Community-acquired pneumonia among children: the latest evidence for an updated management

Infectious acute respiratory failure in patients under 5 years of age: a retrospective cohort study

BACKGROUND

Acute lower respiratory infections in children under 5 years present a real challenge for diagnosis and treatment and are the first cause of mortality for this group of age. The study aimed to describe the characteristics of infectious acute respiratory failure due to bronchiolitis, pulmonary infection or severe acute asthma related to a virus or bacteria in this population of children under 5 years old at admission to the paediatric intensive care unit (PICU), PICU management and outcomes in order to better identify the needs of these patients. Our secondary aim was to compare the characteristics and PICU management of this population (1) depending on their age (less or more than 6 months old) and (2) depending on the pulmonary imaging (absence or presence of an alveolar condensation on the chest X-ray or lung ultrasound).

METHODS

We conducted a retrospective study in two PICUs in the Ile-de-France region. We included children under 5 years old hospitalised between 1 January 2017 and 31 December 2021 due to a respiratory infection complicated by acute respiratory failure.

RESULTS

We included 707 patients. The median age was 3 months. On arrival, patients were oxygen-dependent with a mean fraction of inspired oxygen (FiO2) of 34% and 63% required non-invasive ventilation (NIV). During hospitalisation, more than 70% required ventilatory support by NIV and 10% by tracheal intubation. 18% required volaemic expansion and 4% vasopressors. Nearly 90% of PCRs for respiratory viruses were positive, and respiratory syncytial virus (RSV) was found in almost two-thirds of cases. Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae were frequently found. Significantly, patients aged less than 6 months old needed more NIV, had less alveolar condensation, had slightly lower oxygen requirements, a less frank inflammatory syndrome and a more frequently positive PCR for respiratory viruses.

CONCLUSIONS

We highlighted similarities between patients hospitalised for lower respiratory infection in PICU in France and those in Australia or Brazil. Optimal management relies mainly on NIV, oxygen therapy with FiO2 under 40% and available antibiotics. These results lead us to believe that the implementation of NIV training and equipment could help reduce mortality due to lower respiratory infections in children worldwide.

Mechanism of KLF2 in young mice with pneumonia induced by Streptococcus pneumoniae

BACKGROUND

Streptococcus pneumoniae (Spn) is a major causative agent of pneumonia, which can disseminate to the bloodstream and brain. Pneumonia remains a leading cause of death among children aged 1-59 months worldwide. This study aims to investigate the role of Kruppel-like factor 2 (KLF2) in lung injury caused by Spn in young mice.

METHODS

Young mice were infected with Spn to induce pneumonia, and the bacterial load in the bronchoalveolar lavage fluid was quantified. KLF2 expression in lung tissues was analyzed using real-time quantitative polymerase chain reaction and Western blotting assays. Following KLF2 overexpression, lung tissues were assessed for lung wet-to-dry weight ratio and Myeloperoxidase activity. The effects of KLF2 on lung injury and inflammation were evaluated through hematoxylin and eosin staining and enzyme-linked immunosorbent assay. Chromatin immunoprecipitation and dual-luciferase assay were conducted to examine the binding of KLF2 to the promoter of microRNA (miR)-222-3p and cyclin-dependent kinase inhibitor 1B (CDKN1B), as well as the binding of miR-222-3p to CDKN1B. Levels of miR-222-3p and CDKN1B in lung tissues were also determined.

RESULTS

In young mice with pneumonia, KLF2 and CDKN1B were downregulated, while miR-222-3p was upregulated in lung tissues. Overexpression of KLF2 reduced lung injury and inflammation, evidenced by decreased bacterial load, reduced lung injury, and lower levels of proinflammatory factors. Co-transfection of miR-222-3p-WT and oe-KLF2 significantly reduced luciferase activity, suggesting that KLF2 binds to the promoter of miR-222-3p and suppresses its expression. Transfection of CDKN1B-WT with miR-222-3p mimics significantly reduced luciferase activity, indicating that miR-222-3p binds to CDKN1B and downregulates its expression. Overexpression of miR-222-3p or downregulation of CDKN1B increased bacterial load in BALF, lung wet/dry weight ratio, MPO activity, and inflammation, thereby reversing the protective effect of KLF2 overexpression on lung injury in young mice with pneumonia.

CONCLUSIONS

KLF2 alleviates lung injury in young mice with Spn-induced pneumonia by transcriptional regulation of the miR-222-3p/CDKN1B axis.

The Epidemiologic and Clinical Features of Radiographic-Confirmed Community-Acquired Pneumonia Among Chinese Children: A Retrospective Hospital-Based Study

BACKGROUND

To help understand the disease burden of vaccine-preventable bacterial disease, we delineated the epidemiologic and clinical characteristics of radiographic-confirmed community-acquired pneumonia (CXR-CAP) among Chinese children.

METHODS

We retrospectively screened the electronic database of the hospital information system to identify all pediatric CAP cases admitted to the Children's Hospital of Soochow University between 2010 and 2014. Radiographic findings and clinical data were extracted from the medical charts through individual chart reviews. CXR-CAP cases were defined as the presence of consolidation or pleural effusion noted on chest radiograph reports. We employed a multivariate logistic regression model to identify the potential risk factors associated with CXR-CAP.

