key: cord-0703135-48nto2qm
authors: Rao, Suchitra; Lamb, Molly M.; Moss, Angela; Mistry, Rakesh D.; Grice, Kathleen; Ahmed, Wasiu; Santos-Cantu, Daniela; Kitchen, Elizabeth; Patel, Chandni; Ferrari, Ilaria; Dominguez, Samuel R.
title: Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness: A Randomized Clinical Trial
date: 2021-06-04
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.11836
sha: 5f2601fecffcbfa67e7402d2ea630feff49a4e94
doc_id: 703135
cord_uid: 48nto2qm

IMPORTANCE: There is high usage of antibiotics in the emergency department (ED) for children with acute respiratory illnesses. Studies have reported decreased antibiotic use among inpatients with rapid respiratory pathogen (RRP) testing. OBJECTIVE: To determine whether RRP testing leads to decreased antibiotic use and health care use among children with influenzalike illness (ILI) in an ED. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial among children aged 1 month to 18 years presenting to an ED with ILI from December 1, 2018, to November 30, 2019, was conducted. Data were analyzed March 23, 2020, to April 2, 2021. All children received a nasopharyngeal swab for RRP testing and were randomized 1:1 to the intervention group or control group (results not given, routine clinical care). Results were available in 45 minutes. Intention-to-treat analyses and modified intention-to-treat (clinician knows results) analyses were conducted using multivariable Poisson regression. INTERVENTIONS: Rapid respiratory pathogen test results given to clinicians. MAIN OUTCOMES AND MEASURES: Antibiotic prescribing was the primary outcome; influenza antiviral prescribing, ED length of stay, hospital admission, and recurrent health care visits were the secondary outcomes. RESULTS: Among 931 ED visits (intervention group, 452 children group and control group, 456 children after exclusion of those not meeting criteria or protocol violations), a total of 795 RRP test results (85%) were positive. The median age of the children was 2.1 years (interquartile range, 0.9-5.6 years); 509 (56%) were boys. Most children (478 [53%]) were Hispanic, 688 children (76%) received government insurance, and 314 (35%) had a high-risk medical condition. In the intention-to-treat intervention group, children were more likely to receive antibiotics (relative risk [RR], 1.3; 95% CI, 1.0-1.7), with no significant differences in antiviral prescribing, medical visits, and hospitalization. In inverse propensity-weighted modified intention-to-treat analyses, children with test results known were more likely to receive antivirals (RR, 2.6; 95% CI, 1.6-4.5) and be hospitalized (RR, 1.8; 95% CI, 1.4-2.5); there was no significant difference in antibiotic prescribing (RR, 1.1; 95% CI, 0.9-1.4). CONCLUSIONS AND RELEVANCE: The use of RRP testing in the ED for ILI did not decrease antibiotic prescribing in this randomized clinical trial. There is a limited role for RRP pathogen testing in children in this setting. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03756753

Newer molecular-based platforms enable more rapid pathogen detection with enhanced sensitivity and specificity. While some pediatric studies using these newer platforms have demonstrated decreased antibiotic use and hospital length of stay among inpatients, guidance regarding whether patients in an outpatient acute care setting would benefit from point-of-care respiratory testing using important clinical outcomes is lacking in the pediatric population.

To determine the proportion of children with influenza like illness who undergo rapid respiratory panel testing who are prescribed an antibiotic in the intervention group (result of test known to providers) compared with the control group (result not known to providers).

The primary outcome will be the proportion of children with ILI who are prescribed an antibiotic at the ED visit.

Secondary Objectives 1) To compare the proportion of children treated with antivirals, ED length of stay, hospitalization, repeat ED visits, number of healthcare visits, number of tests ordered per visit (chest x-ray, blood cultures, CSF cultures, urine cultures) and relative clinical charge differences between the intervention and control groups. 2) To determine whether results of the rapid point of care test influenced provider decision making in the ED. 3) To determine whether there is patient/family acceptance of the point-of-care respiratory test.

