Background
Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are used at rates of 34% to 99% in uncomplicated cases.

Objectives
To evaluate the effectiveness of antibiotics for bronchiolitis.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2010, issue 4), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (January 1966 to November 2010), EMBASE (1990 to December 2010) and Current Contents (2001 to December 2010).

Selection criteria
Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, re-admissions, complications or adverse events and radiological findings.

Data collection and analysis
Two review authors independently analysed the search results.

Main results
Five studies (543 participants) met our inclusion criteria. One study randomised 52 children to either ampicillin or placebo and found no significant difference between the two groups for length of illness. A small study (21 children) with higher risk of potential bias randomised children with proven RSV infection to clarithromycin or placebo and found clarithromycin may reduce hospital re-admission (8% antibiotics versus 44% placebo; Fishers exact; P = 0.081). The two studies (267 children) providing adequate data for length of hospital stay showed no difference between antibiotics and control (pooled mean difference 0.34; 95% CI -0.71 to 1.38). Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures. None of the trials reported deaths.

Authors' conclusions
This review found minimal evidence to support the use of antibiotics for bronchiolitis. Research to identify a possible small subgroup of patients who have complications from bronchiolitis such as respiratory failure and who may benefit from antibiotics is justified.

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Antibiotics for bronchiolitis in children

Respiratory syncytial virus (RSV) is the most common respiratory pathogen in infants and young children worldwide. More than 50 years after its discovery, and despite relentless attempts to identify pharmacological therapies to improve the clinical course and outcomes of this disease, the most effective therapy remains supportive care. Although the quest for a safe and effective vaccine remains unsuccessful, pediatricians practicing during the past decade have been able to protect at least the more vulnerable patients with safe and effective passive prophylaxis. This review summarizes the history, microbiology, epidemiology, pathophysiology, and clinical manifestations of this infection in order to provide the reader with the background information necessary to fully appreciate the many challenges presented by the clinical management of young children with bronchiolitis. The last part of this article attempts an evidence-based review of the pharmacologic strategies currently available and those being evaluated, intentionally omitting highly experimental approaches not yet tested in clinical trials and, therefore, not likely to become available in the foreseeable future.

Respiratory syncytial virus prevention and therapy: past, present, and future.

Background: Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are often used. Objectives: To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014). Selection criteria: Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings. Data collection and analysis: Two review authors independently analysed the search results. Main results: We included seven studies with a total of 824 participants. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission. In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness. One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin. The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02). Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures. There were no deaths reported in any of the arms of the seven included studies. No other adverse effects were reported. Authors' conclusions: This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics.

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Antibiotics for bronchiolitis in children under two years of age

Severe bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit. This was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports. Patients’ baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95 % CI 1.5–2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €. nCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden.

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Improved clinical and economic outcomes in severe bronchiolitis with pre-emptive nCPAP ventilatory strategy.

Bronchiolitis is one of the most common causes of respiratory failure in infants. There are no established treatment options for bronchiolitis. Surfactant may be useful in bronchiolitis because of its favourable effect on lung mechanics. Three small randomised controlled trials (RCTs) enrolling 79 participants suggested that the use of surfactant for critically ill infants and children with bronchiolitis may decrease the duration of mechanical ventilation and duration of intensive care unit stay without any side effects. The limited number of studies with small numbers of participants were the limitations of this review. No adverse effects and no complications were observed in the treatment group or control group of any of the three included studies. There is a need for larger trials to establish such benefits of surfactant for bronchiolitis in critically ill infants and children.