RESULTS

Among the 27,485 hospitalized CAP cases with radiologic data, 6322 (23.00%) were identified as CXR-CAP cases, while 21,163 (77.00%) were categorized as non-CXR-CAP cases. Children with CXR-CAP were notably older than those without CXR-CAP (non-CXR-CAP; χ2 = 1313.22; P < 0.01). CXR-CAP cases exhibited a higher rate of intensive care unit admission (3.55% vs. 1.94%; P < 0.01), extended hospital stays (73.87% vs. 63.79%; P < 0.01) and increased mortality rates (0.19% vs. 0.04%; P < 0.01). The factors associated with CXR-CAP included age (>12 months), season (summer and autumn), fever, abnormal breath sounds, C-reactive protein (>8 mg/L) and alanine transaminase (>40 U/L).

CONCLUSIONS

CXR-CAP cases consisted of a substantial proportion of hospitalized patients with CAP and had more severe clinical manifestations than in-patients without CXR-CAP among Chinese children.

Childhood Pneumonia in Low- and Middle-Income Countries: A Systematic Review of Prevalence, Risk Factors, and Healthcare-Seeking Behaviors

Childhood pneumonia is a major contributor to illness and death in children under the age of five globally. Despite advancements in medical science, the burden of pediatric community-acquired pneumonia (CAP) remains high, particularly in low- and middle-income countries. This systematic review aims to synthesize existing literature on the prevalence, risk factors, and healthcare-seeking behaviors associated with pediatric CAP to inform the development of targeted community-based interventions. An extensive search of various databases such as Medline, EMBASE, Web of Science, Cochrane, PubMed, PubMed Central, Helinet, SpringerLink, Google Scholar, and Biomed Central was performed, resulting in 65 potentially relevant studies. After a thorough evaluation process, 25 studies were selected for the final analysis. These selected studies offered valuable information on the epidemiology, risk factors, and healthcare-seeking behaviors associated with childhood pneumonia. The review revealed that environmental factors such as indoor air pollution, overcrowding, and exposure to tobacco smoke are significant risk factors for pediatric pneumonia. Additionally, socioeconomic factors, including poverty and a lack of access to clean water and sanitation, contribute to the vulnerability of children to this disease. Poor healthcare-seeking behaviors, driven by limited knowledge and awareness of pneumonia symptoms and treatment, further exacerbate the situation. The review also highlighted the critical role of vaccination, particularly against Haemophilus influenzae type b (Hib) and pneumococcus, in preventing pneumonia. However, gaps in vaccination coverage and challenges in accessing healthcare services remain barriers to effective pneumonia control. In light of these findings, the review recommends the implementation of community-based interventions that address the multifaceted determinants of pediatric pneumonia. These interventions should focus on improving environmental conditions, enhancing access to preventive measures such as vaccination, and promoting better healthcare-seeking behaviors through education and awareness campaigns. It is essential for healthcare providers, policymakers, and community members to collaborate in developing and implementing culturally appropriate and sustainable interventions. This cooperation aims to lessen the impact of pneumonia on children and their families.

Analysis of Childhood Pneumonia: A Comparison Between the Pre- and During the COVID-19 Pandemic in a Reference Hospital in Brazil

Introduction

Community-acquired pneumonia (CAP) is one of the most common causes of childhood morbidity and mortality, causing about two million deaths per year worldwide. The complicated CAP (CCAP) results from the worsening of CAP. Their incidence has reduced in the last 30 years due to vaccination. However, the coronavirus disease (COVID-19) pandemic reduced vaccination coverage, resulting in increased incidence of CCAP in 2021 and 2022.

Objective

To analyze the clinical and epidemiological profile of CAP in children under five years of age in two periods: pre- (2018 to 2019) and during the COVID-19 pandemic (2020 to 2022).

Methods

This cross-sectional retrospective study was conducted at the Professor Fernando Figueira Institute of Integral Medicine (IMIP). We analyzed the sociodemographic and clinical variables of children with CAP aged below five years who were admitted to IMIP from 2018 to 2022. Analysis encompassed the Pearson's Chi-square test, Fischer's exact test, and Student's T tests.

Results

A total of 468 children were analyzed: 382 in the pre-pandemic period and 86 during the COVID-19 pandemic. Concerning the antibiotic therapy, the most prescribed was Ampicillin (45.00%) in both periods. The combination of Oxacillin and Ceftriaxone was prescribed in 6.86% of cases in the pre-pandemic period; this value increased to 20.90% during the COVID-19 pandemic. Pleural effusion represented 12.10% of cases in the pre-pandemic period and 24.40% during the COVID-19 pandemic. The presence of pleural empyema went from 1.60% to 8.20%, and necrotizing pneumonia from 1.30% to 5.90% in the respective periods. Regarding ICU admission, 5.30% were admitted during the pre-pandemic period and 34.10% during the COVID-19 pandemic. Clinical suspicion of influenza presented a positivity rate of 17.60%.

Conclusion

Children with CAP presented a higher frequency of complications during the COVID-19 pandemic. Further research is needed to find the cause of increased CAP complications in this period.

Compassionate use of contezolid in a toddler with severe community-acquired pneumonia induced by staphylococcus aureus: a case report and follow-up

Background

Initial choices of antimicrobial therapy for most cases of community-acquired pneumonia (CAP) in children under 5 years of age are typically based on local epidemiology, risk factors assessment, and subsequent clinical parameters and positive cultures, which can lead to the underdiagnosis and underestimation of lung infections caused by uncommon pathogens. Contezolid, an orally administered oxazolidinone antibiotic, gained approval from the National Medical Products Administration (NMPA) of China in June 2021 for managing complicated skin and soft tissue infections (cSSTI) caused by staphylococcus aureus (SA), streptococcus pyogenes, or streptococcus agalactis. Owing to its enhanced safety profile and ongoing clinical progress, the scope of contezolid's clinical application continues to expand, benefiting a growing number of patients with Gram-positive bacterial infections.

