Acute bronchiolitis: The economic impact of non-compliance with national guidelines.

INTRODUCTION: Acute bronchiolitis is a common reason for admission to the pediatric emergency department. Evidence has shown that most interventions do not change the natural course of the disease. MATERIAL AND METHODS: This study aimed to evaluate the economic impact of the non-compliance with the acute bronchiolitis Portuguese national guideline. A retrospective study of pediatric emergency episodes of a Portuguese hospital that had a diagnosis of acute bronchiolitis during 2019, was conducted. RESULTS: The sample included 344 emergency episodes. Non-compliance with the guideline occurred in 71.8% of the episodes, mostly due to unjustified treatment. Following guideline in the studied hospital for one year would have resulted in an estimated overall 76.6% cost reduction, with a reduction in mean direct costs per patient of 14.93 €, corresponding to a medium saving of 3.89 € for each patient and a reduction of 11.03 € for the Portuguese National Health Service. Analyzing the unjustified mean direct costs, of these 2.97 € were related to inpatient diagnostic tests and therapeutic and the remaining 11.96 € were related to outpatient therapy. Mean direct costs imputed to the patient for outpatient treatment represented only 3.31 €, therefore most of mean direct costs is paid by the National Health Service. CONCLUSIONS: Compliance with guideline would allow the reduction of total estimated costs by about 76.6%, representing a waste of resources, without compromising the quality of care provided. Most of the cost associated with non-compliance with the guideline is justified by outpatient therapy, 67% of which was paid by the National Health Service.

Bronchiolitis: Increased severity in the post-COVID-19 era.

INTRODUCTION: Acute bronchiolitis is a pressing public health concern, leading to numerous infant hospitalizations worldwide annually. The notable decrease in bronchiolitis hospitalizations during the COVID-19 pandemic sparked concerns about a potential resurgence post-pandemic. Questions also arose about the severity of post-pandemic cases compared to prepandemic ones. This study aimed to compare bronchiolitis severity before and after the COVID-19 pandemic, alongside changes in the epidemiology of bronchiolitis viral agents. MATERIAL AND METHODS: We conducted a retrospective analysis of medical records concerning infants under 12 months hospitalized for acute bronchiolitis in our pediatric pulmonology department over a period of 5 years: 2 pre-COVID years (2018-2020), the COVID year (2020), and 2 post-COVID years (2021-2023). Clinical and laboratory data were collected using standardized forms. RESULTS: Hospital admissions exhibited comparable rates pre- and post-COVID but witnessed a decline during the COVID period. Post-COVID, bronchiolitis severity increased, with longer hospitalization durations (p < 0.001) and increased oxygen therapy (p = 0.04), coinciding with a surge in the prevalence of RSV infections (p = 0.01). Patients testing positive for RSV were significantly younger (p = 0.005) and exhibited more severe symptoms. DISCUSSION AND CONCLUSION: This study reveals a significant increase in bronchiolitis severity and a rise in RSV cases following the COVID pandemic. The implementation of preventive measures such as nirsevimab is crucial to alleviate the burden of respiratory illnesses in vulnerable populations. Continued vigilance and research are needed to address the evolving challenges of bronchiolitis in the post-COVID era.

Respiratory Syncytial Virus Infection and Apnea Risk As Criteria for Hospitalization in Full Term Healthy Infants.

Introduction Apnea is recognized as a serious and potentially life-threatening complication associated with Respiratory Syncope Virus (RSV). The literature reports a wide range of apnea rates for infants with comorbid factors. Prematurity and young chronological age have been historically associated with the risk of apnea in hospitalized infants. Few studies have specifically examined the risk of apnea in healthy infants presenting to the emergency department. Methods This is a retrospective review of infants diagnosed with RSV using a PCR assay. Patients were divided into "mild" and "severe" cohorts based on symptoms at presentation. This study occurred in the NYU Langone Long Island (NYULI) pediatric emergency department (ED), a midsize academic hospital in the Northeast United States. The study included infants <6 months of age, born full term without comorbid conditions such as chronic lung or cardiac conditions, seen in NYULI ED over three consecutive RSV seasons (2017-2020). The primary outcome was the risk of apneic events. Secondary outcomes included hospital admission, ICU admission, length of stay, and supplemental oxygen support. Results The risk of apnea was <2%, regardless of disease severity. There were no significant differences in demographics between mild and severe disease. Cohorts differed significantly in the number of hospitalizations (41 milds vs. 132 severe), ICU admissions (2 milds vs. 27 severe), need for oxygen support (17 milds vs. 92 severe), hospital readmissions (2 milds vs. 42 severe), and length of stay (2 days milds vs. 3 days severe). Conclusions Apnea does not pose a significant risk for healthy full-term infants with RSV disease of any severity. The decision to admit this population to the hospital should be based on clinical presentation and not solely on the perceived risk of apnea.

