Bronchiolitis: Diagnostic Challenges, Empirical Antibiotic Choices, And Stewardship

Dr. Ayah Mohammed Eshbeel, Dr. Fatema Nadem, Dr. Abdulah Mohammed Abd Alhamed Abou Kaff, Dr. Abdalghani Fuad Mukhalalati

Abstract


Bronchiolitis remains the leading cause of lower respiratory tract infection in infants, posing significant diagnostic and management challenges for pediatric clinicians. This narrative review synthesizes current evidence regarding the epidemiological burden, clinical presentation, diagnostic dilemmas, and evolving management strategies, with a particular focus on empirical antibiotic choices and antimicrobial stewardship. Despite its predominantly viral etiology, bacterial coinfection is a persistent concern, often leading to inappropriate antibiotic prescribing. We explore the utility of diagnostic tools, the role of biomarkers, and the controversies surrounding pharmacological interventions such as bronchodilators and corticosteroids. Furthermore, the review addresses the impact of the post-COVID-19 pandemic epidemiology, the emergence of novel preventive strategies like nirsevimab, and the specific considerations for high-risk populations. By highlighting key clinical takeaways, identifying practice gaps, and outlining future research priorities, this article aims to optimize diagnostic approaches, promote judicious antibiotic use, and enhance overall care for infants with bronchiolitis.

Keywords


Bronchiolitis, Infants, Respiratory syncytial virus (RSV), Bacterial coinfection, Empirical antibiotic therapy, Antimicrobial stewardship, Nirsevimab, Clinical management

Full Text:

PDF

References


Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742.

National Institute for Health and Care Excellence (NICE). Bronchiolitis in children: diagnosis and management. NICE guideline [NG9]. Published June 1, 2015. Updated August 2021.

World Health Organization (WHO). Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses. 2nd edition. Geneva: WHO; 2013.

Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121-1131. doi:10.1056/NEJMoa1714855.

Jones JM, Fleming-Dutra KE, Prill MM, et al. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(34):920-925. doi:10.15585/mmwr.mm7234a4.

Moline HL, Toepfer AP, Tannis A, et al. Respiratory Syncytial Virus Disease Burden and Nirsevimab Effectiveness in Young Children From 2023-2024. JAMA Pediatr. 2025;179(1):e2427176. doi:10.1001/jamapediatrics.2024.27176.

García-García ML, Calvo C, Rey C, et al. Antibiotic Utilization in Hospitalized Children with Bronchiolitis: A Multi-Center Study. J Clin Med. 2023;12(23):7412. doi:10.3390/jcm12237412.

Osborne CM, et al. Diagnostic Challenges Associated With the Prevalence of Bacterial Coinfection in Bronchiolitis. Hosp Pediatr. 2024;14(8):e355. doi:10.1542/hpeds.2024-007678.

Mecklin M, Heikkilä P, Korppi M. Low age, low birthweight and congenital heart disease are risk factors for intensive care in infants with bronchiolitis. Acta Paediatr. 2017;106(10):1650-1655. doi:10.1111/apa.14021.

Kalil J, et al. Pediatric Inpatient Antimicrobial Stewardship Program Safely Reduces Antibiotic Use in Patients with Bronchiolitis. Pediatr Qual Saf. 2019;4(5):e206. doi:10.1097/pq9.0000000000000206.

Rhim JW, et al. Clinical Factors Associated with Inappropriate Antibiotic Use in Children Hospitalized with Acute Bronchiolitis. Children (Basel). 2025;12(10):1303. doi:10.3390/children12101303.

Buendía JA, et al. Systematic review and meta-analysis of efficacy and safety of continuous positive airways pressure versus high flow oxygen cannula in acute bronchiolitis. BMC Pediatr. 2022;22(1):685. doi:10.1186/s12887-022-03719-x.

Dafydd C, et al. Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis. BMJ Open Respir Res. 2021;8(1):e000844. doi:10.1136/bmjresrc-2020-000844.

Payne AB, et al. Effectiveness of nirsevimab among infants in their first RSV season in the United States, October 2023–March 2024. Lancet Reg Health Am. 2025;41:100912. doi:10.1016/j.lana.2025.100912.

Barnes MVC, et al. Mucosal Immune Responses to Respiratory Syncytial Virus. Cells. 2022;11(7):1153. doi:10.3390/cells11071153.

Sastre B, et al. Immune recovery following bronchiolitis is linked to a drop in inflammatory cytokines. Pediatr Allergy Immunol. 2019;30(3):328-335. doi:10.1111/pai.13021.

Vandini S, et al. Immune and inflammatory response in bronchiolitis due to respiratory syncytial virus. Paediatr Respir Rev. 2017;24:60-64. doi:10.1016/j.prrv.2017.03.001.

Checchia PA, et al. Defining the risk and associated morbidity and mortality of severe respiratory syncytial virus infection among infants with congenital heart disease. Infect Dis Ther. 2017;6(1):31-56. doi:10.1007/s40121-016-0142-x.

Lapillonne A, et al. Impact on parents of bronchiolitis hospitalization of full-term infants. BMC Pediatr. 2012;12:171. doi:10.1186/1471-2431-12-171.

Bradley JS, et al. The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-76. doi:10.1093/cid/cir531.

Friedman JN, et al. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health. 2014;19(9):485-498. doi:10.1093/pch/19.9.485.

Zorc JJ, Hall CB. Bronchiolitis: Recent Evidence on Diagnosis and Management. Pediatrics. 2010;125(2):342-349. doi:10.1542/peds.2009-2092.

Cunningham S, et al. Oxygen targets in babies with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet. 2015;386(9998):1041-1048. doi:10.1016/S0140-6736(15)00163-4.

Everard ML, et al. Inhaled hypertonic saline is not effective for bronchiolitis in infants: a systematic review and meta-analysis. Cochrane Database Syst Rev. 2017;12(12):CD006458. doi:10.1002/14651858.CD006458.pub4.

Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014;(6):CD001266. doi:10.1002/14651858.CD001266.pub4.

Fernandes RM, et al. Glucocorticoids for acute viral bronchiolitis in children and young people. Cochrane Database Syst Rev. 2013;(6):CD004878. doi:10.1002/14651858.CD004878.pub4.

Florin TA, et al. Antibiotic Use and Outcomes in Children Hospitalized With Bronchiolitis. JAMA Pediatr. 2017;171(5):e170043. doi:10.1001/jamapediatrics.2017.0043.

Walsh P, et al. External validation of the Rochester and Philadelphia criteria for identifying serious bacterial infection in febrile infants with bronchiolitis. Arch Pediatr Adolesc Med. 2004;158(11):1044-1048. doi:10.1001/archpedi.158.11.1044.

Schroeder AR, et al. Risk of urinary tract infection in young febrile infants with and without clinical evidence of bronchiolitis. Pediatrics. 2007;120(1):25-31. doi:10.1542/peds.2006-2583.

Levine DA, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infection. Pediatrics. 2004;113(6):1728-1734. doi:10.1542/peds.113.6.1728.




DOI: http://dx.doi.org/10.52155/ijpsat.v58.2.8454

Refbacks

  • There are currently no refbacks.


Copyright (c) 2026 Ayah Mohammed Eshbeel

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.