Challenges With COVID-19 Co-Infections


Sean O’Leary, MD, shares his approach to addressing respiratory infections that are cocirculating with COVID-19 and which viruses clinicians should test for in children.

Tina Tan, MD: As we’ve seen throughout these last couple of months, there have been multiple respiratory viruses that are cocirculating along with COVID-19 in the US and they’re also surging. That includes RSV [respiratory syncytial virus], flu, and human metapneumovirus [HMPV]. There are just a number of these different viruses. What are the challenges that pediatricians are facing? Are they really trying to make the diagnosis, and then how do they determine who should be treated? Who should be hospitalized, etc.?

Sean O’Leary, MD: Great question. This is a real challenge, especially this past fall when RSV was sort of at record levels. A couple of points here, one, there was a large study, looking at coinfections with COVID-19, and other respiratory viruses, and it appeared that you got more severe illness if you had COVID-19 plus something else. So that’s one thing to consider. A lot of the nonpharmaceutical interventions that we were using, like masks, and all the other things that we all know so well, like social and physical distancing, is out the window in most places. So, we have seen this resurgence of respiratory viruses, and we’ll continue to see more respiratory viruses. That’s just how they work. So, what does a pediatrician do with that?

Well, for me, I think about the ones that you can do something about right now, and what information is going to help you make a therapeutic decision. For me, that’s a flu test and a COVID-19 test, because we have therapeutics that we can potentially use for those. COVID-19 still has some potential isolation and quarantine implications as well. Beyond that, I’m not a big proponent of testing for every single virus to try to figure out what it is we do in select circumstances, like, for example, in our hospital in immunocompromised patients where we need to know what’s causing their illness, or to help direct therapy. Although, for the general healthy population, if it’s going to affect your therapeutic decisions, then go ahead and test for that. Also, knowing that your local epidemiology puts out a report every week or 2 about what’s circulating right now, is important. State health departments often do the same.

If there’s very little flu circulating in your community, then you probably shouldn’t test for flu, because your pretest probability is low enough that a false positive is probably a false positive. If there’s a lot of flu circulating, that may be helpful to test and see. I should have said this at the beginning. These are essentially clinically indistinguishable, even loss of smell, which we know goes along with COVID-19. That can happen with flu, too, right? So, you can’t necessarily hang your hat on that. RSV in younger children has a very distinct clinical picture, but influenza, HMPV, and COVID-19 can all cause bronchitis. So, it’s worth looking for the ones we can do something about.

Tina Tan, MD: No. I completely agree. Many kids that are hospitalized with COVID-19 now have coinfections with other respiratory viruses. This has really made some of them quite sick, especially some of the younger babies that are on ECMO [extracorporeal membrane oxygenation] because they have acute respiratory failure. It’s something that’s worth paying attention to out in the community when you have somebody presenting to you with potentially COVID-19 and some other respiratory infection.

Transcript edited for clarity

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