Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
JAMA Pediatr. 2017 Aug 1;171(8):798-804. doi: 10.1001/jamapediatrics.2017.0786.
While most viral respiratory tract infections can be diagnosed clinically, clinicians frequently order tests to identify the specific offending virus. While there has been tremendous growth in the variety, availability, and sophistication of the types of respiratory viral tests, there may have been less critical thought and discussion among frontline clinicians about the clinical utility and specific indications for testing. We summarize the rationale historically used to support respiratory virus testing in children, with a review of the supporting evidence. We outline potential considerations and limitations of the various types of respiratory viral tests and suggest some clinical indications where viral testing may play an important role in clinical management.
The main value of testing for viruses in children who present with a respiratory tract infection is to differentiate between viral and bacterial infections, hopefully facilitating clinical decision making regarding further investigations and the need for antibiotics. We have highlighted commonly cited rationale used to support testing and the generally poor evidence on which to base this rationale. In addition, difficulties with interpretation of respiratory viral testing results include somewhat poor diagnostic test characteristics for some tests, uncertainty regarding true positives and causation of illness, delay in receiving the test result, and the incidence of concurrent bacterial infections or the presence of multiple viruses. We have given some examples of clinical scenarios where respiratory viral testing results could be expected to contribute to more appropriate clinical management decisions.
It is not good enough to "do" just because we "can." We suggest that for many healthy immune-competent children presenting with typical viral respiratory tract symptoms, the diagnosis can be made clinically, and frontline clinicians should think critically before automatically requesting a somewhat uncomfortable, expensive respiratory viral test, the result of which may not contribute to the child's treatment.
虽然大多数病毒性呼吸道感染可以通过临床诊断，但临床医生经常会进行检测以确定具体的致病病毒。尽管呼吸道病毒检测的种类、可用性和复杂性都有了巨大的发展，但一线临床医生可能对检测的临床应用和具体指征的思考和讨论较少。我们总结了历史上用于支持儿童呼吸道病毒检测的基本原理，并对支持证据进行了回顾。我们概述了各种类型的呼吸道病毒检测的潜在考虑因素和局限性，并提出了一些临床指征，其中病毒检测可能在临床管理中发挥重要作用。
对出现呼吸道感染的儿童进行病毒检测的主要价值是区分病毒和细菌感染，希望这有助于临床决策，进一步调查和使用抗生素的必要性。我们强调了常用于支持检测的常见理由以及支持这一理由的一般较差证据。此外，呼吸道病毒检测结果的解释困难包括一些测试的诊断测试特征较差，对真正阳性和疾病因果关系的不确定性，测试结果的延迟，以及并发细菌感染的发生率或多种病毒的存在。我们给出了一些临床情况的示例，在这些情况下，呼吸道病毒检测结果有望有助于更恰当的临床管理决策。
仅仅因为我们“能够”做某件事并不足够。我们建议，对于许多出现典型病毒性呼吸道症状且免疫功能健全的健康儿童，临床诊断即可做出，一线临床医生在自动要求进行某种不舒服且昂贵的呼吸道病毒检测之前，应进行批判性思考，因为检测结果可能无助于儿童的治疗。
