Rapid Influenza Testing Of Febrile children in the Emergency Department
Date First Published:
February 12, 2007
Last Updated:
April 14, 2010
Report by:
Imran Zakria, StR 3 ED (James Paget University Hospital)
Search checked by:
Jim Crawfurd, James Paget University Hospital
Three-Part Question:
In [febrile children presenting to the ED] does [rapid testing of Influenza virus] alter [subsequent management]?
Clinical Scenario:
A baby is brought in to ED, by concerned parents, with high fever and history of generally being unwell with no clear history pointing towards any clear diagnosis or focus of infection. You wonder whether you need to proceed with a full septic screen, or whether a positive diagnosis of influenza on rapid bedside testing would be sufficient to allow safe discharge directly from the ED.
Search Strategy:
PubMed, with the full 3 part question in addition to search on Cochrane and google.
Search Details:
((children) AND (emergency department)) AND (rapid influenza testing) AND ((Humans[Mesh]) AND ((infant[MeSH] OR child[MeSH] OR adolescent[MeSH])) ) Limited to english literature only
Outcome:
11 articles in total were found, remaining 6 studies were selected, one was a simple review from 2005 but with no systematic/meta-analysis and thus was dropped, 2 articles were dropped, one for age consideration (study included patients up to age of 21 years), another for being incomplete (with pending results) and two others were found to be irrelevant to the clinical question on more detailed inspection. The seven remaining studies were selected for appraisal
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Effect of rapid diagnosis on management of influenza A infections. Noyola DE, Demmler GJ. 2000, USA | 1530 pts, age 1-19 y during two consecutive confirmed influenza seasons at an urban children’s hospital | Retrospective case control study. RIT used to detect influenza A virus. RIT +ve as case control group and -ve as control group. Blood cultures used to confirm the results |
Antibiotic prescription,. Duration of antibiotic treatment | In admitted pts: RIT +ve 43% vs 64% RIT -ve. p-0.04 Discharged pts RIT +ve 20% vs 53% RIT -ve p=0.04. RIT +ve 3.5 vs 5.4 days -ve p=0.03 | Retrospective study<br><br>Relied on electronic database for identifying pts who had RIT, then their medical records, so possible selection bias. Underlying diseases and their severity influencing the investigations not explained.<br><br> |
| Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial. Bonner AB, Monroe KW, Talley LI et al. 2003, USA | 391 pts 2 month to 21 years during one confirmed influenza season at tertiary care urban hospital. Data/results for the sub group of 241 pts aged 2-36 months analysed and available as well. |
Prospective Randomised Control Trial. One group, for which physicians were aware (PA) of RIT results and the other group for which they were unaware (PUA) of results for influenza A and B |
CBC requesting | PA 0% vs 13% PUA (p<0.001) | Single influenza season results. Results not confirmed by blood cultures |
| Blood cultures | PA 0% vs 11% PUA (p<0.001) | ||||
| CXR | PA 7% vs 26% PUA (p=001) | ||||
| Financial costs of investigations | PA $15 vs $92 PUA (p<0.001) | ||||
| Antibiotic usage | PA 7% vs 26% PUA (p<0.001) | ||||
| Length of emergency department stay | PA 25 vs 49 min PUA (p<0.001) | ||||
| Impact of Rapid Viral Testing for Influenza A and B Viruses on Management of Febrile Infants Without Signs of Focal Infection. Benito-Fernández, Javier, Vázquez-Ronco, Miguel A, Morteruel-Aizkuren, Elvira et al. 2006, USA | 206 pts aged 0-36 months during two confirmed seasons at a tertiary care children’s hospital |
Prospective observational study. RIT (influenza A & B) for all febrile pts, grouped by results into RIT +ve and RIT eve groups (all pts <3 months old had RIT whether febrile or not |
Blood tests (CBC, CRP, blood cultures) | RIT +ve 33% vs 100% RIT -ve (p <0.01) | No randomisation. No follow up of -ve RIT patients (presumably no follow up of the positives either). No confirmatory tests by viral culture done. |
| Urine analysis | RIT +ve 80% vs 100% RIT -ve (p <0.01) | ||||
| Lumbar puncture | RIT +ve 1.3% vs 21% RIT -ve (p<0.01) | ||||
| CXR | RIT +ve 14% vs 32% RIT -ve (p <0.01) | ||||
| Emergency department stay | RIT +ve 116 vs 192 min RIT -ve (p<0.01) | ||||
| Observation ward admission | RIT +ve 8.3% vs 21% RIT-ve (p<0.01) | ||||
| In-patient admission | RIT +ve 2.3% vs 16.4% RIT -ve (p<0.01) | ||||
| Antibiotic treatment | RIT +ve 0% vs 38% RIT -ve (p<0.01) | ||||
