Respiratory syncytial virus in pediatric patients admitted to a tertiary center in Amman: clinical characteristics, and age-related patterns

RSV is a significant cause of respiratory infections in children. This study presents the demographic and clinical characteristics of children affected with RSV. In terms of demographics, there was a predominance of male children in the study population, which aligns with previous literature suggesting a potential gender susceptibility to RSV [8, 14, 15]. The majority, being less than one year old, emphasizes the vulnerability of infants to RSV, reflecting a common pattern in RSV epidemiology [6]. In our study, the majority affected by RSV were term gestational age and had no co-morbidities. RSV is a heavy burden to children, families, and the health system since it is shown that the majority of those affected and hospitalized are healthy and full-term [1, 6]. Our study’s mean length of stay (LoS) of 9.3 days reflects RSV’s substantial burden on healthcare resources. The recent approval of nirsevimab is particularly significant, as it is eligible for administration in healthy infants under eight months old, potentially decreasing healthcare visits and hospitalizations [13]. The availability and approval of Nirsevimab globally, specifically in low and middle-income countries, could potentially contribute to lowering RSV-related mortality in those regions.

In the present study, over 93% who were admitted to the general inpatient unit or ICU did not experience prior exposure to RSV. This suggests that a history of RSV infection may provide some immunity, which could prevent severe symptoms that may require admission. Two studies reported similar findings, where previous RSV infection is effective in giving short immunity for several months, reducing the risk of severe reinfection and minimizing its duration [16, 17].

Like other lower respiratory infections, the most frequent symptoms in RSV-infected children were cough, shortness of breath, and wheezing. The high percentage of patients requiring oxygen therapy and ICU admission highlights the severity of RSV infections. In a study conducted by Khouri et al., it was found that RSV-positive children are more likely to require oxygen [10]. When comparing age groups and clinical characteristics, our study found patients over the age of one presenting with more shortness of breath than infants. We also found that 70% of our patients over the age of 2 years required ICU admission, which was more significant than patients under 2 years. Older children have a higher likelihood of having co-morbidities, which can increase the risk of severe RSV. In general, RSV globally causes significant morbidity and mortality burden in children 0–5 years old, especially in the first six months of life and in low- or middle-income countries [3].

Our study found that a third of the patients had co-infections. Khouri et al. highlighted that RSV-positive subjects co-infected with other respiratory viruses presented less frequently with nasal congestion and sore throat [10]. In most cases, there are no differences in clinical severity in patients with RSV mono-infections and RSV co-infections [11]. We found no statistical difference when comparing mono-RSV infection and co-infections except in respiratory rate, which was elevated in co-infections. Of the 199 children in our study, around 174 (87.4%) of RSV-infected patients were given antibiotics. This rate exceeds the rates of antibiotic prescriptions found in the USA, Canada, and Europe, which is only around 40–45% [18, 19]. Previous literature suggests that bacterial co-infections in RSV infections are generally considered rare, with one study reporting a prevalence of 1.2% [18]. However, recent studies by Thorburn et al., Ghazaly et al., and Yang et al. have revealed higher rates of bacterial co-infections, particularly in severe RSV cases requiring intensive care unit (ICU) admission and intubation [20‐22]. The high rate of antibiotic use among our cohort despite only 50% required PICU admission may be attributed to the lack of routine laboratory diagnosis of viral infection in Jordan, which can lead to antibiotics administration for respiratory infections in children, or due to the haphazard antibiotics prescription similar to other developing countries [23]. Additionally, results from a nasopharyngeal aspirate (NPA) at institutions offering this test may be available within one to a couple of days. Furthermore, a recent report by Hamdan et al. discusses the patterns of antibiotic use in children hospitalized with RSV in Amman. The report highlights that clinicians in developing countries, where testing for common respiratory viruses is unavailable, rely on clinical presentation and judgment to differentiate between viral and bacterial infections [24].

A limitation of the study was a small study population. Our study included one center; we would suggest a multi-center study throughout Jordan to get more conclusive surveillance.