The intervention will be presentation of results of POC respiratory testing to clinical providers.

The RAPID trial is a randomized controlled trial of rapid respiratory viral testing in children presenting to an ED setting with acute respiratory symptoms. The patient cohort will be children aged 1 month to 18 years presenting to the Children's Hospital Colorado (CHCO) ED with influenza like illness (ILI) who are triaged as level 3, 4, or 5 by the Emergency Severity Index (ESI). These children represent the typical pediatric patient population evaluated in an urgent care setting. All eligible participants will undergo a nasopharyngeal swab and point-of-care respiratory viral testing. The intervention will be presentation of results of POC viral testing to clinical providers; the control group will have the test performed, but providers will not be presented with test results. Participants will be allocated 1:1 by computer-generated randomization.

Population Children 1 month to less than 18 years of age seeking evaluation and management of ILI at the CHCO ED will be eligible for participation in the study. We estimate that a sample size of 392 patients in each group will achieve 90% power at a 0.05 significance level to detect a risk difference of approximately 10% for antibiotics prescribed (primary outcome) for the intervention group compared with the control group, using a two-sided Z test for difference in two independent proportions. Assuming a 20% dropout rate, we will require 470 subjects in each group, 940 subjects each year.

Acute respiratory infections (ARI) represent one of the commonest reasons for pediatric visits the ED or Urgent care, representing 25% of ED visits during the winter months (1) . While the etiology of most ARI is viral (2), it is estimated that in the pediatric ED and UC setting, 55-57% of children are prescribed an antibiotic for an ARI (3). Unnecessary antibiotic prescribing can lead to adverse drug events (4), increased health care costs, and contributes to the development of antibiotic resistance (5) .

Identification of the respiratory pathogen provides an opportunity to guide treatment decisions regarding the further work up and treatment of children with ARI, with the potential to decrease antibiotic use, resource utilization and healthcare costs (6) . Pediatric studies among traditional platforms including DFA, RT-PCR and viral culture have shown that rapid viral detection can lead to reduction in hospitalization, length of stay and antibiotic use (7, 8) , (9) ,(10), (11) .

Newer molecular-based platforms enable even more rapid detection with enhanced sensitivity and specificity. While some pediatric studies using these newer platforms have demonstrated decreased antibiotic use and hospital length of stay among inpatients (9), guidance regarding whether patients in an outpatient acute care setting would benefit from point-of-care respiratory testing using important clinical outcomes is lacking in the pediatric population (8) . Therefore, the objectives of this study were to determine whether knowledge of the respiratory pathogen associated with an acute respiratory illness impacts provider decision making, resulting in decreased antibiotic use and healthcare utilization in the pediatric acute care, outpatient setting.

Study Objectives:

Research question: Does rapid molecular respiratory pathogen testing with clinical decision support decrease antibiotic use, diagnostic testing and length of stay among children seen in the Emergency Department with a respiratory illness compared to those receiving routine clinical care without testing?

Specific Aims:

Aim 1: To determine the clinical impact of rapid respiratory pathogen testing on antibiotic use and healthcare utilization among children in an ED setting. Aim 2: To determine provider decision-making and acceptance and family acceptance of rapid respiratory pathogen testing among children in an ED setting.

The primary objective of the study is to determine whether knowledge of the respiratory pathogen associated with an acute respiratory illness with additional clinical decision support impacts provider decision making, resulting in decreased antibiotic use and healthcare utilization.

Secondary objectives include:

To compare the proportion of children treated with antivirals, ED length of stay, hospitalization, repeat ED visits, number of healthcare visits, number of tests ordered per visit (chest x-ray, blood cultures, CSF cultures, urine cultures) and relative clinical charge differences between the intervention and control groups.

To determine whether results of the rapid point of care test influenced provider decision making in the ED.

To determine whether there is patient/family acceptance of the point-of-care respiratory test.

