Lower respiratory tract infections

Azithromycin for acute bronchiolitis and wheezing episodes in children - a systematic review with meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to analyse the efficacy of azithromycin in acute bronchiolitis and wheezing.

METHODS

PubMed, Scopus, and Web of Science databases were searched for randomized controlled trials comparing azithromycin to placebo in children <2 years of age. Main outcomes were progress of acute wheezing episode and recurrence of wheezing. We used random-effects model to calculate mean difference (MD) with 95% confidence interval (CI) or risk ratios (RR) with CI.

RESULTS

We screened 1604 abstracts and included 7 studies. Risk of bias was low in three and had some concerns in four studies. Need for intensive care unit treatment was assessed in four studies (446 children) and the risk difference was 0.0% (CI -2.0 to 2.0; low quality evidence). Hospitalization duration was -0.27 days shorter in the azithromycin group (MD-0.27, CI -0.47 to -0.07; three studies; moderate quality evidence). Azithromycin did not prevent recurrence of wheezing (RR 0.84, CI 0.45-1.56; three studies), hospital readmissions (RR 1.14, CI 0.82-1.60; four studies).

CONCLUSIONS

We found moderate quality evidence that azithromycin may reduce hospitalization duration. Low certainty evidence suggests that azithromycin does not reduce the need for intensive care unit treatment. Furthermore, azithromycin did not prevent wheezing recurrence.

IMPACT

Azithromycin may reduce hospitalization time in acute bronchiolitis and wheezing episodes among children aged less than two. Azithromycin administrated during the acute wheezing period, does not have preventive effect on wheezing recurrence. Azithromycin seemed to have similar adverse event profile than placebo. Future studies with clinically relevant outcomes, and sufficient sample sizes are needed, before implementing azithromycin into clinical use.

Hospitalisations related to lower respiratory tract infections in Northern Queensland

OBJECTIVE

To investigate the admission characteristics and hospital outcomes for patients admitted with lower respiratory tract infections (LRTI) in Northern Queensland.

METHODS

We perform a retrospective analysis of the data covering an 11-year period, 2006-2016. Length of hospital stay (LOS) is modelled by negative binomial regression and heterogeneous effects are checked using interaction terms.

RESULTS

A total of 11,726 patients were admitted due to LRTI; 2,430 (20.9%) were of Indigenous descent. We found higher hospitalisations due to LRTI for Indigenous than non-Indigenous patients, with a disproportionate increase in hospitalisations occurring during winter. The LOS for Indigenous patients was higher by 2.5 days [95%CI: -0.15; 5.05] than for non-Indigenous patients. The average marginal effect of 17.5 [95%CI: 15.3; 29.7] implies that the LOS for a patient, who was admitted to ICU, was higher by 17.5 days.

CONCLUSIONS

We highlighted the increased burden of LRTIs experienced by Indigenous populations, with this information potentially being useful for enhancing community-level policy making. Implications for public health: Future guidelines can use these results to make recommendations for preventative measures in Indigenous communities. Improvements in engagement and partnership with Indigenous communities and consumers can help increase healthcare uptake and reduce the burden of respiratory diseases.

Diagnosis of common pulmonary diseases in children by X-ray images and deep learning

