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EM Physicians Rarely Consider RSV as Differential Influenza Diagnosis in Adults

As of mid-January, about 9,000 Americans with laboratory-confirmed influenza had sought care for their respiratory ailments and were admitted to the hospital, according to data from the national Centers for Disease Control and Prevention.

However, the flu is not the only dangerous respiratory virus circulating out there.

A report in the American Journal of Emergency Medicine points out that respiratory syncytial virus (RSV) has been recognized for more than 50 years as a cause of morbidity in infants and children.

In the last two decades or so, RSV has been linked to 177,000 annual hospitalizations and as many as 14,000 deaths in older adults during a season that roughly coincides with influenza, a study team lead by researchers from the Alpert School of Medicine at Brown University emphasizes.

At the start of the study, the researchers posited that emergency physicians do not routinely consider RSV in the differential diagnosis (DDx) of influenza-like illness.

To determine if that was the case, the research team conducted an observational study at a university-affiliated urban emergency department (ED) from 2007 to 2014. The focus was all adult inpatients older than 19 with a positive RSV swab ordered within 48 hours of their hospital visit, including their ED visit.

After a data collection form was created, it was used by a single trained clinical research assistant to abstract demographic and clinical variables. The study gave credit to ED care providers for RSV DDx if an RSV swab was ordered as part of the diagnostic ED workup.

Results indicate that a diagnosis of RSV was considered in the ED in only 36% of patients.

The study focused on 295 consecutive inpatients, averaging 66.5 years old with slightly more men than women, who were RSV-positive during the seven-year study period.

Results indicate most patients, 70%, were 60 or older. In terms of clinical presentation, 26% had fever, 29% had oxygen saturation less than 92%, and 49% were wheezing. Most of the patients, 279, required admission, 30 of whom were sent to intensive care units, and 12 patients died.

More than one-third of the patients were immunocompromised patients — 23% were transplant patients, 40% had cancer diagnoses, and 33% had been taking steroids. Yet, researchers point out, being immunocompromised and having COPD/asthma, oxygen saturation less than 92, or wheezing “did not alert the ED provider to order an RSV test.”

When RSV affects adults, it can lead to significant problems and to death, especially in people over age 60, the study authors write. “RSV is not being considered in the DDx diagnosis, and this was especially surprising in the transplant/immunocompromised subgroups,” they note. The researchers advocate educational efforts to raise awareness of RSV in adults and of the antiviral treatment options available.

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