Case summary

In this report, we present the first use of contezolid in a toddler with severe CAP caused by SA, aiming to avoid potential adverse drug reactions (ADRs) associated with vancomycin and linezolid.

Conclusion

Although contezolid has not been officially indicated for CAP, it has been shown to be effective and safe in the management of SA-induced severe CAP in this toddler, suggesting its potential as an alternative option in the dilemma, especially for patients who are susceptible or intolerant to ADRs associated with first-line anti-methicillin-resistant staphylococcus aureus (MRSA) antimicrobial agents.

Dynamics of platelet parameters in children with severe community-acquired pneumonia between viral and bacterial infections

Background

Changes in platelet parameters may vary according to the different pathogens. However, little is known about the differences in platelet parameters in children with severe community-acquired pneumonia (CAP) children of viral and bacterial infections.

Methods

This was a single-center retrospective study that included 156 children with severe CAP. Dynamic changes in platelet parameters, including platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT), were recorded at 24 h, 48 h, 72 h, and day 7 of admission, as well as at discharge.

Results

At 72 h of admission, PLT in the viral infection group was significantly lower than that in the bacterial infection and bacterial and viral coinfections group. Meanwhile, the curve of changes in PLT (ΔPLT) in the viral infection group was clearly separated from the other two groups at this time point. Receiver operating characteristic (ROC) analysis showed that PLT at 72 h of admission could assist in distinguishing bacterial and viral infections in severe pneumonia children with the area under curve (AUC) value of 0.683 [95% confidence interval (CI): 0.561-0.805, P=0.007]. However, its sensitivity and specificity were not high, at 68% and 65%, respectively.

Conclusions

Although the diagnostic value of platelet parameters in bacterial and viral infection in children with severe CAP is limited, they are still expected to be combined with other indicators to provide a reference for timely treatment.

Viral and bacterial microorganisms in Vietnamese children with severe and non-severe pneumonia

To investigate potential respiratory pathogens in children with community-acquired pneumonia (CAP) and risk factors for severe disease. This prospective study was conducted among 467 children at the Thai Binh Paediatric Hospital, Vietnam between 1 July 2020 and 30 June 2021. Clinical data and laboratory results were collected. Twenty-four respiratory microorganisms were tested from nasopharyngeal swabs using real-time PCR. Logistical regression was used to estimate a factor's adjusted odd ratios of the severity of disease. Mean age of patients = 15.4 ± 13.3 months, 63.0% were male. Over 97% of patients had a positive PCR result. 87% of patients were positive for multiple (up to eight) microorganisms. Rhinovirus (46%), respiratory syncytial virus (RSV) (24%), enterovirus (17%), and parainfluenza viruses-3 (13%) were the most frequent viruses. H. influenzae (61%), S. pneumoniae (45%) and M. catarrhalis (30%) were the most common bacteria. 128 (27%) cases were classified as severe pneumonia. Presence of smokers at home (aOR 2.11, 95% CI 1.27-3.52, P value = 0.004), CRP level ≥ 50 mg/dL (aOR  6.11, 95% CI  3.86-9.68, P value < 0.0001), RSV (aOR  1.78, 95% CI  1.07-2.96, P value = 0.03) and H. influenzae (aOR  1.66, 95% CI  1.03-2.67, P value = 0.04) PCR detection associated with a higher risk of severe pneumonia; ,. Causative agents of pneumonia in children are complex. Children positive with RSV and H. influenzae need to be closely monitored to prevent severe pneumonia.

Study on the Common Molecular Mechanism of Metabolic Acidosis and Myocardial Damage Complicated by Neonatal Pneumonia

Pneumonia is a common clinical disease in the neonatal period and poses a serious risk to infant health. Therefore, the understanding of molecular mechanisms is of great importance for the development of methods for the rapid and accurate identification, classification and staging, and even disease diagnosis and therapy of pneumonia. In this study, a nontargeted metabonomic method was developed and applied for the analysis of serum samples collected from 20 cases in the pneumonia control group (PN) and 20 and 10 cases of pneumonia patients with metabolic acidosis (MA) and myocardial damage (MD), respectively, with the help of ultrahigh-performance liquid chromatography-high-resolution mass spectrometry (UPLC-HRMS). The results showed that compared with the pneumonia group, 23 and 21 differential metabolites were identified in pneumonia with two complications. They showed high sensitivity and specificity, with the area under the curve (ROC) of the receiver operating characteristic curve (ROC) larger than 0.7 for each differential molecule. There were 14 metabolites and three metabolic pathways of sphingolipid metabolism, porphyrin and chlorophyll metabolism, and glycerophospholipid metabolism existing in both groups of PN and MA, and PN and MD, all involving significant changes in pathways closely related to amino acid metabolism disorders, abnormal cell apoptosis, and inflammatory responses. These findings of molecular mechanisms should help a lot to fully understand and even treat the complications of pneumonia in infants.

Temporal trend of mortality from infectious respiratory diseases in childhood in Minas Gerais, Brazil, 2000-2020

MAIN RESULTS

From 2000 to 2020, there was a downward trend in mortality due to infectious respiratory disease in children living in Minas Gerais - even in 2020, the year of the COVID-19 pandemic.

IMPLICATIONS FOR SERVICES

There was a reduction in child deaths due to respiratory infections; health services should be alerted as to the considerable presence of ill-defined or inconclusive codes (garbage codes) on death certificates.