Acute lower respiratory infection is the leading cause of child death in developing countries. Current strategies to reduce this problem include early detection and appropriate treatment. Better diagnostic and therapeutic strategies are still needed in poor countries. Artificial-intelligence chest X-ray scheme has the potential to become a screening tool for lower respiratory infection in child. Artificial-intelligence chest X-ray schemes for children are rare and limited to a single lung disease. We need a powerful system as a diagnostic tool for most common lung diseases in children. To address this, we present a computer-aided diagnostic scheme for the chest X-ray images of several common pulmonary diseases of children, including bronchiolitis/bronchitis, bronchopneumonia/interstitial pneumonitis, lobar pneumonia, and pneumothorax. The study consists of two main approaches: first, we trained a model based on YOLOv3 architecture for cropping the appropriate location of the lung field automatically. Second, we compared three different methods for multi-classification, included the one-versus-one scheme, the one-versus-all scheme and training a classifier model based on convolutional neural network. Our model demonstrated a good distinguishing ability for these common lung problems in children. Among the three methods, the one-versus-one scheme has the best performance. We could detect whether a chest X-ray image is abnormal with 92.47% accuracy and bronchiolitis/bronchitis, bronchopneumonia, lobar pneumonia, pneumothorax, or normal with 71.94%, 72.19%, 85.42%, 85.71%, and 80.00% accuracy, respectively. In conclusion, we provide a computer-aided diagnostic scheme by deep learning for common pulmonary diseases in children. This scheme is mostly useful as a screening for normal versus most of lower respiratory problems in children. It can also help review the chest X-ray images interpreted by clinicians and may remind possible negligence. This system can be a good diagnostic assistance under limited medical resources.

The effect of Bacillus Calmette-Guérin (BCG) vaccination in preventing severe infectious respiratory diseases other than TB: Implications for the COVID-19 pandemic

The rapid spread of the Coronavirus pandemic and its significant health and social impact urges the search for effective and readily available solutions to mitigate the damages. Thus, evaluating the effectiveness of existing vaccines like Bacillus Calmette–Guérin (BCG) has attracted attention. The aim of this review was evidence synthesis on the effect of BCG vaccine in preventing severe infectious respiratory disease including COVD-19, but not tuberculosis. We considered studies conducted on human participants of any study design from any country setting that were published in Enlgish. We did a systematic literature search in MEDLINE, Scopus and Google scholar databases and a free search on Google. The identified studies were appraised and relevant data were extracted using Joanna Briggs Institute tools. The extracted findings were synthesized with tables and narrative summary. Nine studies met the inclusion criteria. The findings indicated that BCG vaccine has a strong protective effect against both upper and lower acute respiratory tract infections. For instance in countries with universal BCG vaccination policy, the incidence of COVID-19 was lower compared to the counterparts. Addtionally, BCG vaccine was found to protect against infections like lethal influenza A virus, pandemic influenza (H1N1), and other acute respiratory tract infections. BCG improved the human body’s immune response involving antigen-specific T cells and memory cells. It also induced adaptive functional reprogramming of mononuclear phagocytes that induce protective effects against different respiratory infections other than tuberculosis. In countries with universal BCG vaccination, the incidence and death from acute respiratory viral infection including COVID – 19 is significantly low. However, there is an urgent need for further evidence from well-designed studies to understand the possible role of BCG vaccination over time and across age groups, its possible benefits in special populations such as health workers and cost-savings related to a policy of universal BCG vaccination.

Respiratory, birth and health economic measures for use with Indigenous Australian infants in a research trial: a modified Delphi with an Indigenous panel

Background

There is significant disparity between the respiratory health of Indigenous and non-Indigenous Australian infants. There is no culturally accepted measure to collect respiratory health outcomes in Indigenous infants. The aim of this study was to gain end user and expert consensus on the most relevant and acceptable respiratory and birth measures for Indigenous infants at birth, between birth and 6 months, and at 6 months of age follow-up for use in a research trial.

Methods

A three round modified Delphi process was conducted from February 2018 to April 2019. Eight Indigenous panel members, and 18 Indigenous women participated. Items reached consensus if 7/8 (≥80%) panel members indicated the item was ‘very essential’. Qualitative responses by Indigenous women and the panel were used to modify the 6 months of age surveys.

Results

In total, 15 items for birth, 48 items from 1 to 6 months, and five potential questionnaires for use at 6 months of age were considered. Of those, 15 measures for birth were accepted, i.e., gestational age, birth weight, Neonatal Intensive Care Unit (NICU) admissions, length, head circumference, sex, Apgar score, substance use, cord blood gas values, labour, birth type, health of the mother, number people living in the home, education of mother and place of residence. Seventeen measures from 1-to 6 months of age were accepted, i.e., acute respiratory symptoms (7), general health items (2), health care utilisation (6), exposure to tobacco smoke (1), and breastfeeding status (1). Three questionnaires for use at 6 months of age were accepted, i.e., a shortened 33-item respiratory questionnaire, a clinical history survey and a developmental questionnaire.

