Pneumonia in hospitalized children

Population-based retrospective cohort study on community-acquired pneumonia hospitalization in children with a ventricular septal defect

The cohort consisted of 9400 exposed children diagnosed with ventricular septal defect (VSD). The risk of community-acquired pneumonia (CAP) or asthma with VSD was assessed using the Cox proportional hazard model with an inverse probability of treatment weighting. During a mean follow-up of 6.67 years (starting from 12 months after birth), there were 2100 CAP admission cases among exposed patients (incidence rate: 33.2 per 1000 person-years) and 20,109 CAP admission cases among unexposed children (incidence rate: 29.6 per 1000 person-years), with hazard ration of 1.09 (95% CI 1.04-1.14).

Utilizing metagenomic next-generation sequencing for diagnosis and lung microbiome probing of pediatric pneumonia through bronchoalveolar lavage fluid in pediatric intensive care unit: results from a large real-world cohort

Background

Metagenomic next-generation sequencing (mNGS) is a powerful method for pathogen detection in various infections. In this study, we assessed the value of mNGS in the pathogen diagnosis and microbiome analysis of pneumonia in pediatric intensive care units (PICU) using bronchoalveolar lavage fluid (BALF) samples.

Methods

A total of 104 pediatric patients with pneumonia who were admitted into PICU between June 2018 and February 2020 were retrospectively enrolled. Among them, 101 subjects who had intact clinical information were subject to parallel comparison of mNGS and conventional microbiological tests (CMTs) for pathogen detection. The performance was also evaluated and compared between BALF-mNGS and BALF-culture methods. Moreover, the diversity and structure of all 104 patients' lung BALF microbiomes were explored using the mNGS data.

Results

Combining the findings of mNGS and CMTs, 94.06% (95/101) pneumonia cases showed evidence of causative pathogenic infections, including 79.21% (80/101) mixed and 14.85% (15/101) single infections. Regarding the pathogenesis of pneumonia in the PICU, the fungal detection rates were significantly higher in patients with immunodeficiency (55.56% vs. 25.30%, P =0.025) and comorbidities (40.30% vs. 11.76%, P=0.007). There were no significant differences in the α-diversity either between patients with CAP and HAP or between patients with and without immunodeficiency. Regarding the diagnostic performance, the detection rate of DNA-based BALF-mNGS was slightly higher than that of the BALF-culture although statistically insignificant (81.82% vs.77.92%, P=0.677) and was comparable to CMTs (81.82% vs. 89.61%, P=0.211). The overall sensitivity of DNA-based mNGS was 85.14% (95% confidence interval [CI]: 74.96%-92.34%). The detection rate of RNA-based BALF-mNGS was the same with CMTs (80.00% vs 80.00%, P>0.999) and higher than BALF-culture (80.00% vs 52.00%, P=0.045), with a sensitivity of 90.91% (95%CI: 70.84%-98.88%).

Conclusions

mNGS is valuable in the etiological diagnosis of pneumonia, especially in fungal infections, and can reveal pulmonary microecological characteristics. For pneumonia patients in PICU, the mNGS should be implemented early and complementary to CMTs.

Application of Metagenomic Next-Generation Sequencing (mNGS) Using Bronchoalveolar Lavage Fluid (BALF) in Diagnosing Pneumonia of Children

Pneumonia is the leading cause of death in children; the pathogens are often difficult to diagnose. In this study, the performance of metagenomic next-generation sequencing (mNGS) using bronchoalveolar lavage fluid (BALF) samples from 112 children with confirmed pneumonia has been evaluated. mNGS performed a significantly higher positive detection rate (91.07%, 95% confidence interval [CI] 83.80% to 95.40%) and coincidence rate against the final diagnosis (72.32%, 95% CI 62.93% to 80.15%) than that of conventional methods (70.54%, 95% CI 61.06% to 78.58% and 56.25%, 95% CI 46.57% to 65.50%, respectively) (P < 0.01 and P < 0.05, respectively). Bacteria, viruses, and their mixed infections were common in children with pneumonia. Streptococcus pneumoniae was the most common bacterial pathogen in children with pneumonia, while Haemophilus parainfluenzae and Haemophilus influenzae seemed more likely to cause nonsevere pneumonia in children. In contrast, human cytomegalovirus (CMV) infection and the simultaneous bacterial infections could cause severe pneumonia, especially in children with underlying diseases. After adjustments of antibiotics based on mNGS and conventional methods, the conditions improved in 109 (97.32%) children. mNGS of BALF samples has shown great advantages in diagnosing the pathogenic etiology of pneumonia in children, especially when considering the limited volumes of BALF and the previous use of empirical antibiotics, contributing to the timely adjustment of antibiotic treatments, which can potentially improve the prognosis and decrease the mortality. IMPORTANCE Our study indicates high efficiency of mNGS using BALF for the detection of causative pathogens that cause pneumonia in children. mNGS can be a potential diagnostic tool to supplement conventional methods for children's pneumonia.

