Review Highlights Testing for Respiratory Tract Infections in Children

Impact of Respiratory Tract Infections

A recent review published in JAMA Pediatrics examines the historical context and current implications of respiratory tract infection (RTI) testing in children. These infections, including conditions such as bronchiolitis, the common cold, and seasonal influenza, place a significant burden on healthcare resources. They result in increased physician and nursing time, emergency department visits, and often lead to unnecessary diagnostic tests and antibiotic prescriptions.

Variability in Clinical Practice

The review indicates a notable variability in testing practices among clinicians, which suggests a potential lack of clarity regarding the value and purpose of respiratory viral testing. It appears that frontline clinicians engage in less critical discussion about when and why to conduct these tests.

Observation on Testing Outcomes

For instance, the review highlights that in 2014, over 2,000 children with respiratory symptoms visited the emergency department at The Hospital for Sick Children in Toronto. Although these children underwent testing before discharge, the results were only available the following day, after they had already left the hospital. This scenario illustrates that the tests did not meaningfully impact the treatment of the children.

Evaluating Diagnostic Test Usefulness

The Choosing Wisely Campaign, an initiative by the American Board of Internal Medicine (ABIM) Foundation, has raised questions about the necessity of many commonly-used diagnostic tests. This campaign aims to improve care quality, reduce waste, and protect patients from potential harm.

Given the frequent unnecessary nature of these tests, it is crucial to consider why they are ordered and how their results contribute to clinical decision-making regarding patient treatment.

Key Questions Addressed in the Review

The review explores several important questions regarding respiratory viral testing:
– Why do we test for respiratory viruses?
– Why should we reconsider ordering the test?
– When is viral testing appropriate?

Reasons for Testing Respiratory Viruses

Testing for respiratory viruses primarily serves to differentiate between viral and bacterial infections, minimize further investigations, and diminish unnecessary antibiotic prescriptions. However, the review found instances where testing led to additional testing, particularly when initial results were negative. Additionally, it noted that testing did not necessarily reduce unnecessary antibiotic use.

Other motivations for conducting tests include:
– Shortening hospital stays
– Assisting in resource management for patients with similar viruses
– Providing prognosis regarding illness duration and severity

The review indicated that previous clinical trials have not demonstrated a reduction in hospital stay length. Furthermore, grouping patients with similar viruses to manage resources may inadvertently spread infections to already vulnerable children, potentially leading to longer hospital stays and complications.

Considerations Before Ordering Tests

As the past decade has expanded the availability and variety of viral diagnostic tests, clinicians must weigh the benefits and limitations of these options. Tests can produce false positives and negatives, with the Centers for Disease Control and Prevention advising clinicians to disregard negative rapid influenza test results in high-suspicion cases. In such situations, further testing is recommended if the result is positive and if bacterial co-infection is suspected.

Moreover, testing requires proper sample collection techniques and can be costly. Clinicians often need to batch samples for analysis, complicating the cost and selection of the appropriate test.

When Is Viral Testing Indicated?

Viral testing is essential in specific circumstances, particularly during pandemics or when certain diseases are widespread. Testing can also influence whether a patient in the emergency department will be discharged or admitted. For patients in intensive care, test results may inform treatment options based on the disease’s cause. Additionally, confirming an influenza infection can significantly alter a patient’s management plan and lead to the discontinuation of antibiotics.

Addressing Diagnostic Uncertainty

It is vital for physicians to be well-informed when making diagnoses. Factors such as a lack of confidence, diagnostic uncertainty, and fear of litigation can contribute to unnecessary testing. The review authors emphasize that medicine requires critical thinking and the integration of patient and family preferences into decision-making, acknowledging that some level of diagnostic uncertainty is always present.

Conclusion and Recommendations

The authors conclude that merely being able to perform a test is not sufficient justification for doing so. Frontline clinicians are encouraged to reconsider the automatic ordering of tests that are costly, uncomfortable for patients and healthcare professionals, and often contribute little to treatment outcomes.

Written by Jessica Gelar, HBSc

References:
Gill PJ, Richardson SE, Ostrow O, Friedman JN. Testing for Respiratory Viruses in Children. JAMA. 2017 July 10.