Conclusions

In a modified Delphi process with an Indigenous panel, measures and items were proposed for use to assess respiratory, birth and health economic outcomes in Indigenous Australian infants between birth and 6 months of age. This initial step can be used to develop a set of relevant and acceptable measures to report respiratory illness and birth outcomes in community based Indigenous infants.

Point prevalence surveys of health-care-associated infections: a systematic review

Health-care-associated infections (HAIs) are considered a serious public health issues that contribute substantially to the global burden of mortality and morbidity with respect to infectious diseases. The aim is to assess the burden of health-care-associated infections by collation of available data from published point prevalence surveys (PPS) on HAIs to give future guidance. Study protocol and methodology were designed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Published research papers that conducted a point prevalence survey of HAIs in hospital settings by following the structured survey methodology employed by European Centre of Disease Prevention and Control (ECDC) were included. Of 1212 articles, 67 studies were included in the final analysis conducted across different countries. Overall, 35 studies were conducted in Europe, 21 in Asia, 9 in America, and 2 in Africa. The highest prevalence of HAIs was recorded in a study conducted in adult ICU settings of 75 regions of Europe (51.3%). The majority of the studies included HAI data on urinary tract infections, respiratory tract infections, and bloodstream infections. Klebsiella pneumonia, Pseudomonas aeruginosa and E. coli were the most frequent pathogens responsible for HAIs. PPS is an useful tool to quantify HAIs and provides a robust baseline data for policymakers. However, a standardize surveillance method is required. In order to minimize the burden of HAIs, infection prevention and control programs and antibiotic stewardship may be effective strategies to minimize the risk of HAIs.

Risk factors and mitigation of influenza among Indigenous children in Australia, Canada, United States, and New Zealand: a scoping review

AIM

This review considers prominent risk factors and mitigation strategies of influenza among Indigenous children.

METHODS

Seven electronic databases were searched from the period of 2004-2017 to locate articles discussing influenza among Indigenous children in the developed circumpolar nations of Australia, Canada, United States, and New Zealand. Articles selected for inclusion discussed influenza among Indigenous children as either individuals or as a part of a community. Ancestry searches of articles meeting the review criteria were also undertaken to discern seminal research in this topic area.

RESULTS

From the 39 primary research studies included, marked risk factors and mitigation strategies of influenza among Indigenous children were identified using inductive analysis. Notable risk factors included age under 2 years, cigarette smoke exposure, presence of a chronic illness, and crowded living conditions. Successful mitigation of influenza for Indigenous children included strategies to improve vaccine coverage, provision of health education, and policy change.

CONCLUSION

In the past, the impact of influenza upon Indigenous communities has been devastating for both children and their families. By utilizing existing public health infrastructure and collaborating with culturally unique Indigenous groups, preventive action for Indigenous children at significant risk of contracting influenza can be realized.

Network Meta-Analysis Comparing the Efficacy of Therapeutic Treatments for Bronchiolitis in Children

BACKGROUND

This study aims to compare placebo (PBO) and 7 therapeutic regimens-namely, bronchodilator agents (BAs), hypertonic saline (HS), BA ± HS, corticosteroids (CS), epinephrine (EP), EP ± CS, and EP ± HS-to determine the optimal bronchiolitis treatment.

METHODS

We plotted networks using the curative outcome of several studies and specified the relations among the experiments by using mean difference, standardized mean difference, and corresponding 95% credible interval. The surface under the cumulative ranking curve (SUCRA) was used to separately rank each therapy on clinical severity score (CSS) and length of hospital stay (LHS).