/pdf/surfactant-therapy-for-bronchiolitis-in-critically-ill-2yz1ltg9t4.pdf

Surfactant therapy for bronchiolitis in critically ill infants

Four hundred and twenty nine young children with bronchiolitis admitted consecutively in different hospitals of Bangladesh were evaluated. Three hundred and forty eight children studied for their putative risk factors, clinical profile, management and the outcome. Both cases and controls were examined for respiratory syncytial virus (RSV) antibody status. The diagnosis of bronchiolitis was made on the basis of first attack of wheeze in previously healthy children below two years of age. Detailed history including the possible risk factors, the management and daily follow-up on the ward and the outcome at discharge were documented through a structured questionnaire. Chest x-ray was done in each case to find out the radiological changes. Blood of 266 patients and 30 controls were studied for RSV IgM and IgG antibody by ELISA. There were 66% male and 34% female children. The median age of the children was 3.0 months and 82.7% were below 6 months of age. Most of the babies were born term (88%), with ABW (73%), by normal vaginal delivery (88%). Exclusive or predominant breast-feeding were given in 72% cases. The location of the patient was rural in 55% cases. Around half of the parents were illiterate or slightly educated (up to 5 years schooling) fathers 46.5% and mothers 56% and majority of the parents were poor (74%). In 52% cases the number of family members in one room were four or more. Half of the parents (52%) were smokes and there was atopy in 26.5% families. The clinical features of bronchiolitis were mostly cough (99%), respiratory distress (97%), feeding difficulty (93%) and fast breathing (96%) (median RR 68/min). Fever (1000F or more) was in only 33% cases, though parents complained in 90% cases. All children (100%) had wheeze and crackles in lungs in 96% cases. Liver could be palpable in 83% and spleen in 42% cases. Important radiological features were increased translucency (96%), increased interstitial markings (87%), hyperinflation (75%) and streaky densities (61%). In 69.6% cases TLC was 12,000 or less and only 15% with a neutrophil fraction greater than 60%. Children were positive for IgM antibody in 43.6% cases and both IgM and IgG in 5.3% cases. The main modalities of treatment were antibiotics (99%) (Ampicillin, 76%), oxygen therapy (83%), nebulised salbutamol (76%) and intravenous fluid (51%). The median duration of hospital stay was 4 days. Most of the children were discharged with improvement (96%) with 2% mortality. Not a single case was diagnosed as bronchiolitis in hospitals outside Dhaka. Cefrtiaxone (72.5%) and parenteral steroids (70.5%) were the mainstay of therapy there.

Evaluation of hospitalized infants and young children with bronchiolitis - a multi centre study

The Coronavirus disease 2019 (COVID-19) has turned into a worldwide human tragedy and economic devastation. There had an intensive search for an effective drug against the coronavirus but not led to any breakthrough agents. Only one choice was left namely an effective and safe vaccine. Many people are ambivalent regarding corona vaccines because they also fear possible side effects from vaccination. This study was designed to track the side effects after first and second dose of the Oxford-AstraZeneca vaccines used in Mymensingh district of Bangladesh. This cross-sectional descriptive type of observational study was conducted in Mymensingh Medical College, Mymensingh, Bangladesh during the period of five months from 1 February, 2021 to 30 June, 2021 among 293 purposively selected vaccine recipients who received two doses of the Oxford-AstraZeneca vaccines. Data were collected by face to face interview of the selected vaccine recipients using a semi-structured questionnaire. Data were inputted into SPSS version 26.0. Qualitative data were summarized by percentage and quantitative data were summarized by mean and standard deviation. Necessary bivariate and multivariate analysis was done. Mean age of the respondents was 40.3 years with a standard deviation of ±8.7 years. Among the vaccine recipients female were 159(54.3%) and male were 134(45.7%). The most of the vaccine recipients were graduate and master 256(87.3%) and more than half of the vaccine recipients (156, 53.2%) were government service holder. The most of the vaccine recipients (242, 86.0%) were from urban area and 263(89.8%) vaccine recipients were non-smoker. Sixty eight (23.2%) of the vaccine recipients had different types of co-morbidities. It was found that 217(74.1%) vaccine recipients had side effects after first dose while 162(55.3%) had side effects after second dose. The difference in occurrence of side effects of first and second dose was statistically highly significant (p<0.001). Pain on the injection site was present in 172(58.7%) vaccine recipients after first dose and in 142 (48.5%) after second dose. Fever was prevalent in 98 (33.4%) after first dose and in 61 (20.8) after second dose. Headache was in 61(20.8%) and in 22(7.5%) after first and second dose respectively. Thirty one (10.6%) vaccine recipients had loose motion after first dose and 26(8.9%) had this after second dose. First dose of vaccination caused nausea in 28(9.6%) and second dose caused it in 16(5.5%) vaccine recipients. Joint pain was prevalent in 24(8.2%) after first dose and in 15(5.1%) after second dose. Rash was present in 9(3.1%) and in 3(1.0%) after first and second dose respectively. Cough was present in 5(1.7%) after first dose and in 2(0.7%) after second dose. Each 2(0.7%) had history of fainting and bodyache and 1(0.3%) reported intense weakness after first dose only. Side effects of first dose of AstraZeneca vaccine were more prevalent in female (124, 78.0%) than male (93, 69.4%). The side effects of second dose of AstraZeneca vaccine were also more prevalent in female (103, 64.8%) than male (59, 44.0%). The study results revealed that 217(74.1%) vaccine recipients had side effects after first dose while 162(55.3%) had side effects on second dose of the Oxford-AstraZeneca vaccine. Commonly experienced side effects were pain in the injection site, fever, headache, diarrhoea and joint pain. Most of the people tolerated these side effects and did not use any medicine.

