Delayed Diagnosis of Respiratory Syncytial Virus Infections in Hospitalized Adults: Individual Patient Data, Record Review Analysis and Physician Survey in the United States

Abstract

Background: Despite the prevalence of respiratory syncytial virus (RSV) in adults hospitalized with acute respiratory infections, guidelines for the diagnosis and management of RSV have not been established. This analysis evaluated the role and timeliness of RSV diagnostic testing and its potential impact on clinical outcomes.

Methods: We analyzed individual patient data from hospitalized adults with confirmed RSV infections during 2 North American RSV seasons. Participating physicians reported clinical, virologic diagnosis, and outcome variables using a standardized online case form.

Results: Across 32 US states, 132 physicians reported 379 RSV cases. Polymerase chain reaction-based diagnostics were the most common type of test ordered (94.2%) with <5% ordered specifically to diagnose RSV. Most tests (67.6%) were ordered in hospital wards or intensive care units. Overall, 47.4%, 30.9%, and 21.7% of patients had RSV diagnosed <12, 12‒24, and >24 hours after hospital admission, respectively. Later diagnosis was associated with longer hospital stays (n = 145; R = +0.191; P < .05) and greater antibiotic use.

Conclusion: Diagnosis of RSV infection in hospitalized adults is often delayed, which may affect clinical management and outcomes. Our findings indicate the need to improve the diagnostic strategies in this patient population.

Keywords: acute respiratory infection; adult; diagnosis; record review; respiratory syncytial virus.

Figure 1.

Flow of patients with respiratory syncytial virus, risk group classification, and presenting symptoms at time of hospital admission. Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 2.

A, B, Time intervals between hospital admission and test ordering for tests requested in the emergency departments (ED) (A) or in the hospital ward or intensive care unit (ICU) (B), shown according to the 4 risk groups. C‒E, Intervals between test ordering (in hospital wards or ICU) and receipt of respiratory syncytial virus (RSV) result, shown according to the 4 risk groups (C), location of test request (D), and diagnostic methods (E). F, Intervals between admission and receipt of RSV result, shown according to the 4 risk groups. Data are shown as mean values with standard deviations. Abbreviations: ANOVA, analysis of variance; PCR, polymerase chain reaction.

Figure 3.

Regression analysis of length of stay (LOS) in hospitals and time to respiratory syncytial virus (RSV) diagnosis. The interval from admission to RSV diagnosis was reported by only 145 respondents. In addition, patients tested >4 days after admission (because diagnosis after more than half the typical LOS is unlikely to affect LOS) and those who stayed in the hospital for >3 weeks (threshold set 3 standard deviations above the median LOS) were excluded from the analysis (n = 7). Pearson correlation coefficients (R) were calculated based on variance from the best-fit linear regression (simple least-squares linear regression in IBM SPSS Statistics software, version 23). The P value for the relationship between hospital LOS and interval to diagnosis was calculated using 1-way analysis of variance.

Figure 4.

A–C, Relationships between length of hospital stay (LOS) and time intervals from admission (A) and test ordering (B) to receipt of respiratory syncytial virus (RSV) diagnosis and from admission to test ordering (C). D–F, Relationships between rate of antibiotic use and intervals from admission (D) and test ordering (E) to diagnosis and from admission to test ordering (F). Durations of antibiotic treatment are shown at the bottom of the panel. (See Supplementary Materials for detailed description of these time intervals). Abbreviation: SD, standard deviation.

Figure 5.

Rate and duration of antibiotic use in hospitalized patients with respiratory syncytial virus, shown according to the 4 risk groups. Abbreviations: ED, emergency department; ICU, intensive care unit; SD, standard deviation.