| Accuracy and impact of a point-of-care rapid influenza test in young children with respiratory illnesses. Poehling KA, Zhu Y, Tang YW et al. 2006, USA | 486 pts < 5 years during two consecutive influenza seasons at a university hospital paediatric emergency department | Prospective Randomised Control Trial. TG underwent RIT with results available to the clinician. CG had no RIT. Both groups had formal viral cultures or PCR lab testing for influenza. | Any diagnostic test done | TG 39% vs 52% CT p=0.03 | No follow up. Convenience sample. |
| CXR | TG 23% vs 33% CT p=0.06 | ||||
| Blood count/cultures | TG 10% vs 18% CT p=0.05 | ||||
| Effect of Point-of-care Influenza Testing on Management of Febrile Children Iyer SB, Gerber MA, Pomerantz WJ et al. 2006, USA | 700 pts 2-24 months during 2 influenza seasons at an urban tertiary care hospital |
Prospective Quasi- Randomised Control Trial Intervention group (POCT) underwent RIT for influenza with available results. CG (ST): no RIT results available |
Blood cultures | Reduction in POCT by 22.6% p=0.05 | Convenience sample. Pneumococcus immunisation status & its effects on pts not considered. No follow-up |
| Urine analysis | OR 0.45 vs 0.67 p=0.002 | ||||
| Urine culture | OR 0.46 vs 0.67 p=0.005 | ||||
| Impact of rapid influenza testing at triage on management of febrile infants and young children. Abanses JC, Dowd MD, Simon SD, et al. 2006, USA | 1007 patients aged 3-36 months during one influenza season at an urban children's hospital emergency department | Prospective randomized controlled trial. Febrile patients were randomised at triage into an intervention group (TT) having RIT for influenza A and B with available results or a non-intervention group (SP) for which the physician decided the need for further testing. | RSV testing | TT 7% vs 18% SP (RR 2.5) | Failure of randomisation in TT group due to their non-adherence to their devised protocol so taken as convenience sample. Single influenza season results. |
| CXR | TT 20% vs 26% SP (RR 1.3) | ||||
| CBC | TT 2.5% vs 29% SP (RR 12) | ||||
| Blood cultures | TT 2.5% vs 31% SP (RR 5.7) | ||||
| Urine analysis | TT 4.9% vs 28% SP (RR 9.2) | ||||
| Emergency department length of stay | TT 156 vs 195 min SP | ||||
| Total medical cost per patient | TT $393 vs $666 SP | ||||
| Effect of rapid diagnosis of influenza virus type a on the emergency department management of febrile infants and toddlers. Sharma V, Dowd MD, Slaughter AJ, et al. 2002, USA | 72 patients aged 2-24 months during two consecutive influenza seasons at an urban children's hospital emergency department. | Retrospective observational study. Influenza A virus detection by RIT in two groups: those who had RIT results available (early detection; ED) and those who had diagnosis after discharge (late detection; LD). | Ceftriaxone use | ED 2% vs 24% LD p=0.006 | Selection bias. Small sample size. Retrospective study relying on electronic database, so some patients could be missed if difference in tests and conditions. <br><br>Physician's discretion to do RIT. |
| CBC performed | ED 17% vs 44% LD p=0.02 | ||||
| Urine analysis performed | ED 2% vs 24% LD p=0.006 |
Author Commentary:
Good evidence (level 1b) is available, confirming that rapid influenza testing, when used appropriately, can be a reliable tool in assessment of febrile children attending Emergency Department and improves efficiency.
However, there appears to still be some reluctance to develop any standardised protocol using rapid influenza testing in routine assessment of febrile children.
However, there appears to still be some reluctance to develop any standardised protocol using rapid influenza testing in routine assessment of febrile children.
Bottom Line:
Rapid Influenza testing can have a significant impact on management of febrile children in the ED, especially at times of high influenza prevalence
References:
- Noyola DE, Demmler GJ.. Effect of rapid diagnosis on management of influenza A infections.
- Bonner AB, Monroe KW, Talley LI et al.. Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial.
- Benito-Fernández, Javier, Vázquez-Ronco, Miguel A, Morteruel-Aizkuren, Elvira et al.. Impact of Rapid Viral Testing for Influenza A and B Viruses on Management of Febrile Infants Without Signs of Focal Infection.
- Poehling KA, Zhu Y, Tang YW et al.. Accuracy and impact of a point-of-care rapid influenza test in young children with respiratory illnesses.
- Iyer SB, Gerber MA, Pomerantz WJ et al.. Effect of Point-of-care Influenza Testing on Management of Febrile Children
- Abanses JC, Dowd MD, Simon SD, et al.. Impact of rapid influenza testing at triage on management of febrile infants and young children.
- Sharma V, Dowd MD, Slaughter AJ, et al.. Effect of rapid diagnosis of influenza virus type a on the emergency department management of febrile infants and toddlers.