International variation in the management of infants hospitalized with respiratory syncytial virus

Respiratory syncytial virus (RSV) is a frequent cause of hospitalization among infants. To compare patient management in Europe, the United States, and Australia, we analyzed the charts of 1,563 pediatric patients hospitalized with laboratory-confirmed RSV lower respiratory infections during recent RSV seasons. Half of patients had been seen initially as outpatients. Median duration of hospitalization was 4 days in Australia, Finland, the United Kingdom, and the United States, and 8 or 9 days in Belgium, France, Germany, Italy, and the Netherlands. In a linear regression model that included clinical findings, underlying conditions, prematurity, and age, the leading variable associated with length of stay was "hospitalization in continental Europe". This geographic factor conferred a 1.8-fold longer stay (95% CI: 1.7-1.9) than hospitalization elsewhere. Utilization of nine supportive therapies for RSV varied widely among hospitals, even within the same country. The individual hospital was strongly associated with the use of every therapy studied, independent of patient characteristics and clinical status. Conclusion Management of RSV patients varies markedly by country and hospital. Multicenter RSV trials that measure length of stay should standardize criteria for "readiness for discharge". It may be appropriate to limit international trials to countries with similar median stays for RSV. Variability within multicenter trials could be further controlled by standardizing the use of other therapies and the diagnosis of complications.