Epidemiological and Clinical Characteristics of 5,569 Pediatric Burns in Central China From 2013 to 2019

Background

Pediatric burns of all the ages are prevalent worldwide, posing a severe health risk to children. This study aims to examine pediatric burns' clinical characteristics and epidemiology in central China.

Methods

The pediatric patients of the Burn Research Center, Department of the First People's Hospital of Zhengzhou City from 2013 to 2019 were retrospectively studied and the relevant data were collected from the hospitalized medical records [e.g., demographic, etiology, length of stay (LOS), age, gender, burn area and depth, number of surgeries, cost, and outcome].

Results

A total of 5,569 pediatric burn patients were included, accounting for 43.9% of the total burn population. Electric burns represented a relatively small proportion (1.17%) but were more likely to lead to disabilities or death than scalds (90.63%) and flames (5.12%). The median age was 2 years [interquartile range (IQR): 1–4] and the boys/girls ratio ranged from 1.3:1 to 1.6:1. The most commonly burnt anatomic sites were the limbs (38.3%), with a median %TBSA (total body surface area) of 6 (IQR: 4–10). The complications of shock and pneumonia accounted for 7.6 and 19.2%, respectively. The peak months of pediatric burns included January, May, and August and the rural/urban ratio reached 1.61:1. The percentage of burn wounds treated surgically increased considerably from 2013 to 2019 (3.8 vs. 37.8%). The median hospital LOS was 15 days (IQR: 8–28 days), with the three high-risk factors (e.g., more surgeries, more %TBSA, full-thickness skin burns). The median cost of hospitalization was 1,511 USD (IQR: 848–2,648 USD) and the main risk factors consisted of full-thickness burns, more %TBSA, longer LOS, and more surgical procedures. Among all the patients, LA50 was 78.63% (95% CI = 75.12–83.45) and the overall mortality reached 0.1% since seven deaths were recorded.

Conclusion

Scalds, flames, contact, and chemicals are the main causes of burns among children aged 1–5 years in central China. Accordingly, various prevention strategies should be employed depending upon the cause of the burn.

Pediatric Lower Respiratory Tract Infections: Imaging Guidelines and Recommendations

Lower respiratory tract infection (LRTI) remains a major cause of morbidity and mortality in children. Various organisms cause LRTI, including viruses, bacteria, fungi, and parasites, among others. Infections caused by 2 or more organisms also occur, sometimes enhancing the severity of the infection. Medical imaging helps confirm a diagnosis but also plays a role in the evaluation of acute and chronic sequelae. Medical imaging tests help evaluate underlying pathology in pediatric patients with recurrent or long-standing symptoms as well as the immunocompromised.

Predictive Value of Clinician "Gestalt" in Pediatric Community-Acquired Pneumonia

OBJECTIVES

Validated prognostic tools for pediatric community-acquired pneumonia (CAP) do not exist. Thus, clinicians rely on "gestalt" in management decisions for children with CAP. We sought to determine the ability of clinician gestalt to predict severe outcomes.

METHODS

We performed a prospective cohort study of children 3 months to 18 years old presenting to a pediatric emergency department (ED) with lower respiratory infection and receiving a chest radiograph for suspected CAP from 2013 to 2017. Clinicians reported the probability that the patient would develop severe complications of CAP (defined as respiratory failure, empyema or effusion, lung abscess or necrosis, metastatic infection, sepsis or septic shock, or death). The primary outcome was development of severe complications.

RESULTS

Of 634 children, 37 (5.8%) developed severe complications. Of children developing severe complications after the ED visit, 62.1% were predicted as having <10% risk by the ED clinician. Sensitivity was >90% at the <1% predicted risk threshold, whereas specificity was >90% at the 10% risk threshold. Gestalt performance was poor in the low-intermediate predicted risk category (1%-10%). Clinicians had only fair ability to discriminate children developing complications from those who did not (area under the receiver operator characteristic curve 0.747), with worse performance from less experienced clinicians (area under the receiver operator characteristic curve 0.693).