Overall Study Design:

The RAPID trial is a randomized controlled trial of rapid respiratory viral testing in children presenting to an Emergency Department setting with acute respiratory symptoms. We have almost completed a full year of enrollment, with an anticipated total of 1000 participants. The patient cohort is comprised of children 1 month to 18 years of age presenting to the Children's Hospital Colorado (CHCO) Emergency Department with influenza like illness who are triaged as level 3, 4, or 5 by the Emergency Severity Index, representing the typical patient population who are evaluated in an urgent care setting. All eligible participants will undergo a nasopharyngeal swab and point of care testing, and participants will be allocated 1:1 by computer-generated randomization to either the intervention group -test result available to providers, or the control group-test result not available (routine clinical care).

The primary outcome will be the proportion of children who are prescribed an antibiotic at the ED visit.

Secondary outcomes will include the proportion of patients treated with antivirals, appropriate antiviral use (influenza test that is positive with antiviral prescribed), antibiotic use by diagnosis (diagnoses categorized by antibiotics indicated, possibly indicated, not indicated), ED length of stay, hospitalization, repeat ED visits, number of tests ordered per visit (chest x-ray, blood cultures, urine cultures) and relative clinical charge differences. Additional outcomes will include the impact of rapid test results and education materials on provider decision-making in the ED and patient/family acceptance.

Two dedicated professional research assistants (PRAs) will review the ED track board for patients who are potentially eligible for the study. The track board displays a list of ED patients by location and chief complaint. The study team has a treatment relationship with potential subjects, since one of the coinvestigators is an ED physician, thus enabling pre-screening of potential patients. The PRAs will approach the parents/guardians of the study and will screen the child's symptoms for study eligibility. We will have PRA support in the ED for 10 eight hour shifts a week during the peak times (1400 -2200 or 1600 -2400) for patient enrollment.

The parents/guardians of eligible subjects with influenza-like-illness symptoms (see inclusion criteria below) will be asked to participate in the study and if interested, the PRAs will obtain consent to obtain respiratory specimens for rapid PCR testing, ED and follow up interviews, and to bank respiratory samples. Assent will be obtained by children 7 years of age and older.

Once an eligible child has been fully consented for the study, they will be assigned a unique participant identification number. A PRA will then obtain a computer-generated randomization code for the child which will assign them to either the intervention arm or control group (random permuted blocks of varying sizes will be used to ensure an equal number of subjects in each group).

The study will involve initial parent interview during the visit to the ED (day 0) and collection of a nasopharyngeal specimen, followed by a parent/guardian phone call/text message follow up at day 1 and phone or email follow up at day 10. Once a respiratory specimen has been obtained, the PRA will perform the test using the Biofire RP2 in the ED. For the intervention group, the PRA will obtain results and will give a handout to the ED provider with the test result and a brief questionnaire about whether the results influenced testing or treatment practices. The results will be entered into the electronic medical record in the research encounter note. For the non-intervention group, the PRA will obtain results and will document results in our research database. A summary of the study workflow is provided in Appendix C.

Data collection, computer randomization, automated email and text messaging will be managed with REDCap (Research Electronic Data Capture) tools hosted at the University of Colorado (19) and exported to SAS 9.3 (Cary, NC) for statistical analyses.

Parents will be interviewed in the ED by a PRA regarding the child's demographic characteristics, presenting symptoms, medical comorbidities, and preferred method of contact for follow up. A diary card will be provided to the family member upon discharge from the ED as an aide memoire for the follow-up interview. Parents of children from the intervention group will receive results of the respiratory testing.

PRAs will contact parents by text message on Study Day 1. For parents of children in the intervention group who were not notified of the results on day 0, results of the respiratory test will be provided, with instructions to contact their provider if there are further questions or concerns. Parents of children from both study arms will be asked about whether they preferred knowing the results of the viral testing, and whether it impacted their health-seeking behavior.