RESULTS

This network meta-analysis included 40 articles from 1995 to 2016 concerning the treatment of bronchiolitis in children. All 7 therapeutic regimens displayed no significant difference to PBO with regard to CSS in our study. Among the 7 therapies, BA performed better than CS. As for LHS, EP and EP ± HS had an advantage over PBO. Moreover, EP and EP ± HS were also more efficient than BA. The SUCRA results showed that EP ± CS is most effective, and EP ± HS is second most effective with regard to CSS. With regard to LHS, EP ± HS ranked first, EP ± CS ranked second, and EP ranked third.

CONCLUSIONS

We recommend EP ± CS and EP ± HS as the first choice for bronchiolitis treatment in children because of their outstanding performance with regard to CSS and LHS.

Antibiotics for persistent cough or wheeze following acute bronchiolitis in children

BACKGROUND

Bronchiolitis is a common acute respiratory condition with high prevalence worldwide. This clinically diagnosed syndrome is manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (≤ 14 days), antibiotics are not routinely prescribed unless the illness is severe or a secondary bacterial infection is suspected. Although bronchiolitis is usually self-limiting, some young children continue to have protracted symptoms (e.g. cough and wheezing) beyond the acute phase and often re-present to secondary care.

OBJECTIVES

To compare the effectiveness of antibiotics versus controls (placebo or no treatment) for reducing or treating persistent respiratory symptoms following acute bronchiolitis within six months of acute illness.

SEARCH METHODS

We searched the following databases: the Cochrane Airways Group Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), the World Health Organization (WHO) trial portal, the Australian and New Zealand Clinical Trials Registry, and ClinicalTrials.gov, up to 26 August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing antibiotics versus controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years with a diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies against predefined criteria, and selected, extracted, and assessed data for inclusion. We contacted trial authors for further information.

MAIN RESULTS

In this review update, we added one study with 219 children. A total of two RCTs with 249 children (n = 240 completed) were eligible for inclusion in this review. Both studies contributed to our primary and secondary outcomes, but we assessed the quality of evidence for our three primary outcomes as low, owing to the small numbers of studies and participants; and high attrition in one of the studies. Data show no significant differences between treatment groups for our primary outcomes: proportion of children (n = 249) who had persistent symptoms at follow-up (odds ratio (OR) 0.69, 95% confidence interval (CI) 0.37 to 1.28; fixed-effect model); and number of children (n = 240) rehospitalised with respiratory illness within six months (OR 0.54, 95% CI 0.05 to 6.21; random-effects model). We were unable to analyse exacerbation rate because studies used different methods to report this information. Data showed no significant differences between treatment groups for our secondary outcome: proportion of children (n = 240) with wheeze at six months (OR 0.47, 95% CI 0.06 to 3.95; random-effects model). One study reported bacterial resistance, but only at 48 hours (thus with limited applicability for this review). Another study reported adverse events from which all children recovered and remained in the study.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs are needed to evaluate the efficacy of antibiotics for reducing persistent respiratory symptoms. This is particularly important in populations with high acute and post-acute bronchiolitis morbidity (e.g. indigenous populations in Australia, New Zealand, and the USA).

Characteristics and respiratory risk profile of children aged less than 5 years presenting to an urban, Aboriginal-friendly, comprehensive primary health practice in Australia

AIM

There are no published data on factors impacting on acute respiratory illness (ARI) among urban Indigenous children. We describe the characteristics and respiratory risk profile of young urban Indigenous children attending an Aboriginal-friendly primary health-care practice.

METHODS

We conducted a cross-sectional analysis of data collected at baseline in a cohort study investigating ARI in urban Indigenous children aged less than 5 years registered with an Aboriginal primary health-care service. Descriptive analyses of epidemiological, clinical, environmental and cultural factors were performed. Logistic regression was undertaken to examine associations between child characteristics and the presence of ARI at baseline.