PERSPECTIVES

It is necessary to maintain the effectiveness of health actions among the mother and child population and to improve the records held on the Mortality Information System, in order to enable better monitoring of mortality as well as to enable analytical studies to be conducted.

OBJECTIVE

to analyze temporal trends in mortality due to infectious respiratory disease in children under 12 years old in Minas Gerais, Brazil, from 2000 to 2020.

METHODS

this was an ecological study using data on infectious respiratory disease in children under 12 years old registered on the Mortality Information System; the variables studied were etiological agent, anatomical site of infection and sex; trends were analyzed by joinpoint regression.

RESULTS

of the 4,688 registered deaths, the etiological agent of the disease was unspecified for 84.5% of them, and 88% were due to lower respiratory tract infections; there was a decreasing trend in deaths and in the proportion of deaths due to unspecified etiologic agents; in 2020, there was an increase in deaths with viral etiology and systemic involvement.

CONCLUSION

in addition to the change in the etiologic profile, there was a reduction in mortality due to infectious respiratory diseases in children, even considering 2020, the year of the COVID-19 pandemic.

Optimization strategy for the early timing of bronchoalveolar lavage treatment for children with severe mycoplasma pneumoniae pneumonia

BACKGROUND

Early evaluation of severe mycoplasma pneumoniae pneumonia (SMPP) and the prompt utilization of fiberoptic bronchoscopic manipulation can effectively alleviate complications and restrict the progression of sequelae. This study aim to establish a nomogram forecasting model for SMPP in children and explore an optimal early therapeutic bronchoalveolar lavage (TBAL) treatment strategy.

METHODS

This retrospective study included children with mycoplasma pneumoniae pneumonia (MPP) from January 2019 to December 2021. Multivariate logistic regression analysis was used to screen independent risk factors for SMPP and establish a nomogram model. The bootstrap method was employed and a receiver operator characteristic (ROC) curve was drawn to evaluate the accuracy and robustness of the model. Kaplan-Meier analysis was used to assess the effect of lavage and hospitalization times.

RESULTS

A total of 244 cases were enrolled in the study, among whom 68 with SMPP and 176 with non-SMPP (NSMPP). A prediction model with five independent risk factors: left upper lobe computed tomography (CT) score, sequential organ failure assessment (SOFA) score, acute physiology and chronic health assessment (APACHE) II score, bronchitis score (BS), and c-reactive protein (CRP) was established based on the multivariate logistic regression analysis. The ROC curve of the prediction model showed the area under ROC curve (AUC) was 0.985 (95% confidence interval (CI) 0.972-0.997). The Hosmer-Lemeshow goodness-of-fit test results showed that the nomogram model predicted the risk of SMPP well (χ2 = 2.127, P = 0.977). The log-rank result suggested that an early BAL treatment could shorten MPP hospitalization time (P = 0.0057).

CONCLUSION

This nomogram model, based on the left upper lobe CT score, SOFA score, APACHE II score, BS, and CRP level, represents a valuable tool to predict the risk of SMPP in children and optimize the timing of TBAL.

Advancements in the Management of Severe Community-Acquired Pneumonia: A Comprehensive Narrative Review

Pneumonia, classified as a lower respiratory tract illness, affects different parts of the bronchial system as well as alveoli and can present with varying severities depending on co-morbidities and causative pathogens. It can be broadly classified using the setting in which it was acquired, namely the community or hospital setting, the former being more common and spreading through person-to-person droplet transmission. Community-acquired pneumonia (CAP) is currently the fourth leading cause of death worldwide, and its high mortality makes continual insight into the management of the condition worthwhile. This review explores the literature specifically for severe CAP (sCAP) and delves into the diagnosis, various modalities of treatment, and management of the condition. This condition can be defined as pneumonia requiring mechanical ventilation in the ICU and/or presenting with sepsis and organ failure due to pneumonia. The disease process is characterized by inflammation of the lung parenchyma, initiated by a combination of pathogens and lowered local defenses. Acute diagnosis of the condition is vital in reducing negative patient outcomes, namely through clinical presentation, blood/sputum cultures, imaging modalities such as computed tomography scan, and inflammatory markers, identifying common causative pathogens such as Streptococcus pneumoniae, rhinovirus, Legionella, and viral influenza. Pathogens such as Escherichia coli should also be investigated in patients with chronic obstructive pulmonary disease. The mainstay of treating sCAP includes rapid ICU admission once a diagnosis has been confirmed, initiating sepsis protocol, and treatment with combined empiric antibiotic regimens consisting of beta-lactams and macrolides. Corticosteroid use alongside antibiotics shows promise in reducing inflammation, but its use has to be judged on a case-by-case basis. New drugs such as omadacycline, delafloxacin, and zabofloxacin have shown valid evidence for the treatment of resistant causative organisms. The main guidelines for preventing sCAP include maintaining a healthy lifestyle, and annual pneumococcal and influenza vaccines are recommended for the most vulnerable patient groups, such as those with COPD and immunosuppression.

Childhood Pneumonia: What's Unchanged, and What's New?