Parents will be contacted on day 10+/-3 by phone or email and asked a series of questions regarding the child's duration of fever, illness, antibiotic and antiviral use, and additional medically attended visits (primary care, ED or urgent care, hospitalization). Additional visits, antiviral and antibiotic prescriptions will be verified in the electronic health record. We will determine the preferred method of contact during the initial interview, and if phone is preferred, then we will determine the preferred time of the call. We will attempt 3 phone calls and 3 emails. If a parent has not sent an email response by day 13, they will be contacted by phone.

We will provide participants $20 for participation on Study Day 0 and $10 for participation on Study Day 10 to increase participation rates and minimize dropout rates.

Nasopharyngeal swabs will be obtained for testing by the clinical nurses. Providers of children in the control arm who want to perform testing as part of routine clinical care will have the option of using the specimen already obtained for the research study.

Respiratory specimens will be collected using a nasopharyngeal (NP) FLOQSwab and placed in Universal Transport Media (Copan Diagnostics Inc., Murrieta, CA). Nasopharyngeal swabs will be collected for study purposes. If a respiratory specimen has already been collected during the ED visit, these will be used for testing, and no additional testing will be required. Nasopharyngeal aspirates or swabs will be permitted for the study. This source is cleared by the FDA for the RP2 respiratory pathogen panel (RPP) and the collection method is standard clinical and research practice at our institution. We have successfully used this system to collect clinical specimens for several previous and ongoing studies. Risks of the procedure are minimal and include mild local discomfort at the time of specimen collection.

We will obtain consent from parents or guardians regarding banking residual respiratory (obtained for our research study or clinical purposes) samples which will be stored at -80°C in Dr. Dominguez's freezer at the CHCO Clinical Microbiology laboratory located at Children's Hospital Colorado (depending on the assay and sample) in case repeat or additional testing is requested. These samples can be used for future research after the child has been discharged from care.

Immediately after specimen collection, testing will be performed by the study personnel on site in the ED, and providers of children in the intervention arm will receive notification of results.

As described above, once a specimen has been obtained using the FLOQswab, it will be placed in universal transport media, and a sample will be tested using the RP2 pathogen panel, following the standard protocols. Testing results will be available in 45 minutes. Residual sample in UTM will be stored for potential future testing, and additional sample processing will not be required.

Once a patient has been enrolled in the study, they will be randomly allocated a study arm. For those patients in the intervention group, once the result is available, the PRAs will notify the provider of the result in real-time as written materials. The results of the testing will also be entered into the electronic medical record. The PRA and provider will notify the family members of the results. Families of the intervention group will be notified of their study results either in person or by text message on Study Day 1.

Traditionally at our institution's ED, respiratory viral testing is conducted at the discretion of the provider. Our medical staff are advised to order testing only if it is likely to influence clinical care (Appendix A). The PI and Co-PI are responsible for influenza testing and treatment guidelines, which are provided in Appendix A.

Inclusion criteria: 1) Age 1 month to < 18 years 2)

For children aged 1 month to 12 months of age: Presentation to the study sites with temperature > 37.8°C or cough, sore throat, runny nose or nasal congestion 3)

For children aged > 1 year to 18 years of age: Presentation to the study sites with influenza like illness, defined as temperature of >37.8⁰C and at least one of the following: cough, sore throat, runny nose or nasal congestion 4)

Triage Level 3,4,5 based on Emergency Severity Index (refer to Appendix B for algorithm) Influenza-Like Illness: Temperature of >37.8⁰C and at least one of the following: cough, sore throat, runny nose or nasal congestion for children 12 months to 18 years of age, and for children < 1 year of age, was defined as temperature of >37.8⁰C or at least one of the following: cough, sore throat, runny nose or nasal congestion.

Appropriate antiviral use: Test positive for influenza and antiviral (oseltamivir, zanamivir, or orperamivir prescribed.

