BRIEF RESEARCH COMMUNICATION |
https://doi.org/10.5005/jp-journals-10081-1439 |
Profile of Children Admitted with Respiratory Syncytial Virus Infections in a Quaternary Care Hospital in Kerala, India
1,2Department of Pediatrics, Aster Medcity, Kochi, Kerala, India
Corresponding Author: Jeeson Unni, Department of Pediatrics, Aster Medcity, Kochi, Kerala, India, Phone: +91 9847245207, e-mail: jeeson1955@gmail.com
Received: 25 April 2024; Accepted: 11 July 2024; Published on: 05 November 2024
ABSTRACT
Aims and background: Respiratory infections are fairly common in pediatric age group, and respiratory syncytial virus (RSV) is a frequently encountered etiological agent. It is known to occur as seasonal outbreaks. This study was conducted to know the profile of the kids admitted with RSV during a probable outbreak in Kerala, India.
Materials and methods: This was a retrospective descriptive study of data from the electronic medical record (EMR) of children admitted from September 1 to October 31, 2023 to one of four pediatric units of our hospital when the institute had a peak in the number of admissions for respiratory illnesses. Data of all children who had been tested with QIAstat respiratory panel and were positive for RSV were analyzed for their clinical presentation, laboratory investigations, and treatment.
Results: An etiological agent was identified in 32 out of 35 cases for whom the viral respiratory panel was tested (91%). RSV was detected in 23 cases. It was more common among infants. Approximately 79% of them had fever, and 21% had respiratory distress. Thrombocytosis and elevated C-reactive protein (CRP) were seen in 21% and 52% of cases, respectively. Around 17% required oxygen via nasal prongs, and 9% required high-flow nasal cannula (HFNC). Only one case with septicemia was treated with antibiotics. All children with RSV infection had an uneventful recovery.
Conclusions: Identification of viral agent during outbreaks of respiratory infections would reduce the unnecessary use of antibiotics and oseltamivir.
Keywords: Clinical profile, Kerala, Outbreak, Respiratory syncytial virus
How to cite this article: M Irshad, Unni J. Profile of Children Admitted with Respiratory Syncytial Virus Infections in a Quaternary Care Hospital in Kerala, India. Pediatr Inf Dis 2024;6(4):131–133.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Respiratory infections account for the major proportion of cases seeking medical attention among the pediatric age group. Children under 5 years of age form the bulk of the caseload, though it is fairly common in school-going children and adolescents as well. It has been estimated that acute respiratory infections account for 30 to 50% of the total pediatric outpatient visits and 20 to 30% of pediatric admissions.1
Usual presentations are with cough, cold, and fever with no or varying degrees of respiratory distress. The vast majority of these infections are caused by viruses, and the commonly implicated etiological agents include respiratory syncytial virus (RSV), rhinovirus, metapneumovirus, influenza, and coronavirus.2 Finding the virus responsible for the symptoms is important as it helps to promptly initiate antiviral therapy in cases like influenza. It also helps to reduce the widespread use of antibiotics, and thereby preventing the emergence of resistant bacterial strains. Identification of viral agent is done by the use of commercially available diagnostic panels using multiplex real-time polymerase chain reaction (RT-PCR) assays.3 The present study was undertaken to identify the profile of children admitted with RSV infection in one of the four pediatric units at our hospital.
MATERIALS AND METHODS
This was a retrospective descriptive study of data from the electronic medical record (EMR) of children admitted from September 1 to October 31, 2023 to one of four pediatric units of our hospital when the institute had a peak in the number of admissions for respiratory illnesses. Children presenting with cough and/or cold with or without fever were considered, and those who agreed to a respiratory viral panel were studied in detail. Virus identification was done from nasopharyngeal swabs using QIAstat respiratory panel. It is a multiplexed nucleic acid RT-PCR test intended for the qualitative detection and differentiation of nucleic acid from multiple respiratory agents. Patient particulars, results of blood works [total counts, C-reactive protein (CRP)], and viral panel tests were tabulated in Excel and analyzed.
RESULTS
During the study period, 45 children were admitted in our unit with cough and cold, and 35 in whom a viral respiratory panel was available were studied in detail. The baseline characteristics of the cases are as follows: 16 of them were boys with a male-to-female ratio of 84. Infants and children from 1 to 5 years accounted for 40% (14) of the cases.
A causative agent was detected in 32 of them, corresponding to a positivity rate of 91%. A single agent was detected in 84% of the cases, while 2 and 3 viruses were detected in 12% and 3% of the cases, respectively (Table 1). Respiratory syncytial virus was detected in 71% of the children. H1N1 and metapneumovirus, each accounted for 12% of the cases. The remaining cases were either rhino/enterovirus or corona NL63 (3%). Among infants, the vast majority of cases were caused by RSV (91%). In children between 1 and 5 years, RSV and H1N1 contributed to 55% and 20% of the cases, respectively.
