Role of real-time reverse transcription polymerase chain reaction for detection of respiratory viruses in critically ill children with respiratory disease: Is it time for a change in algorithm?

Abstract

Direct fluorescence antibody assay testing is a suboptimal method for the detection of respiratory viruses in critically ill children with lower respiratory tract infection. Given the importance of a prompt and accurate viral diagnosis for this group of patients, we suggest that real-time reverse transcription-polymerase chain reaction becomes part of the routine diagnostic algorithm in critically ill children when a viral etiology is suspected, even if conventional tests yield a negative result.

Detection of respiratory coinfections in pediatric patients using a small volume polymerase chain reaction array respiratory panel: More evidence for combined droplet and contact isolation

“…Patients with viral coinfections had higher mortality rates, although this was not statistically significant. 22 In another study of patients with hematologic disorders, no significant differences were noted in presentation or outcome between episodes of febrile neutropenia caused by bacterial infection and those caused by mixed viral and bacterial infections. 23 Some combinations of pathogens, especially coinfection with RSV, have been associated with longer length of stay.…”

“…Based on review of the published pediatric literature using molecular techniques to identify respiratory pathogens, the reported rates of coinfection with pathogen combinations that would require combined isolation vary from an estimated 4% to 15% of the total samples tested. 5,17,18,22 Of note, combined isolation precautions are routinely recommended for some respiratory viruses, including adenovirus, because of known mechanisms of transmission. 10 This estimated rate of pathogens requiring combined isolation precautions would be even higher if detection of adenovirus alone is included.…”

Clinical Disease Severity of Respiratory Viral Co-Infection versus Single Viral Infection: A Systematic Review and Meta-Analysis

“…Note: N = number, CI = confidence interval, GRADE [31] = Grading of Recommendations Assessment, Development and Evaluation, RR = risk ratio, SD = standard deviation, CI = confidence interval.GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.aSerious design limitations: Eight [15], [19], [21], [32], [22], [35], [23] [24] of the eleven studies had serious design limitations including the absence of notification or adjustment for important prognostic factors and the absence of evidence provided on the similarity of co-interventions between both groups.bSerious Inconsistency: There was high statistical heterogeneity ( I 2  = 72%, p<0.001), which was not explained on further subgroup analysis.cSerious indirectness of the comparison: Only three [33] [19] [24] of the eleven studies focused primarily on the comparison of disease severity between single vs viral co-infections.dNo serious imprecision: The assumption of our a priori hypothesis of no difference was met. Cumulative sample size was appropriate.…”

“…aSerious design limitations: Eight [15], [19], [21], [32], [22], [35], [23] [24] of the eleven studies had serious design limitations including the absence of notification or adjustment for important prognostic factors and the absence of evidence provided on the similarity of co-interventions between both groups.…”

Prospective Multicenter Study of Viral Etiology and Hospital Length of Stay in Children With Severe Bronchiolitis

“…However, given that one of three children with RSV and almost one of four without RSV will have a co-infection, the effectiveness of these cohorting practices is questionable, especially given that some of the co-infecting pathogens require droplet precautions and not just contact precautions. Some have suggested routinely using PCR to test for multiple respiratory viruses in critically ill children with lower respiratory infections, 36 but the expense of using molecular testing for all children with severe bronchiolitis may not outweigh the potential benefits for the family and clinicians. Although one possibility would be to limit the testing to RSV and HRV, the benefits of having a more complete picture of the infecting viruses, providing guidance about the potential severity of illness, possibly reducing antibiotic prescriptions, 37 and following the HRV positive children closely for the development of asthma, 12–14 most likely do not outweigh the expense of the molecular testing for HRV.…”