CONCLUSIONS

Clinicians have only fair ability to discriminate children with CAP who develop severe complications from those who do not. Clinician gestalt performs best at very low or higher predicted risk thresholds, yet many children fall in the low-moderate predicted risk range in which clinician gestalt is limited. Evidence-based prognostic tools likely can improve on clinician gestalt, particularly when risk is low-moderate.

A decade's experience of pediatric lung abscess and empyema at a community hospital

BACKGROUND

Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices.

METHODS

A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed.

RESULTS

Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst.

CONCLUSION

Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice.

Factors Associated with Failure of Intermittent Nebulization with Short-Acting Beta-Agonists in Children with Severe Asthma Exacerbation

Purpose

Intermittent nebulization of short-acting beta-agonists (SABA) is the initial treatment of choice for children with asthma exacerbation. However, children with severe asthma exacerbation (SAE) may not show an adequate response and need aggressive stepwise therapy. We aimed to explore factors associated with a poor response to intermittent nebulized SABA in children with SAE.

Methods

A retrospective cohort study of children with SAE diagnosed according to the definition of the British Guidelines on the Management of Asthma, who were admitted at Hat Yai Hospital from January 1, 2015, to December 31, 2017. All children were treated with intermittent SABA nebulization. Treatment failure was defined as children needing escalated therapy. Logistic regression with confounding score adjustment was used to explore the predictors of treatment failure.

Results

One hundred thirty-three children were included in the analysis, 59 were in the failure group and 74 were in the success group. After adjusting for potential confounders, they were significantly associated with a previous history of intubation (adjusted OR 6.46, 95% CI 1.13 to 36.79, p=0.036), receiving <3 doses of nebulized salbutamol in the emergency room (ER, aOR 3.21, 95% CI 1.15 to 9.02, p=0.027), ER measured oxygen saturation (SpO₂) <92% (adjusted OR 3.02, 95% CI 1.18 to 7.75, p=0.022), and exacerbation triggered by pneumonia (adjusted OR 2.67, 95% CI 1.19 to 6.00, p=0.017).

Conclusion

We identified four prognostic factors of treatment failure in children with SAE: a previous history of intubation; receiving <3 doses of nebulized salbutamol in the ER, SpO₂ at ER <92%; and exacerbation triggered by pneumonia. Further prospective studies are required to confirm our findings before clinical implementation.

Antibiotics for treating community-acquired pneumonia in people with sickle cell disease

BACKGROUND

As a consequence of their condition, people with sickle cell disease are at high risk of developing an acute infection of the pulmonary parenchyma called community-acquired pneumonia. Many different bacteria can cause this infection and antibiotic treatment is generally needed to resolve it. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia. This is an update of a previously published Cochrane Review.

OBJECTIVES

To determine the efficacy and safety of the antibiotic treatment approaches (monotherapy or combined) for people with sickle cell disease suffering from community-acquired pneumonia.

SEARCH METHODS

We searched The Group's Haemoglobinopathies Trials Register (01 September 2016), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched LILACS (1982 to 01 September 2016), African Index Medicus (1982 to 20 October 2016) and WHO ICT Registry (20 October 2016).

SELECTION CRITERIA

We searched for published or unpublished randomized controlled trials.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane methodologies, but no eligible randomized controlled trials were identified.

MAIN RESULTS

We were unable to find any randomized controlled trials on antibiotic treatment approaches for community-acquired pneumonia in people with sickle cell disease.

AUTHORS' CONCLUSIONS

The updated review was unable to identify randomized controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia. Randomized controlled trials are needed to establish the optimum antibiotic treatment for this condition. The trials regarding this issue should be structured and reported according to the CONSORT statement for improving the quality of reporting of efficacy and improved reports of harms in clinical research. Triallists should consider including the following outcomes in new trials: number of days to become afebrile; mortality; onset of pain crisis or complications of sickle cell disease following community-acquired pneumonia; diagnosis; hospitalization (admission rate and length of hospital stay); respiratory failure rate; and number of participants receiving a blood transfusion.There are no trials included in the review and we have not identified any relevant trials up to September 2016. We therefore do not plan to update this review until new trials are published.