| Total cases enrolled | 35 |
| Male:female | 84:100 |
| Virus detected in | 32 (91%) |
| Number of viruses detected | |
| Only one virus | 27 (84%) |
| Two viruses | 4 (12%) |
| More than two | 1 (3%) |
| Organism identified | |
| RSV | 23 (71%) |
| H1N1 | 4 (12%) |
| Metapneumovirus | 4 (12%) |
Respiratory syncytial virus was more common among infants (56%) than in older children. Among the 23 children with RSV infection, 20 had it as a monoinfection, while 3 of them had associated H1N1, rhino/enterovirus, or adenovirus in the panel. One case had associated Pseudomonas growth on blood culture. Table 2 contains details of clinical presentation, treatment, and outcome of the 23 RSV cases. 21% of the RSV cases presented with only cough and no associated fever. 30% of them had low oxygen saturation, and 21% had respiratory distress on admission. The vast majority of them (70%) did not require respiratory support, while 17% of them required oxygen via nasal prongs, and 9% of them needed high-flow nasal cannula (HFNC). The child with Pseudomonas bacteremia was on invasive ventilation and was treated with antibiotics. 21% of the RSV cases had thrombocytosis and none had thrombocytopenia. CRP was positive in 52% of the cases, and no treatment-related decisions were made solely based on CRP. Those on HFNC were initially started on oseltamivir empirically, but the drug was discontinued after the panel reported negative for influenza virus. All the cases recovered with appropriate supportive therapy.
| Number of RSV cases | 23 |
| Infants | 13 (56%) |
| Clinical features | |
| Cough | 23 (100%) |
| Fever | 18 (79%) |
| Low oxygen saturation | 7 (30%) |
| Respiratory distress | 5 (21%) |
| Laboratory investigations | |
| Thrombocytosis | 5 (21%) |
| Positive CRP | 12 (52%) |
| Treatment details | |
| Oxygen via nasal prongs | 4 (17%) |
| HFNC | 2 (9%) |
| Mechanical ventilation | 1 (4%) |
| Antibiotics | 1 (4%) |
| Recovery | 23 (100%) |
DISCUSSION
We report a probable epidemic of RSV between September and October 2023 in Kochi. RSV is responsible for a huge proportion of respiratory infections in children, presenting as upper or lower respiratory tract infection, either as upper respiratory illness (URI), bronchiolitis, pneumonia, or croup.4 The commonly affected population is infants between the age group of 2 and 6 months.5
It has been debated that nasopharyngeal colonization may or may not translate into the disease itself. Though this is true, studies have shown nasopharyngeal colonization to be a risk factor for the development of pneumonia. RSV has been isolated in the nasopharynx of children with respiratory tract infection,6-8 and a significant association between nasopharyngeal carriage and viral acute respiratory tract infection (ARTI) has been demonstrated.6
A US-based study estimated that RSV infection results in approximately 1 of 334 hospitalizations, 1 of 38 visits to the emergency department, and 1 of 13 visits to the primary care office each year.9 RSV follows a seasonal trend with more cases reporting during the winter season. Clustering of the cases with properly correlated clinical and demographic profiles can guide the clinician in reaching the diagnosis of RSV.10
In a study conducted in Taiwan, it was found that RSV had 2 to 3 outbreaks in their 13-year database, with cases peaking from February to May and July to August.11 A study in Italy found an increase in RSV cases in 2021 exceeding the median seasonal peak with the involvement of older children.12 In our study, RSV was reported more commonly among infants than older children. In India, studies reported a mean age of 9 months,13,14 while another study reported an even younger mean age of 5 months.14 Boys and girls were equally affected in other studies.15,16 In India, RSV is more common in the winter months,17 and in our study also we found the surge of RSV in the months of September and October.
Cough was present in all the children with RSV, 79% of them had associated fever, and 21% of them presented with respiratory distress, similar to other reports.15 The proportion of children presenting with respiratory distress was higher in other studies that reported respiratory distress in 75%13 and 96%18 of cases resulting in higher rates of assisted and mechanical ventilation.13,19 This can be partly explained by the relatively larger number of children admitted to our hospital due to parental concern, owing to the sudden clustering of cases in the neighborhood. CRP was found to be positive in 52% of the cases in our study. A similar trend was observed in a study in which the elevated levels of CRP were not correlating with bacterial coinfection, suggesting that it was the reason for the high overall rate of antibiotic prescription in a mostly viral disease.20 The decision to add antibiotics was not made by the CRP alone in our study, and only one case with Pseudomonas septicemia that required mechanical ventilation was treated with antibiotics. However, RSV in infants has been reported to be associated with high rates of acute otitis media requiring antibiotic administration,16 unlike in our cohort.
Stopping oseltamivir if the respiratory panel was negative for influenza is recommended by WHO,21 and studies have shown there was no significant difference in terms of length of hospital stay and 30-day, 60-day, and 90-day readmission rates between those who were continued on oseltamivir and those who were stopped.22 Respiratory viral panel, in conjunction with procalcitonin, can lead to a rapid de-escalation of antibiotics and initiation of targeted antiviral therapy.23 Limitations do exist with these tools, and decisions should be made in conjunction with the complete clinical picture.
LIMITATIONS
Only children presenting to the health facility were recruited, only nasopharyngeal aspirate was used to identify the organisms, data from only a single unit from the center were presented, and some organisms were not studied for identification. As the carriage of an organism does not necessarily correlate with the etiology of the pneumonia, noninclusion of simultaneous age-matched controls is also a limitation. The details of vaccines received by children were also not studied.
CONCLUSION
An RSV epidemic would increase admissions for respiratory ailments manifold. Identification of the etiologic agent helps in reducing unnecessary use of antibiotics and oseltamivir during an epidemic.
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