Appropriate antibiotic use: Antibiotics prescribed or administered in the ED for a patient with a diagnosis for which antibiotics are definitely or probably indicated:

Antibiotics definitely indicated-sepsis, rule out sepsis, shock, pneumonia Antibiotics probably indicatedpharyngitis, otitis Antibiotics not indicated -URI, LRTI, croup, bronchiolitis, reactive airway disease, extrapulmonary manifestations, other, dehydration

Family acceptance: Family report in survey data that they would be likely or very likely for their child to undergo repeat point of care respiratory testing in the future.

Withdrawal/Study Termination Participants will be followed until completion of day 10 +/-3 activities.

A participant may withdraw from the study at any time at his/her own request, or may be withdrawn at any time at the discretion of the investigator for safety, behavioral, compliance, or administrative reasons. This is expected to be uncommon.

If a participant withdraws from the study, he/she may request destruction of any samples taken and not tested, and the investigator must document this in the site study records.

The study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Written notification will be provided documenting reason for study suspension or termination to the investigators, funding agency, and regulatory authorities, as appropriate.

Circumstances that may warrant termination or suspension include, but are not limited to:

• Determination of unexpected, significant, or unacceptable risk to participants • Insufficient compliance to protocol requirements • Data that are not sufficiently complete and/or evaluable • Determination of futility after a sufficient time has passed for accrual of the primary and secondary outcomes Loss to follow up Participants will be asked to complete day 0/1 and day 10 +/-3 follow up.

A participant will be considered lost to follow-up if he or she fails to complete the day 10 +/-survey and neither the participant nor his or her proxy can be contacted by the study site.

Follow-up calls or emails will be completed for all subjects enrolled in the study on day 10 +/-3.

Email attempts will be set to automatically send on days 9,10,11 from date of enrollment. If there is no response to the email, then 1 call attempt will be made on day 12.

Phone call attempts will be made until completion of the survey on days 10,11,12 from date of enrollment.

If there is no response to the phone calls the subject will be considered a lost to follow-up (LTFU).

If the parents call back or request a call back that is out of the range (ie. day 13), the study team will complete this call, but will remind the parent to only answer the questions for the appropriate date range.

Our power calculations are based on a prospective observational cohort study of 1478 children aged 6 months to 8 years of age with an influenza like illness evaluated in an ED/UC setting, whereby 30% have received an antibiotic, and a clinically significant reduction in antibiotic prescribing would be an effect size of 10%. We estimated that a sample size of 392 patients in each group will achieve 90% power at a 0.05 significance level to detect a risk difference of approximately 10% for antibiotics prescribed (primary outcome) for the intervention group compared with the control group, using a twosided Z test for difference in two independent proportions. Assuming a 20% dropout rate, we will require 470 subjects in each group, 940 subjects each year.

• For all study objectives, unless otherwise specified, we will summarize data descriptively using frequencies for categorical variables and measures of central tendency for continuous variables.

•

We will assess bivariable associations between the two arms (a)control and intervention and b) season 1 versus season 2) for covariates including demographic factors and clinical factors outlined above.

• Proportions will be compared using the Chi-square test or the Fisher exact test when needed. Mean values will be compared using student's t test for normally distributed data, otherwise the Wilcoxon-Rank-Sum or Kruskal-Wallis test will be used.

For categorical outcomes, 2x2 tables presenting the number of patients in each category of the independent variable by outcome (e.g. Antibiotic versus no antibiotic) will be evaluated and odds ratios and 95% CI will be estimated.

Because patients may have multiple visits within the data set, the number of patients with multiple visits and the number of visits per patient among those with multiple visits will be evaluated. Depending on the distribution of visits per patient and number of visits in patients with multiple visits, for multivariable analyses we will consider analyzing only the first visit. Alternatively, we will consider performing random effect models in order to account for the clustering of visits within patients.

Unless otherwise stated, analyses will be conducted on the intention to treat as well as the pragmatic group as defined below.