RESULTS

Between February 2013 and October 2015, 180 Indigenous children were enrolled; the median age was 18.4 months (7.7-35), 51% were male. A total of 40 (22%) children presented for a cough-related illness; however, ARI was identified in 33% of all children at the time of enrolment. A total of 72% of children were exposed to environmental tobacco smoke. ARI at baseline was associated with low birthweight (adjusted odds ratio (aOR) 2.54, 95% confidence interval (CI) 1.08-5.94), a history of eczema (aOR 2.67, 95% CI 1.00-7.15) and either having a family member from the Stolen Generation (aOR 3.47, 95% CI 1.33-9.03) or not knowing this family history (aOR 3.35, 95% CI 1.21-9.26).

CONCLUSIONS

We identified an urban community of children of high socio-economic disadvantage and who have excessive exposure to environmental tobacco smoke. Connection to the Stolen Generation or not knowing the family history may be directly impacting on child health in this community. Further research is needed to understand the relationship between cultural factors and ARI.

The Incidence and Short-term Outcomes of Acute Respiratory Illness with Cough in Children from a Socioeconomically Disadvantaged Urban Community in Australia: A Community-Based Prospective Cohort Study

BACKGROUND

Acute respiratory illnesses with cough (ARIwC) are predominant causes of morbidity in Australian Indigenous children; however, data on disease burden in urban communities are scarce. This study aimed to determine the incidence of ARIwC, the predictors of recurrent (≥4 episodes) ARIwC, and development of chronic cough following an ARIwC in urban, predominantly Indigenous, children aged <5 years from northern Brisbane, Australia.

METHODS

Prospective cohort study of children aged <5 years registered with a primary healthcare center. ARIwC episodes and outcomes were collected for 12 months. Recurrent ARIwC was defined as ≥4 episodes in 12 months. Chronic cough was defined as cough lasting >4 weeks. Children who developed chronic cough were reviewed by a pediatric pulmonologist. Incidence densities per child-month of observation were calculated and predictors of recurrent ARIwC and chronic cough were evaluated in logistic regression models.

RESULTS

Between February 2013 and November 2015, 200 children were enrolled; median age of 18.1 months, range (0.7-59.7 months) and 90% identified as Indigenous. A total of 1,722 child-months of observation were analyzed (mean/child = 8.58, 95% CI 8.18-9.0). The incidence of ARIwC was 24.8/100 child-months at risk (95% CI 22.3-27.5). Twenty-one children (10.5%) experienced recurrent ARIwC. Chronic cough was identified in 70/272 (25.7%) episodes of ARIwC. Predictors of recurrent ARIwC were presence of eczema, mold in the house, parent/carer employment status, and having an Aboriginal and Torres Strait Islander mother/non-Aboriginal and Torres Strait Islander father (compared to both parents being Aboriginal and Torres Strait Islander). Predictors of chronic cough included being aged <12 months, eczema, childcare attendance, previous history of cough of >4 weeks duration, having an Aboriginal and Torres Strait Islander mother/non-Aboriginal and Torres Strait Islander father (compared to both parents being Aboriginal and Torres Strait Islander), and a low income. Of those with chronic cough reviewed by a pediatric pulmonologist, a significant underlying disorder was found in 14 children (obstructive sleep apnea = 1, bronchiectasis = 2, pneumonia = 2, asthma = 3, tracheomalacia = 6).

DISCUSSION

This community of predominantly Aboriginal and Torres Strait Islander and socially disadvantaged children bear a considerable burden of ARIwC. One in 10 children will experience more than three episodes over a 12-month period and 1 in five children will develop chronic cough post ARIwC, some with a serious underlying disorder. Further larger studies that include a broader population base are needed.

Hospitalizations at Nonfederal Facilities for Lower Respiratory Tract Infection in American Indian and Alaska Native Children Younger than 5 Years of Age, 1997-2012

OBJECTIVES

To evaluate hospitalizations at nonfederal facilities for lower respiratory tract infection (LRTI) in American Indian/Alaska Native (AI/AN) children and to compare associated rates and risk factors in AI/AN children and white children.