Critical Case of a Preterm Infant Infected With Respiratory Syncytial Virus Managed in the Pediatric Intensive Care Unit: A Case Report.

We describe a critical case of a respiratory syncytial virus (RSV) infection in a preterm infant resulting in respiratory failure with advanced respiratory interventions and discharge from our hospital without the requirement for home oxygen therapy or tube feeding. The infant, delivered at 35 weeks gestation due to a premature rupture of the membranes with a birth weight of 2 kg, initially demonstrated a stable postnatal course. The baby required no resuscitation, with Apgar scores of 8 and 9 at one and five minutes, respectively. The infant was discharged in good condition after four days of hospitalization. This report presents a critical case of RSV infection in a preterm infant requiring intensive care. The infant, born at 35 weeks gestation, initially appeared healthy but developed severe symptoms at 22 days old. The emergency evaluation revealed significant respiratory distress and confirmed RSV pneumonia. Following extensive interventions, including mechanical ventilation to manage severe symptoms, along with complications such as pneumothorax and a cardiac arrest episode, the infant exhibited a positive response to subsequent treatments. The infant responded positively to high-frequency oscillatory ventilation and inhaled nitric oxide. Gradual weaning from advanced ventilation led to successful extubation, followed by recovery with high-flow nasal cannula therapy. The case highlights the challenges of managing severe RSV infections in preterm infants and the efficacy of intensive care interventions in facilitating the infant's remarkable recovery and discharge.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies.

AIM: To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS: A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS: Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION: Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Relationship between the systemic immune-inflammatory index and the severity of acute bronchiolitis in children.

OBJECTIVE: Acute bronchiolitis (AB) is one of the most common respiratory diseases in early childhood and is still an important health problem worldwide. The systemic immune-inflammatory index (SII) is thought to have potential to be a new-generation inflammatory biomarker. We sought to investigate the value of SII for severity assessment in children with AB. METHODS: A total of 74 AB patients were included in a prospective observational study. Patients were classified into 3 AB groups according to this classification: mild (1-5 points), moderate (6-10 points), and severe (11-12 points). Complete blood count, C-reactive protein, and procalcitonin tests were carried out. Modified Tal score was evaluated to determine severity. The performance of parameters to predict the severity of AB was assessed using the receiver operating characteristic (ROC). RESULTS: Whereas neutrophil count (P = .037), neutrophil-to-lymphocyte ratio (P = .030), and SII (P = .030) values increased significantly with disease severity, red cell distribution width (P = .048) values were higher in the moderate AB group. The SII was found to have the highest area under the curve in the comparison of the mild-moderate groups combination and the high group on ROC analysis (P = .009). CONCLUSION: The SII values of pediatric patients hospitalized with the diagnosis of AB were significantly higher in the high-severity group. The SII may offer additional severity stratification in children with AB.

Intravenous Magnesium Sulfate for Acute Bronchiolitis: Evaluation of the Effect on Clinical Course and Outcomes.

The aim of the present study was to assess the efficacy of intravenous (IV) magnesium sulfate (MgSO4) for children with bronchiolitis. A retrospective cohort study was performed at a pediatric emergency department. Aged between 1 and 24 months, children with moderate/severe bronchiolitis according to the Modified Respiratory Distress Assessment Instrument (mRDAI) score were included. Patients who received 40 mg/kg/dose of IV MgSO4 (group 1, n: 74) or not (group 2, n: 33) were compared. Respiratory rate and mRDAI score significantly decreased at the second hour of MgSO4 treatment and the decrease was observed for 4th, 8th, and 12th hours, compared with group 2. Patients in group 2 had a higher rate of requirement and an earlier start high-flow nasal cannula oxygen therapy and a longer hospital stay than group 1. Intravenous MgSO4 provided significant improvement on clinical severity, need for respiratory support, length of hospital stay, and outcomes.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials.