Analysis populations: All analyses will be performed on an intention to treat and pragmatic modified "intention to study" basis.

Enrolled Cohort: all subjects who had a signed informed consent form Intention to treat Cohort: all subjects who had a signed informed consent form and underwent respiratory testing after screening Modified "intention to study" Cohort: all subjects who had a signed informed consent form after screening but will be classified according to a modified intervention group (provider knows results) or modified control group (provider does not know results).

with results given to provider and children in control group where provider ordered standard of care respiratory or flu test.

Modified control group (Group 2): provider does not know results-includes children in intervention group where children were discharged before results were available and given to provider and children in control group whose provider did not order clinical respiratory test.

Per-protocol Cohort: all subjects who had a signed informed consent form after screening, underwent POC testing, and underwent follow up at day 10 +/-3 after their initial visit and did not have any of the following occur: a. Did not undergo follow-up at day 10 after their initial visit. b. Were in the intervention arm but results were not available to providers c. Were in the control arm but clinical testing was performed d. Had a protocol deviation e. Had an indeterminate POC result

For dichotomous variables, we will first estimate the unadjusted odds ratio and 95% CI using a 2x2 table where the independent variable will be intervention arm and the outcome will be each of our dichotomous secondary outcomes of interest, antibiotic use, hospitalization, antiviral use (yes vs no). We will also assess the association of covariates selected a priori (age group, high risk medical condition) with the independent variable and with the outcome. Any covariates that are associated with both the independent variable and outcome at the level of P < 0.2 on bivariable analysis (and are not in the causal pathway) will be considered in the multivariable model. Next, we will use log binomial regression to estimate the risk ratio (and 95%CI) for antibiotic use, adjusted for covariates that met the criteria above. If the model fails to converge, we will use Poisson regression with robust variance.

We will also explore our secondary outcomes of interest expressed as continuous variables (number of recurrent visits to the ED, ED length of stay). We will first look at the distribution of these data graphically and will perform bivariable analysis using the appropriate test to compare the median values/data distributions. For multivariable analyses we will use a log linear model to compare these variables between the mild versus moderate to severe groups, adjusting for covariates if needed as described above, and will exponentiate the coefficients to yield geometric mean ratios. We will verify to ensure statistical assumptions are met for each model.

Please see attached data collection form for information that will be obtained (Appendix D). A summary of variables is provided in the table below. 

We have received full board approval for the study (COMIRB #18-1492). A waiver of consent was obtained for provider surveys.

This protocol has been registered under ClinicalTrials.gov Identifier: NCT03756753

Data entry and management are outlined in the Manual of Operations.

Details regarding the chart reviews are outlined in the RAPID Chart Review Guide.

Electronic case report forms and study data management will be performed using the REDCap Study Data Management System through the CCTSI Informatics Core. REDCap is a HIPAA compliant research data management system developed at Vanderbilt University and deployed at over 52 institutions. At UCD-Anschutz, REDCap is supported by the School of Public Health's Development and Informatics Service Center (DISC) and the CCTSI Informatics Core. The UCD REDCap installation recently passed a rigorous 6 week security threat analysis performed by the UCD-Anschutz HIPAA Security Officer. All study data are stored on a secure database server which is separate from the webfacing server --a best-practices for internet-based security. All user access requires user accounts and passwords. All user actions are recorded in a secure audit log. The database server is routinely backedup. All security patches and application updates are applied immediately upon release by DISC. Only study personnel will have access to the data.

The study data will be analyzed using SAS version 9.4. Data quality is managed at each stage of its lifecycle. Data collected in REDCap conforms at inception to highly structured data elements and protocol-specific rules, subsequent data transfers are checked to conform to format and semantic specifications and all data is assessed for referential integrity across sources through a set of reconciliation practices upon integration then followed by a variety of logical checks.