Childhood pneumonia is still a significant clinical and public health problem. India contributes the highest number of deaths due to pneumonia, accounts for about 20% of global mortality among under five children. Various etiologic agents including bacteria, viruses and atypical organism are responsible for childhood pneumonia. Recent studies suggest that viruses are one of the major causes of childhood pneumonia. Among viruses, respiratory syncytial virus has got great attention and several recent studies are reporting it as an important organism for pneumonia. Lack of exclusive breast feeding during first six months, improper timing of start and content of complimentary feeding, anemia, undernutrition, indoor pollution due to tobacco smoking and use of coal and wood for cooking food and lack of vaccinations are important risk factors. X-ray chest is not routinely performed to diagnose pneumonia while use of lung ultrasound is increasing to detect consolidation, pleural effusion, pneumothorax and pulmonary edema (interstitial syndrome). Role of C-reactive protein (CRP) and procalcitonin is similar, to differentiate between viral and bacterial pneumonia, however duration of antibiotics is better guided by procalcitonin. Newer biomarkers like IL-6, presepsin and triggering receptor expressed on myeloid cells 1 are needed to be evaluated for their use in children. Hypoxia is significantly associated with childhood pneumonia. Therefore, use of pulse oximetry should be encouraged for early detection and prompt treatment of hypoxia to prevent adverse outcomes. Among the available tools for risk of mortality assessment in children due to pneumonia, PREPARE score is the best but external validation will be needed.

Timing of bronchoscopy and application of scoring tools in children with severe pneumonia

BACKGROUND

There is still a lack of effective scoring criteria for assessing the severity of pulmonary infection associated with changes in the endobronchial lining of the bronchus in children. This study aimed to ascertain the timing and value of endoscopic scoring of fibreoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) in children with severe pneumonia.

METHOD

The clinical data of 229 children with severe pneumonia treated with BAL in the Pediatric Intensive Care Unit of the First Affiliated Hospital of Xinxiang Medical University between November 2018 and December 2021 were collected. According to the severity of the disease, patients were divided into an invasive ventilation group and a non-invasive ventilation group, as well as an early BAL group (receiving BAL within 1 day of admission) and a late BAL group (receiving BAL 2 days after admission). A Student's t-test, Chi-square test, receiver operating characteristic (ROC) curve and survival curve were used to analyse the bronchitis score, aetiology of BAL fluid and survival data.

RESULTS

The scores of endoscopic mucosal oedema, erythema and pallor and the total score in the invasive ventilation group were higher than those in the non-invasive ventilation group (P < 0.05), and they were consistent with the Sequential Organ Failure Assessment (SOFA) scores. The secretion colour score was lower in the early BAL group than in the late BAL group (P < 0.05). On the bronchitis scores, which were evaluated using a ROC curve, the difference in the mucosal erythema, pallor, oedema and total score of the invasive and non-invasive groups was statistically significant (P < 0.05), which was consistent with the area under the ROC of the SOFA scores. Acute Physiology and Chronic Health Assessment II and SOFA scores after FOB were lower than those before treatment (P < 0.05). In terms of ICU hospitalisation days and total hospitalisation days, the time of the early FOB patients was shorter than that of the late FOB patients (P < 0.05). A total of 22 patients (9.61%) died. The Kaplan-Meier analysis and log-rank test showed that the survival rate of the non-invasive ventilation group was higher than that of the invasive ventilation group (P < 0.05).

CONCLUSION

This study found that FOB combined with BAL is an important method for the diagnosis and treatment of severe pneumonia. Early BAL can reduce hospitalisation and ICU time; however, it cannot improve the survival rate. The endoscopic score has a certain role to play in assessing the severity of pulmonary inflammation, but studies with a large sample are still needed to confirm this.

Modern approaches at the management of children with community-acquired pneumonia

Experts of The Union of Pediatricians of Russia have developed current clinical guidelines for management of children with community-acquired pneumonia, which were approved by the Scientific and Practice Council of Ministry of Public Health of the Russian Federation in January 2022. Particular attention is paid to the etiological structure, modern classification, diagnostic tests and flagship approaches to antibacterial therapy of community-acquired pneumonia in children based on the principles of evidentiary medicine. 

The role of human bocavirus as an agent of community-acquired pneumonia in children under 5 years of age in Fortaleza, Ceará (Northeast Brazil)

The human bocavirus (HBoV) is an agent of upper and lower respiratory infections, affecting mainly children under 5 years of age. Community-acquired pneumonia (CAP) is an important public health problem in developing countries, representing one of the main causes of hospitalizations and deaths in children. The aim of this study was to describe the prevalence of HBoV and the clinical and epidemiological characteristics in children diagnosed with CAP. For this purpose, nasopharyngeal aspirates were collected from 545 children aged 0 to 60 months diagnosed with CAP between January 2013 and December 2014 in a reference pediatric hospital in Fortaleza, Ceará, Brazil. The samples were subjected to PCR for detection of HBoV and parainfluenza 4 (PIV4) and indirect immunofluorescence for detection of respiratory syncytial virus (RSV), adenovirus (AdV), influenza A and B (FLU A and FLU B), and parainfluenza 1, 2, and 3 (PIV1, PIV2, PIV3). Clinically, most CAP were non-complicated (487/545; 89.3%); however, 10.7% (58/545) of children were treated in the ICU/resuscitation sector. Among the total samples analyzed, 359 (65.8%) were positive for at least one virus surveyed and 105 (19.2%) samples had two or more viruses. HBoV was detected in 87 samples (15.9%), being the second most prevalent virus. RSV, AdV, FLU A, FLU B, and PIV 1-3 were detected in 150 (27.5%), 45 (8.2%), 30 (5.5%), 3 (0.5%), and 131 (24%) samples, respectively. The age average was 12.1 months in children infected with HBoV, and the most frequent symptoms were dyspnea and cough. In addition, 90.6% of HboV-positive children received antibiotics as empirical treatment. HBoV did not show any circulation pattern; however, it seemed to be more frequent in the first half of the year, totaling 68.9% of the cases. HBoV is a frequent agent of pneumonia in the child population studied.