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .

Inhaled nitric oxide in acute bronchiolitis: A systematic review and meta-analysis.

OBJECTIVE: Until date there is lack of effective therapies in acute bronchiolitis in infants. The aim was to analyze inhaled nitric oxide efficacy in acute bronchiolitis. DESIGN: Systematic review and meta-analysis of randomized controlled trials. SETTING: Pediatric specialized healthcare. PATIENTS: All infants (age less than 2 years) having acute bronchiolitis, which requires emergency room visit or hospitalization. INTERVENTION: Inhaled nitric oxide. MAIN OUTCOME MEASURES: Need for intensive care unit admission. Secondary outcomes were length of hospital stay and adverse events. Risk ratios (RR) and mean differences with 95% confidence intervals (CI) calculated by random-effects DerSimonian and Laird inverse variance method. Peto Odds ratios were used for rare outcomes. Evidence certainty assessed according to GRADE. RESULTS: 186 studies were screened and three included for analysis. Two had low risk of bias and one had some concerns. Three studies (166 infants) analyzed length of hospital stay and the duration was -11.3 h (CI: -26.8 to +4.2 h) shorter in the nitric oxide group. Evidence certainty was ranked as low. Overall adverse event rates were similar (3 studies, 166 infants, RR: 0.94, CI: 0.70-1.26), but treatment related harms were more common in nitric oxide group (2 studies, 98 infants, OR: 3.86, CI: 1.04-14.40). Evidence certainty in both was rated as low. CONCLUSIONS: Low certainty evidence suggests that inhaled nitric oxide does not reduce length of hospital stay but may have higher rate of treatment associated harms. Future studies with larger sample sizes are needed to better estimate both the efficacy and adverse events.

Air pollution after acute bronchiolitis is a risk factor for preschool asthma: a nested case-control study.

BACKGROUND: Acute bronchiolitis and air pollution are both risk factor of pediatric asthma. This study aimed to assess subsequent exposure to air pollutants related to the inception of preschool asthma in infants with acute bronchiolitis. This study aimed to assess subsequent exposure to air pollutants related to the inception of preschool asthma in infants with acute bronchiolitis. METHODS: A nested case-control retrospective study was performed at the Kaohsiung Medical University Hospital systems between 2009 and 2019. The average concentration of PM10, PM2.5, SO2, NO, NO2, and NOX was collected for three, six, and twelve months after the first infected episode. Adjusted regression models were employed to evaluate the association between asthma and air pollution exposure after bronchiolitis. RESULTS: Two thousand six hundred thirty-seven children with acute bronchiolitis were included. Exposure to PM10, PM2.5, SO2, NO, NO2, and NOX in the three, six, and twelve months following an episode of bronchiolitis was found to significantly increase the risk of preschool asthma in infants with a history of bronchiolitis.(OR, 95%CI: PM10 = 1.517-1.559, 1.354-1.744; PM2.5 = 2.510-2.603, 2.148-3.061; SO2 = 1.970-2.040, 1.724-2.342; ; NO = 1.915-1.950, 1.647-2.272; NO2 = 1.915-1.950, 1.647-2.272; NOX = 1.752-1.970, 1.508-2.252) In a sensitive analysis of hospitalized infants, only PM10, PM2.5, SO2, and NO were found to have significant effects during all time periods. (OR, 95%CI: PM10 = 1.613-1.650, 1.240-2.140; PM2.5 = 2.208-2.286, 1.568-3.061; SO2 = 1.679-1.622, 1.197-2.292; NO = 1.525-1.557, 1.094-2.181) CONCLUSION: The presence of ambient PM10, PM2.5, SO2 and NO in the three, six, and twelve months following an episode of acute bronchiolitis has been linked to the development of preschool asthma in infants with a history of acute bronchiolitis.

Outcomes of viral coinfections in infants hospitalized for acute bronchiolitis.