Tracking Side Effects of the COVID-19 Vaccine in Mymensingh District of Bangladesh.

Background: The presentation of corona virus disease 2019 (COVID-19) may include neurological features and patients with neurological disorders may develop concomitant COVID-19 during pandemic. Hyperglycemia leads to higher propensity to COVID-19 infection with higher disease severity. 
Objective: To assess the neurological diagnoses, glycemic status and outcome in patients hospitalized primarily for neurological problems and subsequently diagnosed as COVID-19. 
Methods: This retrospective cohort study was conducted in National Institute of Neurosciences (NINS) & Hospital, Dhaka, Bangladesh. Patients admitted to adult Neurology ward during April to November 2020 primarily for neurological problems and diagnosed as confirmed COVID-19 (with positive RT-PCR test for COVID-19) were included. The hospital records were reviewed and recorded in a checklist. Outcome of patients referred to COVID-19 dedicated hospitals was obtained over telephone. 
Results: The study included 85 patients with COVID-19 [median age 60 years (IQR: 45-65); 63.5% male]. Acute ischemic stroke was the most common neurological diagnosis (32.9%), followed by acute hemorrhagic stroke and subarachnoid hemorrhage (22.4% and 15.3% respectively). Other neurological diagnoses were meningoencephalitis (7.1%), Guillain Barre Syndrome (4.7%), Myasthania Gravis (1.2%), brain abscess (1.2%) and intracranial space occupying lesion (1.2%). Fourteen percent patients had no definite neurological diagnosis, they were admitted for delirium. History of diabetes was present in 18% patients. The mortality was 27% and the proportion of mortality was significantly higher in patients known to have DM in comparison to those who were not (p=0.012). The mean age and proportion of male sex was significantly higher among those who expired. 
Conclusion: There is high rate of mortality in neurological patients with COVID-19 who have variable neurological diagnosis including stroke, autoimmune disease and cerebral infections. Co-existent diabetes further increases the rate of mortality. 
Journal of National Institute of Neurosciences Bangladesh, July 2021, Vol. 7, No. 2, pp. 97-102

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S Akhter

Papers

Evaluation of hospitalized infants and young children with bronchiolitis - a multi centre study

Tracking Side Effects of the COVID-19 Vaccine in Mymensingh District of Bangladesh.

Glycemic Status and Outcome of Neurological Patients with COVID-19 Admitted at Referral Neuroscience Institute of Bangladesh