Ultrasound image intelligent diagnosis in community-acquired pneumonia of children using convolutional neural network-based transfer learning

BACKGROUND

Studies show that lung ultrasound (LUS) can accurately diagnose community-acquired pneumonia (CAP) and keep children away from radiation, however, it takes a long time and requires experienced doctors. Therefore, a robust, automatic and computer-based diagnosis of LUS is essential.

OBJECTIVE

To construct and analyze convolutional neural networks (CNNs) based on transfer learning (TL) to explore the feasibility of ultrasound image diagnosis and grading in CAP of children.

METHODS

89 children expected to receive a diagnosis of CAP were prospectively enrolled. Clinical data were collected, a LUS images database was established comprising 916 LUS images, and the diagnostic values of LUS in CAP were analyzed. We employed pre-trained models (AlexNet, VGG 16, VGG 19, Inception v3, ResNet 18, ResNet 50, DenseNet 121 and DenseNet 201) to perform CAP diagnosis and grading on the LUS database and evaluated the performance of each model.

RESULTS

Among the 89 children, 24 were in the non-CAP group, and 65 were finally diagnosed with CAP, including 44 in the mild group and 21 in the severe group. LUS was highly consistent with clinical diagnosis, CXR and chest CT (kappa values = 0.943, 0.837, 0.835). Experimental results revealed that, after k-fold cross-validation, Inception v3 obtained the best diagnosis accuracy, PPV, sensitivity and AUC of 0.87 ± 0.02, 0.90 ± 0.03, 0.92 ± 0.04 and 0.82 ± 0.04, respectively, for our dataset out of all pre-trained models. As a result, best accuracy, PPV and specificity of 0.75 ± 0.03, 0.89 ± 0.05 and 0.80 ± 0.10 were achieved for severity classification in Inception v3.

CONCLUSIONS

LUS is a reliable method for diagnosing CAP in children. Experiments showed that, after transfer learning, the CNN models successfully diagnosed and classified LUS of CAP in children; of these, the Inception v3 achieves the best performance and may serve as a tool for the further research and development of AI automatic diagnosis LUS system in clinical applications.

REGISTRATION

www.chictr.org.cn ChiCTR2200057328.

ΔRDW: A Novel Indicator with Predictive Value for the Diagnosis and Treatment of Multiple Diseases

Elevated red blood cell distribution width (RDW) is a powerful predictor of poor prognosis in a variety of diseases, but a single measurement of RDW cannot reflect the dynamic change of diseases. ΔRDW, as a risk stratification tool, can be used to record changes in RDW before and after treatment; also, it allows investigators to name the unit change of RDW in the studied population. So far, there have been few relevant studies on the predictive value of ΔRDW for different diseases; this article aims to review the studies and summaries of the current understandings on the correlation between ΔRDW and disease outcomes.

A Proof of Concept of the Role of TDM-Based Clinical Pharmacological Advices in Optimizing Antimicrobial Therapy on Real-Time in Different Paediatric Settings

Introduction: Antimicrobial treatment is quite common among hospitalized children. The dynamic age-associated physiological variations coupled with the pathophysiological alterations caused by underlying illness and potential drug-drug interactions makes the implementation of appropriate antimicrobial dosing extremely challenging among paediatrics. Therapeutic drug monitoring (TDM) may represent a valuable tool for assisting clinicians in optimizing antimicrobial exposure. Clinical pharmacological advice (CPA) is an approach based on the correct interpretation of the TDM result by the MD Clinical Pharmacologist in relation to specific underlying conditions, namely the antimicrobial susceptibility of the clinical isolate, the site of infection, the pathophysiological characteristics of the patient and/or the drug-drug interactions of cotreatments. The aim of this study was to assess the role of TDM-based CPAs in providing useful recommendations for the real-time personalization of antimicrobial dosing regimens in various paediatric settings. Materials and methods: Paediatric patients who were admitted to different settings of the IRCCS Azienda Ospedaliero-Universitaria of Bologna, Italy (paediatric intensive care unit [ICU], paediatric onco-haematology, neonatology, and emergency paediatric ward), between January 2021 and June 2021 and who received TDM-based CPAs on real-time for personalization of antimicrobial therapy were retrospectively assessed. Demographic and clinical features, CPAs delivered in relation to different settings and antimicrobials, and type of dosing adjustments were extracted. Two indicators of performance were identified. The number of dosing adjustments provided over the total number of delivered CPAs. The turnaround time (TAT) of CPAs according to a predefined scale (optimal, <12 h; quasi-optimal, between 12-24 h; acceptable, between 24-48 h; suboptimal, >48 h). Results: Overall, 247 CPAs were delivered to 53 paediatric patients (mean 4.7 ± 3.7 CPAs/patient). Most were delivered to onco-haematological patients (39.6%) and to ICU patients (35.8%), and concerned mainly isavuconazole (19.0%) and voriconazole (17.8%). Overall, CPAs suggested dosing adjustments in 37.7% of cases (24.3% increases and 13.4% decreases). Median TAT was 7.5 h (IQR 6.1-8.8 h). Overall, CPAs TAT was optimal in 91.5% of cases, and suboptimal in only 0.8% of cases. Discussion: Our study provides a proof of concept of the helpful role that TDM-based real-time CPAs may have in optimizing antimicrobial exposure in different challenging paediatric scenarios.

Value of Neutrophil to Lymphocyte Ratio, Platelet to Lymphocyte Ratio, and Red Blood Cell Distribution Width in Evaluating the Prognosis of Children with Severe Pneumonia

Objective

To investigate the value of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and red blood cell distribution width (RDW) in evaluating the prognosis of children with severe pneumonia (SP).