BACKGROUND AND OBJECTIVE: The clinical relevance of the detection of multiple respiratory viruses in acute bronchiolitis (AB) has not been established. Our goal was to evaluate the effect of viral coinfections on the progression and severity of AB. METHODS: A retrospective observational study was conducted in a tertiary hospital in Spain from September 2012 to March 2020. Infants admitted for AB with at least one respiratory virus identified by molecular diagnostic techniques were included. A comparison was made between single-virus infections and viral coinfections. The evolution and severity of AB were determined based on the days of hospitalization and admission to the pediatric intensive care unit (PICU). RESULTS: Four hundred forty-five patients were included (58.4% male). The median weight was 5.2 kg (IQR 4.2-6.5), and the median age was 2.5 months (IQR 1.4-4.6). A total of 105 patients (23.6%) were admitted to the PICU. Respiratory syncytial virus (RSV) was the most frequent etiological agent (77.1%). A single virus was detected in 270 patients (60.7%), and viral coinfections were detected in 175 (39.3%), of which 126 (28.3%) had two viruses and 49 (11%) had three or more viruses. Hospital length of stay (LOS) increased in proportion to the number of viruses detected, with a median of 6 days (IQR 4-8) for single infections, 7 days (IQR 4-9) for coinfections with two viruses and 8 days (IQR 5-11) for coinfections with ≥ 3 viruses (p = 0.003). The adjusted Cox regression model showed that the detection of ≥ 3 viruses was an independent risk factor for a longer hospital LOS (HR 0.568, 95% CI 0.410-0.785). No significant association was observed between viral coinfections and the need for PICU admission (OR 1.151; 95% CI 0.737-1.797). CONCLUSIONS: Viral coinfections modified the natural history of AB, prolonging the hospital LOS in proportion to the number of viruses detected without increasing the need for admission to the PICU.

SIGNIFICANCE: What is KnownThe main etiological agent of acute bronchiolitis (AB) is respiratory syncytial virus (RSV); however, other viruses are frequently detected. All viruses may be the sole etiological cause or may occur in association, and a high prevalence of viral coinfection has been described.To date, there are conflicting results on the role of viral coinfections in the severity of bronchiolitis.What is NewViral coinfections influence the progression of AB. The simultaneous detection of 3 or more respiratory viruses is a risk factor for longer hospital stay.The presence of viral coinfections does not condition a greater need for admission to the PICU.

Clinical application of a lung sound analysis in infants with respiratory syncytial virus acute bronchiolitis.

BACKGROUND: Objective investigation of the characteristics of acute bronchiolitis in infants is important for its diagnosis and treatment. METHODS: Lung sound data of 50 patients diagnosed with respiratory syncytial virus (RSV) acute bronchiolitis (m:f = 29:21, median of age 7 months), 20 patients with RSV acute respiratory tract infections without acute bronchiolitis (m:f = 10:10, 5 months) and 38 age-matched control infants (m:f = 23:15, 8 months) were analyzed using a conventional method and compared. Furthermore, the relationships between lung sound parameters and clinical symptoms (clinical score, length of hospital stay and SpO2 level) in the bronchiolitis and the non-bronchiolitis patients were examined. RESULTS: Results of lung sound analysis showed that the inspiratory sound power of patients with RSV respiratory tract infections was low and the expiratory sound power was high compared with those of the controls. When the patients with RSV respiratory tract infections were divided into the bronchiolitis and non-bronchiolitis groups, the expiratory/inspiratory ratio of the bronchiolitis patients was greater than that of the non-bronchiolitis patients. There was no difference in the clinical symptoms, clinical score and length of hospital stay between the bronchiolitis and non-bronchiolitis patients, except for the SpO2 level on admission. CONCLUSION: Lung sound analysis confirmed that patients with RSV acute bronchiolitis present with marked airway narrowing. Considering these results as a characteristic of acute bronchiolitis, it would be meaningful to reflect it in the improvement of diagnosis, treatment and subsequent management.

In Vivo Evidence of Respiratory Syncytial Virus Persistence in a Subset of Pulmonary Dendritic Cells Following a Primary Infection.

