in children with
typical presentations
Compare rates of intended abx therapy before
and after CXR in bronchiolitis

Methods

Prospective cohort of 265 infants 2-23 mo

All bronchiolitis and all got CXRs in ER
CXR interpreted as one of:
Simple Bronchiolitis airspace dx only
Complex Bronchiolitis airway and airspace dx
Inconsistent Diagnosis lobar consolidation

Results
Radiological

Interpretations

Simple = 246/265 (92.8%)

Complex = 17/265 (6.9%)
Inconsistent = 2/265 (0.75%)
133 CXR needed to identify 1 inconsistent
15 CXR needed to identify 1 complex

Antibiotic

Administration

7 (2.6%) identified for abx pre-radiography

39 (14.7%) received abx post-radiography

Intended

Disposition

Same in pre- and post- radiography in 258/265

(97.4%)

So How Does This Impact

Practice?

Conclusions/Recommendations
Prev healthy infants with typical
bronchiolitis do not need imaging
Risk of airspace disease appears
particularly low in children with
sats > 92% and mild to moderate
distress
More than 5x as many kids
received abx therapy post-XR
compared to pre-XR plan

Take Home Messages!

SBI Risk?
significantly lower risk of SBI with febrile bronchiolitis (2-4%) vs fever
without bronchiolitis (10-12%) especially in 29-90d group
Risk increased by UTI solely (2-10% depending on age group)
No reports (in these studies) of meningitis or bacteremia in bronchiolitis
groups

RSV Testing?
RSV+ lower risk (7%) for SBI then RSV- (12%), but not negligible due to UTI
risk
<28d risk of SBI is substantial and not altered by RSV+ vs RSV In clinical bronchiolitis, RSV status makes little difference in risk for SBI

Septic Work-Up?
< 28 days FSWU (+/- LP) risk of UTI approx 10%
29-90 days - obtaining urine culture is appropriate

CXR?
Prev healthy infants with typical bronchiolitis do not need imaging,
Consider if sats < 92% or severe respiratory distress.

References

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Prospective study of the risk for serious bacterial infection in hospitalized
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Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants

younger than 60 to 90 days with bronchiolitis. Ach Pediatr Adolesc Med.
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Luginbuhl L, Newman T, Pantell R, Finch S, Wasserman R. Office-based

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Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D, MacPhee S,

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Questions?