d) Send Respiratory PCR Panel (Biofire) testing

f) Supportive care with close follow up

Here’s how others answered:

Q9 graph

Distinguishing Bacterial and Viral Pneumonia

  • Rapid identification of viral pathogens has changed the way we practice medicine
  • Respiratory PCR Panel (aka at Harbor, the Biofire) includes a number of bacterial and viral pathogens (see panel)
    • Sensitivity and Specificity >95%
  • Rapidly de-escalate or stop antimicrobial therapy in these patients
  • Decreases length of stay on admitted patients
  • Decreased time to appropriate isolation

Biofire panel

Etiology of Pneumonia

  • Symptoms more likely to be pneumonia
  • 3 of the following: acute-onset cough, new or increased mucopurulent sputum, fever (>38°C), pleuritic chest pain, dyspnea, and abnormal breath sounds on auscultation
  • Positive Chest X-ray
  • Etiology
    • 2-33% may have more than one pathogen (viral and bacterial)
    • The more ill the patient is the more likely to have both
    • Younger the patient is the more likely it is to be viral (80% for under 2 yrs)

Molecular Testing and Your Patient

  • The reason to do the Biofire is 2-fold
    • If Influenza you might consider oseltamivir
    • To help the provider & parents understand diagnosis
  • “Antibacterial therapy is not necessary for children, either outpatients, or inpatients, with a positive test result for influenza virus in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.”
  • Other molecular testing we have at Harbor include:
    • Biofire Meningoencephalitis Panel – CSF panel
    • Procalcitonin – helps differentiate between bacterial and viral pneumonia
      • Best studied in adult patients

Case Patient

  • Given the hazy bilateral infiltrates and multiple ill family members this patient would be a candidate to watch and wait
  • The Biofire might help you to reassure yourself and the parents
  • Given the patient is not severely ill (no respiratory distress & no desaturations reported), we would recommend holding off on antibiotics
  • Delayed or “wait and see Rx” would not be unreasonable here as well
    • Amoxicillin/clavulanate would be reasonable for the wait and see Rx or at the follow up visit if not improved
  • However, giving a dose of Ceftriaxone often happens frequently
    • This does not mean that the antibiotics need to be continued, especially if a viral pathogen is found, reassuring you that this is viral
  • For severe pneumonia it would be recommended to give and continue antibiotics even if the Respiratory PCR Panel came back with a virus because a higher percentage of these kids have a secondary bacterial pathogen as well

References

  1. Arch Pathol Lab Med. 2015 May;139(5):636-41
  2. Clin Infect Dis. 2011 Oct;53(7):e25-76