Methods

A retrospective analysis of the data of 91 children with SP admitted to our hospital from March 2018 to March 2021. According to the survival status after 28 days of treatment, all children were divided into the survival group (n = 59) and the death group (n = 32). The clinical data and laboratory indicators of the patients were recorded. Multivariate logistic regression was used to analyze the risk factors of prognosis, and the ROC curve was used to analyze the predictive value of each index.

Results

The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and CURB-65 score of the death group were higher than those of the survival group (P < 0.05). The RDW, NLR, PLR, and high-sensitivity C-reactive protein, procalcitonin blood lactic acid (Lac) of the death group, were higher than those of the survival group, and LYM was lower than the survival group (P < 0.05). Multivariate regression analysis showed that APACHE II score, RDW, NLR, PLR, and Lac were all independent risk factors for poor prognosis in children with SP (P < 0.05). The AUC of NLR, PLR, and RDW for evaluating the prognosis of children with SP were 0.798, 0.781, and 0.777, respectively. The sensitivity was 56.25%, 90.63%, and 56.25%, respectively, and the specificity was 89.83%, 55.93%, and 91.53%, respectively. The AUC of NLR, PLR, and RDW combined to evaluate the prognosis of children with SP was 0.943. When the best cut-off value was 0.8528, the sensitivity was 93.75%, and the specificity was 91.53%.

Conclusion

NLR, PLR, and RDW have certain predictive value for the prognosis of children with SP; the combination of the three indicators has a higher value in evaluating the prognosis of children with SP, which can better guide the prognostic treatment.

The protective effect of Qingfei Huatan decoction on pulmonary function and its influence on the immunological function in children with severe pneumonia

OBJECTIVE

This research explores and analyzes the protective effect of the mixed Chinese herbs Qingfei Huatan decoction on the pulmonary and immunological functions in children with severe pneumonia.

METHODS

120 children with severe pneumonia hospitalized from May 2018 to May 2020 were enrolled in the study and randomly placed into an observation group or a control group (n=60 in each group). The control group was administered conventional treatment, and the observation group was administered the mixed Chinese herbs Qingfei Huatan decoction in addition to the treatment administered to the control group. The therapeutic efficacy, the changes in pulmonary function, the serum inflammatory levels, and the peripheral blood T lymphocyte subsets were compared between the two groups.

RESULTS

The total effective treatment rate in the observation group was critically superior to the total effective treatment rate in the control group (P<0.05). The FVC, FEV1, and FEV1/FVC levels in the two groups after the treatment were remarkably higher than they were before the treatment (P<0.05), and the observation group had superior post-treatment pulmonary function than the control group (P<0.05). The TNF-α, IL-6, and CRP levels in the two groups in after the treatment were lower than they were before the treatment (P<0.05), and the observation group had lower post-treatment inflammatory cytokine levels than the control group (P<0.05). The two groups' CD4⁺ and CD4⁺/CD8⁺ levels increased substantially after the treatment compared to before the treatment (P<0.05), and the posttreatment levels in the observation group were notably higher than they were in the control group (P<0.05).

CONCLUSION

The mixed Chinese herbs Qingfei Huatan decoction and the routine treatment combination has a good clinical effectiveness in children with severe pneumonia. It can effectively promote the pulmonary function of children. Its effect may be correlated with the suppression of inflammation in the body and the improvement of the immunological function in children.

Aetiology of acute respiratory infection in preschool children requiring hospitalisation in Europe-results from the PED-MERMAIDS multicentre case-control study

Background

Both pathogenic bacteria and viruses are frequently detected in the nasopharynx (NP) of children in the absence of acute respiratory infection (ARI) symptoms. The aim of this study was to estimate the aetiological fractions for ARI hospitalisation in children for respiratory syncytial virus (RSV) and influenza virus and to determine whether detection of specific respiratory pathogens on NP samples was associated with ARI hospitalisation.

Methods

349 children up to 5 years of age hospitalised for ARI (following a symptom-based case definition) and 306 hospital controls were prospectively enrolled in 16 centres across seven European Union countries between 2016 and 2019. Admission day NP swabs were analysed by multiplex PCR for 25 targets.

Results

RSV was the leading single cause of ARI hospitalisations, with an overall population attributable fraction (PAF) of 33.4% and high seasonality as well as preponderance in younger children. Detection of RSV on NP swabs was strongly associated with ARI hospitalisation (OR adjusted for age and season: 20.6, 95% CI: 9.4 to 45.3). Detection of three other viral pathogens showed strong associations with ARI hospitalisation: influenza viruses had an adjusted OR of 6.1 (95% CI: 2.5 to 14.9), parainfluenza viruses (PIVs) an adjusted OR of 4.6 (95% CI: 1.8 to 11.3) and metapneumoviruses an adjusted OR of 4.5 (95% CI: 1.3 to 16.1). Influenza viruses had a PAF of 7.9%, PIVs of 6.5% and metapneumoviruses of 3.0%. In contrast, most other pathogens were found in similar proportions in cases and controls, including Streptococcus pneumoniae, which was weakly associated with case status, and endemic coronaviruses.

Conclusion

RSV is the predominant cause of ARI hospitalisations in young children in Europe and its detection, as well as detection of influenza virus, PIV or metapneumovirus, on NP swabs can establish aetiology with high probability. PAFs for RSV and influenza virus are highly seasonal and age dependent.