STUDY DESIGN

We used Kids' Inpatient Database samples from 1997-2012 to identify discharges in non-Hispanic AI/AN and white children ages <5 years with a principal or secondary diagnosis code indicating LRTI. To address systematic underreporting and misclassification of race in administrative databases, population rates were estimated by deriving race- and year-specific denominators from hospital births.

RESULTS

During the study period, LRTI-associated discharge rates (per 1000) declined for white children (from 14.8 to 10.9; P < .001 for trend). For AI/AN children, rates varied widely by census region and were highest in the West, where they ranged from 38.6 in 1997 to 26.7 in 2012 (P = .35 for trend). Discharges in AI/AN children were associated with low household income, Medicaid insurance, and rural residence. In a case-cohort analysis of infants hospitalized with LRTI in 2012, discharge rates were higher for AI/AN infants than for white infants only in the West (72.8 vs 22.2; aOR, 2.5; 95% CI, 1.8-3.4).

CONCLUSIONS

Among young children who use nonfederal hospitals, LRTI-associated hospitalizations occur at substantially higher rates for AI/AN children than for white children. These hospitalizations occur at rates that are particularly high for AI/AN infants in the West, where rates are comparable with those reported for Indian Health Service enrollees.

Eighteen Years of Respiratory Syncytial Virus Surveillance: Changes in Seasonality and Hospitalization Rates in Southwestern Alaska Native Children

BACKGROUND

Alaska Native infants from the Yukon-Kuskokwim Delta (YKD) experienced respiratory syncytial virus (RSV) hospitalization rates 5 times higher and an RSV season twice as long as the general US infant population. We describe trends in hospitalization rates and seasonality during 18 years of continuous RSV surveillance in this population and explore contributions of climate and sociodemographic factors.

METHODS

We abstracted clinical and RSV test information from computerized medical records at YKD Regional Hospital and Alaska Native Medical Center from 1994 to 2012 to determine hospitalization rates and RSV season timing. Descriptive village and weather data were acquired through the US Census and Alaska Climate Research Center, University of Alaska, Fairbanks, respectively.

RESULTS

During 1994-2012, YKD infant RSV hospitalization rates declined nearly 3-fold, from 177 to 65 per 1000 infants/yr. RSV season onset shifted later, from mid October to late December, contributing to a significantly decreased season duration, from 30 to 11 weeks. In a multivariate analysis, children from villages with more crowded households and lacking plumbed water had higher rates of RSV hospitalizations (relative rate, 1.17; P = 0.0005 and relative rate, 1.45; P = 0.0003). No association of temperature or dew point was found with the timing or severity of RSV season.

CONCLUSIONS

Although the RSV hospitalization rate decreased 3-fold, YKD infants still experience a hospitalization rate 3-fold higher than the general US infant population. Overcrowding and lack of plumbed water were associated with RSV hospitalization. Dramatic changes occurred in RSV seasonality, not explained by changes in climate.

In vitro activity of levofloxacin against lower respiratory tract pathogens

Background:

Considerable morbidity and mortality are associated with lower respiratory tract infections (LRTIs) that put a considerable strain on the health budget. Selection of appropriate antibiotics as empirical therapy maximizes positive patient outcomes, and that depends on regular surveillance of infective agents and their antibiograms, which vary according to the geographical areas.

Aim:

The aim was to study the drug susceptibility pattern of the isolated pathogens of the respiratory tract infections.

Settings and Design:

Retrospective study for a period of 1-year 3 months from January 2013 to March 2014 at a Tertiary Care Hospital.

Materials and Methods:

Eleven hundred and eighty-four sputum samples from both outdoor and indoor patients with symptoms of LRTI were processed, and antibiotic sensitivity test was done to commonly used antibiotics. Descriptive statistics was used to analyze the data.