Underlying congenital heart disease in Nigerian children with pneumonia

BACKGROUND

Pneumonia is a common cause of childhood morbidity and mortality globally. Some congenital heart disease (CHD) may predispose their sufferer to bronchopneumonia.

OBJECTIVE

To evaluate the contribution of CHD to pneumonia in children seen in a tertiary hospital.

METHODS

Over a year, consecutive children diagnosed radiologically with pneumonia were evaluated echocardiographically for CHD. Certain characteristics in children with pneumonia and CHD were compared to those without CHD.

RESULTS

There were 121 children with pneumonia of which 61(50.40%) were males and their mean age was 10.2 ± 10.93 months. The prevalence of CHD was 14(11.57%), the commonest CHD was ventricular septal defect (VSD) in 7(50.00%). Most of the CHD with septal defect had moderate to large defects. Children with CHD were 3 and 256 times more likely to have heart failure and murmur respectively compared to those without CHD, p = 0.084 and <0.0001. Children with CHD stayed longer in the hospital 11.50 ± 7.03 days than those without CHD 7.38 ± 5.34 days, p = 0.012.

CONCLUSION

The children with CHD were more likely to have heart failure and murmur compared to those without CHD. Prevalence of CHD in children with pneumonia in this study is high, evaluation of children with pneumonia for CHD is therefore recommended.

Antibiotics for treating community acquired pneumonia in people with sickle cell disease

BACKGROUND

As a consequence of their condition, people with sickle cell disease are at high risk of developing an acute infection of the pulmonary parenchyma called community-acquired pneumonia. Many different bacteria can cause this infection and antibiotic treatment is generally needed to resolve it. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia.

OBJECTIVES

To determine the efficacy and safety of the antibiotic treatment approaches (monotherapy or combined) for people with sickle cell disease suffering from community-acquired pneumonia.

SEARCH METHODS

We searched The Group's Haemoglobinopathies Trials Register (25 May 2012), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched LILACS (1982 to 27 April 2012), African Index Medicus (1982 to 27 April 2012) and WHO ICT Registry (27 April 2012).

SELECTION CRITERIA

We searched for published or unpublished randomized controlled trials.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies, but no eligible randomized controlled trials were identified.

MAIN RESULTS

We were unable to find any randomized controlled trials on antibiotic treatment approaches for community-acquired pneumonia in people with sickle cell disease.

AUTHORS' CONCLUSIONS

The updated review was unable to identify randomized controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia. Randomized controlled trials are needed to establish the optimum antibiotic treatment for this condition. The trials regarding this issue should be structured and reported according to the CONSORT statement for improving the quality of reporting of efficacy and improved reports of harms in clinical research. Triallists should consider including the following outcomes in new trials: number of days to become afebrile; mortality; onset of pain crisis or complications of SCD following CAP; diagnosis; hospitalisation (admission rate and length of hospital stay); respiratory failure rate; and number of participants receiving a blood transfusion.There are no trials included in the review and we have not identified any relevant trials up to May 2012. We therefore do not plan to update this review until new trials are published.

[Aetiology and diagnosis of community acquired pneumonia and its complicated forms]

Community Acquired Pneumonia (CAP) is a common childhood disease, involving several paediatric subspecialties in its diagnosis and treatment. This has prompted the Spanish Society of Paediatric Pulmonology (SENP) and the Spanish Society of Paediatric Infectious Diseases (SEIP) to prepare a consensus document on the diagnosis of CAP, assessing the practical aspects by means of evidence-based medicine. It discusses the aetiology and epidemiology, with the current changes and the validity of certain laboratory tests, such as acute phase reactants, microbiological and imaging techniques, guiding the paediatricians in the real value of these tests.

Common childhood bacterial infections

Children with infectious diseases are commonly encountered in primary care settings. Identification of the subset of patients with bacterial infections is key in guiding the best possible management. Clinicians frequently care for children with infections of the upper respiratory tract, including acute otitis media, otitis externa, sinusitis, and pharyngitis. Conjunctivitis is not an uncommon reason for office visits. Bacterial pneumonia, urinary tract infections, and gastroenteritis are regularly seen. Over the last decade, a growing number of children have had infections of the skin and soft tissue, driven by the increased prevalence of infections caused by methicillin-resistant Staphylococcus aureus. The following review addresses the epidemiology and risk factors for specific infections and examines the clinical presentation and selection of appropriate diagnostic methods in such conditions. Methods to prevent these bacterial infections and recommendations for follow-up are suggested. Management of these infections requires that antimicrobial agents be used in a judicious manner in the outpatient setting. Such antibiotic therapy is recommended using both available clinical evidence and review of disease-specific treatment guidelines.