Respiratory syncytial virus (RSV) causes annual epidemics of infections affecting the whole population. In vitro, it has been shown to infect and persist in human dendritic cells (DCs) for prolonged periods. Initially persistence is associated with low levels of replication before the virus becomes dormant. Reactivation of viral replication can be triggered many months later. Infection of DCs is likely to influence the host's ability to generate effective long-term memory responses. A well-established animal was utilized to confirm that RSV both infects and persists in pulmonary DCs in vivo. Mice were infected with a modified strain of RSV expressing red fluorescent protein (RSV-RFP) when replicating. Clinical symptoms of infection were monitored using weight change and inflammatory cell counts from bronchoalveolar lavage, which correlated with the RSV viral titer (quantitative polymerase chain reaction). Lung tissues were collected at 3, 5, 7, and 21 days postinfection (dpi) to assess leukocyte populations by flow cytometry. Clinical symptoms and RSV viral load peaked at 5 dpi. RSV-RFP was most prevalent in macrophages at 3 dpi and also observed in B cells and DCs. At 21 dpi, RSV-RFP remained evident in a subset of conventional DCs (CD103+CD11b+) even though both clinical symptoms and pulmonary inflammation had resolved. These results confirm that in this well-established mouse model, RSV persists in lung conventional DCs following resolution of the acute infection. Further work is required to explore whether the virus continues with low-level replication before becoming dormant in vivo, as has been described in vitro.

Etiologies of Acute Bronchiolitis in Children at Risk for Asthma, with Emphasis on the Human Rhinovirus Genotyping Protocol.

This research aims to determine acute bronchiolitis' causative virus(es) and establish a viable protocol to classify the Human Rhinovirus (HRV) species. During 2021-2022, we included children 1-24 months of age with acute bronchiolitis at risk for asthma. The nasopharyngeal samples were taken and subjected to a quantitative polymerase chain reaction (qPCR) in a viral panel. For HRV-positive samples, a high-throughput assay was applied, directing the VP4/VP2 and VP3/VP1 regions to confirm species. BLAST searching, phylogenetic analysis, and sequence divergence took place to identify the degree to which these regions were appropriate for identifying and differentiating HRV. HRV ranked second, following RSV, as the etiology of acute bronchiolitis in children. The conclusion of the investigation of all available data in this study distributed sequences into 7 HRV-A, 1 HRV-B, and 7 HRV-C types based on the VP4/VP2 and VP3/VP1 sequences. The nucleotide divergence between the clinical samples and the corresponding reference strains was lower in the VP4/VP2 region than in the VP3/VP1 region. The results demonstrated the potential utility of the VP4/VP2 region and the VP3/VP1 region for differentiating HRV genotypes. Confirmatory outcomes were yielded, indicating how nested and semi-nested PCR can establish practical ways to facilitate HRV sequencing and genotyping.

Respiratory Syncytial Virus-Load Kinetics and Clinical Course of Acute Bronchiolitis in Hospitalized Infants: Interim Results and Review of the Literature.

Respiratory Syncytial Virus (RSV) bronchiolitis is the leading cause of hospitalization in infants. The role of RSV load in disease severity is still debated. We present the interim results of a prospective monocentric study enrolling previously healthy infants hospitalized for RSV bronchiolitis, collecting nasopharyngeal aspirates every 48 h from admission to discharge, and evaluating RSV load dynamics in relation to clinical outcome measures of bronchiolitis severity, including: need, type and duration of oxygen therapy, length of hospitalization, and the bronchiolitis clinical score calculated at admission. The results showed that the highest viral replication occurs within the first 48 hours after admission, with a significant decrease at subsequent time points (p < 0.0001). Moreover, higher RSV-RNA values were associated with the need for oxygen therapy (p = 0.03), particularly high-flow nasal cannula type (p = 0.04), and longer duration of respiratory support (p = 0.04). Finally, higher RSV load values were correlated with lower white blood cells, especially lymphocyte counts and C-reactive protein levels (p = 0.03, p = 0.04, and p = 0.01, respectively), as well as with patients of a younger age (p = 0.02). These data suggest that RSV may actively contribute to the clinical severity of bronchiolitis, together with other potential non-viral factors.

Epidemiology and Risk Factor Analysis of Children with Bronchiolitis Admitted to the Intensive Care Unit at a Tertiary Care Center in Saudi Arabia.

