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Meta-Analysis
. 2014 Sep 15;2014(9):CD006452.
doi: 10.1002/14651858.CD006452.pub4.

Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department

Quynh Doan  1 , Paul Enarson, Niranjan Kissoon, Terry P Klassen, David W Johnson
Affiliations
Meta-Analysis

Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department

Quynh Doan et al. Cochrane Database Syst Rev. .

Abstract

Background: Pediatric acute respiratory infections (ARIs) represent a significant burden on pediatric Emergency Departments (EDs) 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.

Objectives: To determine if the use of a rapid viral detection test for children with an acute respiratory infection (ARI) in Emergency Departments (EDs) changes patient management and resource use in the ED, compared to not using a rapid viral detection test. We hypothesized that rapid viral testing reduces antibiotic use in the ED as well as reduces the rate of ancillary testing and length of ED visits.

Search methods: We searched CENTRAL (2014, Issue 6), MEDLINE (1950 to July week 1, 2014), MEDLINE In-Process & Other Non-Indexed Citations (15 July 2014), EMBASE.com (1988 to July 2014), HealthStar (1966 to 2009), BIOSIS Previews (1969 to July 2014), CAB Abstracts (1973 to July 2014), CBCA Reference (1970 to 2007) and ProQuest Dissertations and Theses (1861 to 2009).

Selection criteria: Randomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.

Data collection and analysis: Two review authors used the inclusion criteria to select trials, evaluate their quality, and extract data. We obtained missing data from trial authors. We expressed differences in rate of investigations and antibiotic use as risk ratios (RRs), and expressed difference in ED length of visits as mean differences (MDs), with 95% confidence intervals (CIs).

Main results: No new trials were identified in this 2014 update. We included four trials (three RCTs and one quazi-RCT), with 759 children in the rapid viral testing group and 829 in the control group. Three out of the four studies were comparable in terms of young age of participants, with one study increasing the age of inclusion up to five years of age. All studies included either fever or respiratory symptoms as inclusion criteria (two required both, one required fever or respiratory symptoms, and one required only fever). All studies were comparable in terms of exclusion criteria, intervention, and outcome data. In terms of risk of bias, one study failed to utilize a random sequence generator, one study did not comment on completeness of outcome data, and only one of four studies included allocation concealment as part of the study design. None of the studies definitively blinded participants.Rapid viral testing resulted in a trend toward decreased antibiotic use in the ED, but this was not statistically significant. 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, or blood or urine testing in the ED. No study made mention of any adverse effects related to viral testing.

Authors' conclusions: There is insufficient evidence to support routine rapid viral testing to reduce antibiotic use in pediatric EDs. Rapid viral testing may or may not reduce rates of antibiotic use, and other investigations (urine and blood testing); these studies do not provide enough power to resolve this question. However, rapid viral testing does reduce the rate of chest X-rays in the ED. An adequately powered trial with antibiotic use as an outcome is needed.

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Conflict of interest statement

Quynh Doan: none known. Terry Klassen: none known. Paul Enarson: none known. Niranjan Kissoon: none known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Antibiotics use, Outcome 1 Antibiotics prescribed in ED.
1.2
1.2. Analysis
Comparison 1 Antibiotics use, Outcome 2 Sensitivity analysis per risk of bias.
2.1
2.1. Analysis
Comparison 2 ED length of visit, Outcome 1 Mean ED length of visit in minutes.
2.2
2.2. Analysis
Comparison 2 ED length of visit, Outcome 2 Sensitivity analysis per risk of bias.
3.1
3.1. Analysis
Comparison 3 Laboratory investigations, Outcome 1 Blood investigations (cell count and/or cultures).
3.2
3.2. Analysis
Comparison 3 Laboratory investigations, Outcome 2 Urine testing.
3.3
3.3. Analysis
Comparison 3 Laboratory investigations, Outcome 3 Blood investigation: sensitivity analysis per risk of bias.
3.4
3.4. Analysis
Comparison 3 Laboratory investigations, Outcome 4 Urine testing: sensitivity analysis per risk of bias.
4.1
4.1. Analysis
Comparison 4 Chest radiography, Outcome 1 Chest radiography.
4.2
4.2. Analysis
Comparison 4 Chest radiography, Outcome 2 Sensitivity analysis per risk of bias.
5.1
5.1. Analysis
Comparison 5 Visits to physician or ED post ED discharge, Outcome 1 Post ED discharge visit to MD.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Bonner 2003 {published and unpublished data}
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References to studies excluded from this review

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References to other published versions of this review

Doan 2009
    1. Doan Q, Enarson P, Kissoon N, Klassen TP, Johnson DW. Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD006452.pub2] - DOI - PubMed

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