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

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

The diagnostic accuracy of high-mobility group box 1 protein and twelve other markers in discriminating bacterial, viral and co-infected bronchial pneumonia in Han children

Pneumonia in children is common and can lead to grave consequences if not addressed in a proper and timely manner. In the management of pneumonia, early identification of the causative infective agent is of obvious importance for treatment, as it allows selection of the appropriate antibiotics. However, such identification requires laboratory test results, which may not be immediately available. The aim of this study was to evaluate the accuracy and usefulness of 13 markers in differentiating between viral and bacterial pneumonia in Han children (34 healthy controls and 78 patients). It was found that WBC counts were more accurate in diagnosis of the type of agent responsible for infection than was the degree of expression of HMGB1. Among the 13 markers investigated, HMGB1 was the best at discriminating between co-infected (bacterium and virus) and single-infected (bacterium or virus) children with bronchial pneumonia. HMGB1 expression of less than 1.0256, excluded most co-infections (the negative predictive value was greater than 89.7%). Diagnosed sole viral pneumonia clinically overlapped with bacterial pneumonia, but bacterial pneumonia was more often associated with higher white blood cell (WBC) counts (WBC ≥ 13,000 cells/mm(3)). When the two marker readouts--HMGB1 < 1.0256 and WBC ≥ 13,000 cells/mm(3)--were combined, the positive predictive value for bacterial pneumonia alone was 92.3%. These findings can help clinicians discriminate between bronchial pneumonia caused by virus, bacterium or both with a high specificity.

Guidelines for diagnosing and treating pulmonary infiltrates in children with acute leukaemia: impact of timely decisions

AIM

Children with leukaemia are at increased risk of pulmonary complications, often with unspecific clinical data, delayed diagnosis and a high mortality rate. We evaluated the usefulness of diagnostic-therapeutic guidelines (DTG) in which specific times for decision making were incorporated.

METHODS

Clinical charts of children with acute leukaemia and suspicion of pulmonary involvement were reviewed. Patients were allocated to group I if their diagnostic and therapeutic decisions were in accordance with the DTG, and to group II if not.

RESULTS

Children from group I (n=32) and group II (n=28) did not differ with respect to age (9.3+/-0.5 years old, mean+/-SEM), gender, type, risk and stage of leukaemia, anaemia and neutropenia. Total length of hospital stay and hospitalization due to the pulmonary disease were shorter in group I than in group II (14.8+/-2.1 vs. 28.5+/-3.7 days, p=0.0016; and 10.8+/-1.0 vs. 18.4+/-1.8 days, p=0.0003, respectively). Two patients (6.3%) died due to the pulmonary pathology in group I, and nine (32.1%, p=0.016) in group II.

CONCLUSIONS

Diagnostic-therapeutic guidelines that incorporate timely decisions constitute a useful algorithm to reduce the length of hospital stay and mortality in children with acute leukaemia and pulmonary infiltrates. A prospective study is needed to validate these results.

Antibiotics for treating community acquired pneumonia in people with sickle cell disease

BACKGROUND

As a consequence of their condition, people with sickle cell disease are at high risk of developing an acute infection of the pulmonary parenchyma called community-acquired pneumonia. Many different bacteria can cause this infection and antibiotic treatment is generally needed to resolve it. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia.

OBJECTIVES

To determine the efficacy and safety of the antibiotic treatment approaches (monotherapy or combined) for people with sickle cell disease suffering from community-acquired pneumonia.

SEARCH STRATEGY

We searched The Group's Haemoglobinopathies Trials Register (December 2005), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to December 5th, 2005), EMBASE (1974 to December 7th, 2005), and LILACS (1982 to December 2005). Date of most recent search: December 2005

SELECTION CRITERIA

We searched for published or unpublished randomized controlled trials.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies, but no eligible randomized controlled trials were identified.

MAIN RESULTS

We were unable to find any randomized controlled trials on antibiotic treatment approaches for community-acquired pneumonia in people with sickle cell disease.

AUTHORS' CONCLUSIONS

We were unable to identify randomized controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from community-acquired pneumonia. Randomized controlled trials are needed to establish the optimum antibiotic treatment for this condition.