Bronchiolitis is a leading cause of hospitalization worldwide for children aged ≤2 years. Few studies have compared general ward and pediatric intensive care unit (PICU) admissions, particularly in Saudi Arabia. This retrospective cohort study aimed to compare the demographic and clinical characteristics of children with bronchiolitis admitted to the general ward with those admitted to the PICU. Children (≤6 years) previously diagnosed with bronchiolitis and admitted to the PICU or general ward at a tertiary center in Saudi Arabia between May 2016 and May 2021 were included. Multiplex polymerase chain reaction was used to identify respiratory viruses. Of the 417 patients enrolled, 67 (16.06%) were admitted to the PICU. The PICU group was younger (median, 2 months; interquartile range [IQR], 1-5 months) vs. (6 months; IQR, 2.65-13.25 months). There was a dramatic reduction in bronchiolitis admissions during the COVID-19 pandemic. The most common causative virus was respiratory syncytial virus (RSV) (54.9%). In the multivariate regression analysis, hypoxia, hyperinflation on X-ray, and non-RSV bronchiolitis were independently associated with PICU admission. However, a higher chronological age and cough were protective. Children with Down syndrome, immunodeficiency, or neuromuscular disorders, and intermediate preterm infants (29-33 weeks of gestation) are at a high risk of PICU admission (adjusted odds ratio: 2.4, 7.1, 2.9, and 2.9; p = 0.037, 0.046, 0.033, and 0.029, respectively). Bronchiolitis is still one of the leading causes of PICU admission. Particular attention should be paid to preventive measures, especially in the post-COVID-19 era, targeting high-risk groups.

Evaluation of targeted implementation interventions for reducing investigations and therapies in infants with bronchiolitis.

AIM: To evaluate the impact of locally adapted targeted implementation interventions on bronchiolitis management through reduction in ineffective investigation and therapies within emergency departments. METHODS: A multi-centred, quality improvement study in four different grades of hospitals in Western Australia that provide paediatric emergency and inpatient care. All hospitals incorporated an adapted implementation intervention package for infants under 1 year with bronchiolitis. The proportion whose care complied with guideline recommendations to not receive investigations and therapies of minimal benefit were compared to pre-intervention care in a previous bronchiolitis season. RESULTS: A total of 457 infants in 2019 (pre-intervention) and 443 in 2021 (post-intervention) were included, with mean age of 5.6 months (SD 3.2, 2019; SD 3.0, 2021). In 2019, compliance was 78.1% versus 85.6% in 2021, RD 7.4 (95% CI -0.6; 15.5). The strongest evidence was reduced salbutamol use (compliance improvement: 88.6% to 95.7%, RD 7.1 95% CI (1.7; 12.4)). Hospitals initially at <80% compliance demonstrated greatest improvements (Hospital 2: 95 (78.5%) to 108 (90.8%) RD 12.2 95% CI (3.3; 21.2); Hospital 3: 67 (62.6%) to 63 (76.8%) RD 14.2 95% CI (1.3; 27.2)). CONCLUSION: Targeted site-adapted implementation interventions resulted in improvement in compliance with guideline recommendations, particularly for those hospitals with initial low compliance. Maximising benefits through guidance on how to adapt and effectively use interventions will enhance sustainable practice change.

Molecular Typing of Mastadenoviruses in Simultaneously Collected Nasopharyngeal Swabs and Stool Samples from Children Hospitalized for Acute Bronchiolitis, Acute Gastroenteritis, and Febrile Seizures.

This study determines and compares the frequency of human mastadenovirus (HAdV) presence in children with acute bronchiolitis (AB), acute gastroenteritis (AGE), and febrile seizures (FS), ascertains types of HAdVs associated with each individual syndrome and contrasts the findings with a control group of children. The presence of HAdVs was ascertained in simultaneously collected nasopharyngeal (NP) swabs and stool samples amplifying the hexon gene by RT-PCR; these were sequenced to determine the types of HAdVs. HAdVs were grouped into eight different genotypes. Of these, three (F40, F41, and A31) were found solely in stool samples, whereas the others (B3, C1, C2, C5, and C6) were found in both stool samples and NP swabs. The most common genotypes in NP swabs were C2 (found in children with AGE and FS) and C1 (only in children with FS), whereas in stool samples genotypes F41 (in children with AGE) and C2 (in children with AGE and FS) prevailed, and C2 was simultaneously present in both samples. HAdVs were more often detected in stool samples than in NP swabs in patients (with the highest estimated viral load in stool samples in children with AB and AGE) and healthy controls and were more common in NP swabs in children with AGE than in children with AB. In most patients, the characterized genotypes in NP swabs and stool samples were in concordance.