linical evaluation of viral acute resiratory tract infections in children resenting to the emergency deartment of a tertiary referral hosital in the Netherlands

Background: The relative incidence and clinical impact of individual respiratory viruses remains unclear among children presenting to the hospital emergency depart ment with acute respiratory tract infection (ARTI). Methods: During two winter periods, respiratory virus real-time multiplex PCR results were evaluated from children (<18 years) presenting to the emergency department of a tertiary referral hospital with ARTI that had been sampled within 48 hours of hospital presentation. In an attempt to identify virus-speciﬁc distinguishing clinical features, single virus infections were correlated with presenting signs and symptoms, clinical ﬁndings and outcomes using multivariate logistic regression. Results: In total, 274 children with ARTI were evaluated and most were aged <3 years (236/274, 86%). PCR detected respiratory viruses in 224/274 (81.8%) children and included 162 (59%) single and 62 (23%) mixed virus infections. Respiratory syncytial virus (RSV) and human rhinovirus (HRV) single virus infections were common among children aged <3 years, but proportional differences compared to older children were only signiﬁcant for RSV (95% CI 1.3–15). Clinical differentiation between viral ARTIs was not possible due to common shared presenting signs and symptoms and the high frequency of mixed viral infections. We observed virus-associated out come differences among children aged <3 years. Oxygen treatment was associated with RSV (OR 3.6) and inversely correlated with FLU (OR 0.05). Treatment with steroids (OR 3.4) or bronchodilators (OR 3.4) was associated with HRV. Severe respiratory complications were associated with HRV (OR 3.5) and inversely correlated with RSV (OR 0.24). Conclusions: Respiratory viruses are frequently detected in young children presenting to the hospital emergency department with ARTI and require PCR diagnosis since presenting signs and symptoms are not discriminant for a type of virus. RSV and HRV bear a high burden of morbidity in the pediatric clinical setting. Study procedure – presenting signs and symptoms. The attending physician recorded signs and symptoms of young children aged <3 years using structured medical records. Presenting signs and symptoms manifesting within 48 hours of hospital presentation of children with RSV, HRV, FLU or Other single virus infections were evaluated. Virus-associated symptoms were compared and included fever >38.5 °C, cough, rhinitis, pharyngitis, wheezing, crepitation, dyspnea or tachypnea. The clinical presence of chest wall retractions, nasal flaring, moaning or labored breathing were used to deﬁne dyspnea World Health Organization clinical diagnostic criteria deﬁned tachypnea among children aged <2 months (≥60 breaths per minute, bpm), aged 2 to 12 months (≥50 bpm) and aged ≥12 months (≥40 bpm). Study procedure – outcomes . The attending physician recorded outcomes of children aged <3 years with RSV, HRV, FLU and Other single virus infections. We evaluated laboratory and pulmonary imaging ﬁndings that were obtained within 96 hours of hospital presentation and adverse outcome manifestations (hospital admission, severe respiratory complications, mortality) that were recorded within ≤7 days of hospital presentation. Laboratory ﬁndings included C-reactive protein (CRP) and white blood cell count (WBC). We evaluated cut-offs that would indicate absence of serious bacterial infections (CRP <35 mg/l; WBC <15 x10 9 /L) [14, 15] . We compared bacteriology results that were obtained by PCR (atypical bacteria) or from routine cultures from non-sterile (urine, sputum) and sterile sites (blood, cerebrospinal fluid). Pulmonary imaging ﬁndings were assessed for signs of LRTI (radiologic presence of alveolar or peribronchial inﬁl-trates, interstitial opacities, and hyperinflation). Supplemental treatments included bronchodilators, steroids, oxygen supplementation and antibiotics. Oxygen supplementation was provided during sustained oxygen saturation ≤92% or during dyspnea with abnormal PCO2 levels. Adverse outcomes included hospital admission, development of severe respiratory complications and all-cause