Source: OpenUrlAbstract/FREE Full Text
Investigators from multiple institutions conducted a meta-analysis to assess the effect of respiratory virus (RV) testing on several outcomes in children hospitalized with acute respiratory illness (ARI). Investigators searched 7 medical literature databases for studies that (a) were published between 1985 and 2018; (b) evaluated the effect of RV testing on antibiotic use, ancillary diagnostic tests, hospital length of stay, or use of antiviral agents; and (c) included children <18 years old hospitalized with ARI, defined as an illness of <7 days’ duration with respiratory symptoms suggestive of infection. Two reviewers independently reviewed extracted studies to ensure they met these criteria; discrepancies were resolved by consensus or an arbitrator. When ≥3 studies were available, investigators attempted meta-analyses to assess the effect of RV testing on outcomes overall, as well as within prespecified subgroups of patient age (≤1 and >1 year old), study design (prospective vs retrospective cohort), location of RV test (point of care vs laboratory), and turnaround time for RV test (≤6 and >6 hours).
There were 23 studies included. Of these, 20 reported on the effect of RV testing on antibiotic use, with 7 revealing that a positive RV test was associated with significantly decreased odds of receiving antibiotics, 2 studies revealing that a positive test was associated with significantly increased odds, and 11 studies finding no effect. A meta-analysis of these studies could not be performed because of high levels of clinical and statistical heterogeneity. Meta-analyses of hospital length of stay and use of antiviral agents also could not be performed because of insufficient data in the studies.
In subgroup analyses, there was no difference in antibiotic use according to RV testing by patient age. There were significantly decreased odds of antibiotic use with positive RV testing reported in studies with prospective cohort designs (pooled OR, 0.58; 95% CI, 0.45–0.75) and no difference seen in retrospective studies. The effect of RV testing on performing ancillary testing was not significant (pooled OR, 0.71; 95% CI, 0.48–1.04). Meta-analyses of point-of-care testing and turnaround time could not be performed.
The investigators conclude that available data suggest that RV testing may lower antibiotic use but remain inconclusive because of clinical and statistical heterogeneity among available studies and an insufficient number of studies identified.
Commentary
Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
In the current study, the investigators systematically summarized >30 years of research on the role of RV testing in limiting other therapies. Across large populations, and despite all the work that went into this meta-analysis and its component studies, the evidence is inconclusive. Where does this leave the individual clinician trying to decide whether to perform an RV test?
First, it is important to distinguish good research practice from evidence-based medicine (EBM). According to one commonly used definition, EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.1 Within this definition, we begin to see that it is difficult, if not impossible, to directly link as broad a pursuit as “to systematically review and meta-analyze the impact of RV test results on antibiotics consumption, ancillary testing, hospital length of stay, and antiviral use.” The lack of an overall conclusive meta-analysis is as related to the broad ways of approaching the question itself than it is to anything related to the individual studies’ methodologies.
When left with inconclusive results, we still can strive toward the practice of EBM. Even if there were strong evidence against the usefulness of RV testing as a routine, universal practice, there still can be room for its use in the care of individual patients.
For instance, despite receiving broad-spectrum antibiotics, a child with cerebral palsy presents for the second time with respiratory distress and bilateral opacities on chest radiographs. Would knowledge of a test positive for parainfluenza and respiratory syncytial virus prevent a repeat antibiotic course? Might it prevent a workup for clinical aspiration? (See AAP Grand Rounds. 2019;42[3]:32.2)
Bottom Line
Although there is insufficient evidence to suggest that RV testing helps to limit other tests and treatments, RV testing may be useful in select, individual cases.
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.