Article 5

Abstract

Douglas F. Willson, MD Department of Pediatrics University of Virginia Health Sciences Center Charlottesville, Virginia BRONCHIOLITIS is a common, well-recognized lower respiratory syndrome of young children, frequently accompanied by fever.1 Because fever in infants less than 90 days of age may be an indicator of serious bacterial infection (SBI),2,3 many physicians routinely perform a sepsis evaluation, often including hospitalization for antibiotic treatment.4,5 Several studies have reported a low risk of concomitant SBI in infants and children with bronchiolitis, with SBI rates of 0% to 1.8%.6–11 Consensus has not been reached about the appropriate management of the febrile infant ≤ 90 days of age with a recognizable viral syndrome known to be associated with a low risk of SBI.11,12 Lack of consensus leads to practice variation. Unnecessary evaluation or treatment for sepsis in infants with bronchiolitis has been shown to lead to increased costs, testing, length of hospitalization, and exposure to antibiotics.6,9 This article describes variation in the performance of sepsis evaluations in infants ≤ 90 days of age with bronchiolitis hospitalRandomly selected inpatients with lower respiratory tract infections were selected from April 1, 1995, to September 30, 1996, from 10 pediatric hospitals (n = 804). Those ≤ 90 days of age with bronchiolitis (ICD-9 466.1, n = 303) are included. Medical records were abstracted. Pediatric Comprehensive Severity Index was used for severity scoring. Sepsis evaluation was defined as any culture of blood, urine, or cerebrospinal fluid, or parenteral antibiotic. Growth of any bacterial pathogen defined a serious bacterial infection (SBI). Rate of sepsis evaluations among sites (13% to 84%) was significantly different; mean age (49 days) and severity were not different. Intensive care stay (PICU, 22% to 87%), average length of stay (ALOS, 3–9 days), and mean total costs ($3,490–$16,147) were significantly different among hospitals. Logistic regression predicting sepsis evaluation showed significant predictor variables to be: age, severity, and PICU stay (Odds Ratio [OR] = 3.3). After controlling for these variables, significant variation due to site (OR by site ranged from 0.1 to 4.6) was observed. Total costs were predicted by severity, PICU stay, and sepsis evaluation. There were four infants with SBI (1.3%), all positive for Respiratory Syncytial Virus (RSV). Infants were similar among 10 sites with respect to age and severity; there was a significant difference among sites for sepsis evaluation, ALOS, and costs, after controlling for age, severity, and PICU stay. Risk of SBI was low. Unwarranted variation should be addressed and reduced.