Study records will be maintained per HIPAA Regulations for 7 years after IRB acknowledgement of study closure. No records will be destroyed without the written consent of the sponsor, if applicable. It is the responsibility of the sponsor to inform the investigator when these documents no longer need to be retained.

A protocol deviation is defined as non-compliance with the clinical study protocol, GCP, or MOP requirements. The non-compliance may be on the part of the participant, site investigator, or the site staff. A major protocol deviation is a significant divergence from the protocol that may have significant effect on the subject's safety, rights, or welfare and/or on the integrity of the study data. Major protocol deviations will be sent to the study IRB and local IRB per their guidelines, recorded in source documents and in REDCap.

From the day that we saw you on, XX-XX-2018, and you agreed to participate in this study, did your child have any visits to a doctor or medical care provider? Yes no 5a) If yes, How many times did your child visit a doctor or medical care provider since XX-XX-2018? ______ 5b) if yes, where did you seek medical care? (list all that apply) Primary care office  Specialist clinic Urgent care ED Other (list) ______________________________ 5c) if yes, did you seek medical care because of the results of the respiratory test? Yes no 5d) If no, did you choose not to seek care because of the results of the respiratory test? Yes no 5e) Was your child started on any antibiotics after your ER/Urgent Care visit on XX-XX-2018? Yes no 5f) Was your child started on any antivirals for influenza? Yes no 5g) Since the day when we saw you in the ER/Urgent Care, on XX-XX-2018, was your child hospitalized outside of Children's Hospital for their illness? Yes no

Did you change the way your child was cared for (for example, asked for a particular treatment to be started or stopped) because of the results of the respiratory test? Yes no If yes, what was the change that was made? ______________________________________

Demand on ED resources during periods of widespread influenza activity

Antibiotic Prescribing for Children in United States Emergency Departments

Community-acquired pneumonia requiring hospitalization among U.S. children

US Emergency Department Visits for Adverse Drug Events From Antibiotics in Children

American Academy of Pediatrics Committee on Infectious D. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics

Potential Utility of Multiplex Amplification Respiratory Viral Panel Testing in the Management of Acute Respiratory Infection in Children: A Retrospective Analysis

Impact of Early Multiplex FilmArray Respiratory Pathogen Panel (RPP) Assay on Hospital Length of Stay in Pediatric Patients Younger Than 3 Months Admitted for Fever or Sepsis Workup

A randomized, controlled trial of the impact of early and rapid diagnosis of viral infections in children brought to an emergency department with febrile respiratory tract illnesses

The effect of rapid respiratory viral diagnostic testing on antibiotic use in a children's hospital

Cost-effectiveness of rapid diagnosis of viral respiratory tract infections in pediatric patients

Clinical and financial benefits of rapid detection of respiratory viruses: an outcomes study

The remaining questions will be obtained from review of the chart: Medical comorbidities: asthma/reactive airways disease  chronic pulmonary disease  malignancy  HIV immunosuppression (if so, how?) premature (less than 37 weeks) renal disease  liver disease  genetic syndrome/chromosomal abnormality  global developmental delay  blood disorder metabolic disease  neuromuscular disease  seizure disorder heart disease  on aspirin therapy other _______________  no comorbidities Vital Signs Initial Temperature (C): Initial Heart rate: Initial Respiratory rate: Initial oxygen saturation (on room air):Initial systolic blood pressure: Initial diastolic blood pressure: Highest temperature in ED (C): Heart rate during this time: Initial PEWS:Highest PEWS recorded in ED: Signs: respiratory distress/accessory muscle use  lymphadenopathy  rash hepatomegaly splenomegaly  other Diagnosis  pharyngitis  sinusitis  URTI/viral syndrome  otitis media  LRTI/pneumonia bronchiolitis  croupasthma exacerbation dehydration sepsis rule out sepsis  shock other ____________ extrapulmonary manifestations (dropdown) encephalitis myositishepatitis myocarditis other (specify) ___________ Test results