Seizure in Children Under Five Presenting With Pneumonia in a Critical Care Ward in Bangladesh: Prevalence, Associated Factors, and Outcome

BACKGROUND

Pneumonia is the leading infectious cause of deaths in children under 5 for the last few decades. Development of seizure in those children is common and associated with increased risk of deaths. We therefore investigated the prevalence, associated factors and outcome of seizure in children hospitalized with pneumonia.

METHODS

We conducted a retrospective chart analysis in the intensive care unit of the Dhaka Hospital of icddr,b. Children under 5 with World Health Organization (WHO) classified clinical (excluding seizure as 1 of the clinical diagnostics) and radiologic pneumonia, admitted to the intensive care unit at Dhaka Hospital of icddr,b between August 2013 and December 2017 were analyzed. We initially identified the children with pneumonia who had seizure. For comparison, we have taken 2 folds randomly selected controls from rest of the children with pneumonia having no seizure. Prevalence and outcome of children with pneumonia and seizure were measured. Factors associated with seizure in children with pneumonia compared with those without seizure were also identified. Seizure was characterized by sudden, violent, involuntary, and abnormal repetitive movements with or without loss or impairment of consciousness confirmed by attending physician.

RESULTS

Among a total of 4101 children with pneumonia, 514 (12.5%) had seizure. Compared with children with pneumonia alone children having pneumonia and seizure more often developed respiratory failure (18% vs. 3%, P < 0.001) and died (13% vs. 3%, P < 0.001) during hospitalization. In logistic regression analysis hypoxemia (95% CI: 1.59-3.17, P < 0.001), severe pneumonia (95% CI: 2.13-6.52, P < 0.001), severe sepsis (95% CI: 1.30-2.88, P = 0.001), and hypernatremia (95% CI: 5.31-10.93, P < 0.001) were found to be independent risk factors for seizure. On the contrary, children with pneumonia having seizure were less likely to have severe acute malnutrition (95% CI: 0.26-0.50, P < 0.001).

CONCLUSIONS

Early identification of risk factors for seizure in children with pneumonia may be helpful for clinicians to promptly treat them and therefore may have potential to reduce deaths in those children especially in resource limited settings.

Antibiotic Use and Treatment Outcomes among Children with Community-Acquired Pneumonia Admitted to a Tertiary Care Public Hospital in Nepal

In the era of growing antimicrobial resistance, there is a concern about the effectiveness of first-line antibiotics such as ampicillin in children hospitalized with community-acquired pneumonia. In this study, we describe antibiotic use and treatment outcomes among under-five children with community-acquired pneumonia admitted to a tertiary care public hospital in Nepal from 2017 to 2019. In this cross-sectional study involving secondary analysis of hospital data, there were 659 patients and 30% of them had a history of prehospital antibiotic use. Irrespective of prehospital antibiotic use, ampicillin monotherapy (70%) was the most common first-line treatment provided during hospitalization followed by ceftriaxone monotherapy (12%). The remaining children (18%) were treated with various other antibiotics alone or in combination as first-line treatment. Broad-spectrum antibiotics such as linezolid, vancomycin, and meropenem were used in less than 1% of patients. Overall, 66 (10%) children were required to switch to second-line treatment and only 7 (1%) children were required to switch to third-line treatment. Almost all (99%) children recovered without any sequelae. This study highlights the effectiveness of ampicillin monotherapy in the treatment of community-acquired pneumonia in hospitalized children in a non-intensive care unit setting.

The Impact of the Novel Coronavirus on Brazilian PICUs

OBJECTIVES

To study the impact of the coronavirus disease 2019 pandemic, considering the physical distancing and schools closing, on the characteristics of admission and epidemiology on Brazilian PICUs.

DESIGN

Observational, multicenter, time series analysis, of electronic medical records from 15 PICU in Brazil. Data consisted of all March, April, and May PICU admissions from 2017 to 2020.

SETTING

Fifteen private PICUs in Brazil.

PATIENTS

Pediatric patients admitted to the PICU from March to May since 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The period from March 11, 2020, to March 17, 2020, was considered the "intervention point" studied, corresponding to the suspension of school activities and the beginning of physical distancing in Brazil. During the pandemic period studied, there were 28 cases of coronavirus disease 2019 (one death). The mean age was higher (p = 0.000), the length of stay was shorter (p = 0.000), but mortality rates were similar among the periods (p = 0.36). The model estimated a reduction of 1,483 PICU admissions from March 2020 to May 2020. At the end of May, there was an estimated drop of -146.6 bronchiolitis admissions (95% CI, -242.8 to -50.3; p = 0.016); -71 asthma admissions (95% CI, -93.6 to -48.63; p = 0.000); and -59 community-acquired pneumonia admissions (95% CI, -74.7 to -43.3; p = 0.000) per period. The model showed no effect of the "intervention" (physical distancing) on hospitalization rates for epilepsy, diarrhea, sepsis, bacterial meningitis, or surgery when analyzed individually. When assessed together, the model estimated a reduction of 73.6 admissions (95% IC, -132 to -15.2; p = 0.43).

CONCLUSIONS

The coronavirus disease 2019 pandemic strongly affected Brazilian PICUs, reducing admissions, length of stay, and the epidemiological profile. The measures to oppose the coronavirus disease 2019 pandemic may have prevented thousands of PICU hospitalizations across the country.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

BACKGROUND

Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis.

OBJECTIVES

To produce revised guidelines for pneumonia in South African children under 5 years of age.

METHODS

The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision.

RECOMMENDATIONS

Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided.

VALIDATION

The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.