Results:

Among 502 quality sputum samples, 312 (62.15%) samples showed growth of pathogenic bacteria. The most common pathogens were Klebsiella spp. (38.14%), Moraxella spp. (16.02%), Streptococcus pneumoniae (14.10%), Pseudomonas spp. (9.93%), S. aureus (9.29%). It was found that the overall susceptibility pattern was <50% for amoxicillin, amoxicillin-clavulanic acid, cefuroxime, cotrimoxazole and erythromycin whereas for cefotaxime, cefixime, and cefoperazone-sulbactum it was 60.08%, 51.59%, 69.04%, respectively. The susceptibility to ciprofloxacin, ofloxacin, and levofloxacin were 66.67%, 70.19% and 83.33%, respectively.

Conclusion:

Klebsiella spp. was the most common LRTI pathogen. There was limited activity of amoxicillin, amoxicillin-clavulanic acid, cefuroxime, cotrimoxazole and erythromycin for the treatment of LRTI whereas levofloxacin, (being an oral drug with good compliance) had good activity against respiratory pathogens and could be used for empiric treatment in LRTI.

Coal Mine Air Pollution and Number of Children Hospitalizations because of Respiratory Tract Infection: A Time Series Analysis

To analyze the relationship between levels of air pollution and number of children hospitalizations because of respiratory tract infection in Shenmu County, the data regarding meteorological factors, environmental pollutants, that is SO(2) and NO(2), Particulate Matter 10 (PM10), and hospitalizations of children less than 16 years of age was collected during the time duration of November 2009 to October 2012. Using SAS 9.3, descriptive data analysis for meteorological and environmental factors and hospital admissions were performed along with main air pollutants determination. Using the statistical software R 3.0.1, a generalized additive Poisson regression model was established, the linear fitting models of the air pollutant concentrations and meteorological factors were introduced considering the lag effect, and the relative risk of the main atmospheric pollutants on children hospitalization was evaluated. The results showed that the primary air pollutant in Shenmu County is PM10 and its Pearson correlation coefficient with Air Pollution Index (API) is 0.917. After control of long term climate trend, "week day effect," meteorological factors, and impact of other contaminants, it was found that, on the same day and during the lag of 1 to 10 days, PM10 concentrations had no significant effect on children hospitalization rate.

Ethnic variations in morbidity and mortality from lower respiratory tract infections: a retrospective cohort study

OBJECTIVE

There is evidence of substantial ethnic variations in asthma morbidity and the risk of hospitalisation, but the picture in relation to lower respiratory tract infections is unclear. We carried out an observational study to identify ethnic group differences for lower respiratory tract infections.

DESIGN

A retrospective, cohort study.

SETTING

Scotland.

PARTICIPANTS

4.65 million people on whom information was available from the 2001 census, followed from May 2001 to April 2010.

MAIN OUTCOME MEASURES

Hospitalisations and deaths (any time following first hospitalisation) from lower respiratory tract infections, adjusted risk ratios and hazard ratios by ethnicity and sex were calculated. We multiplied ratios and confidence intervals by 100, so the reference Scottish White population's risk ratio and hazard ratio was 100.

RESULTS

Among men, adjusted risk ratios for lower respiratory tract infection hospitalisation were lower in Other White British (80, 95% confidence interval 73-86) and Chinese (69, 95% confidence interval 56-84) populations and higher in Pakistani groups (152, 95% confidence interval 136-169). In women, results were mostly similar to those in men (e.g. Chinese 68, 95% confidence interval 56-82), although higher adjusted risk ratios were found among women of the Other South Asians group (145, 95% confidence interval 120-175). Survival (adjusted hazard ratio) following lower respiratory tract infection for Pakistani men (54, 95% confidence interval 39-74) and women (31, 95% confidence interval 18-53) was better than the reference population.

CONCLUSIONS

Substantial differences in the rates of lower respiratory tract infections amongst different ethnic groups in Scotland were found. Pakistani men and women had particularly high rates of lower respiratory tract infection hospitalisation. The reasons behind the high rates of lower respiratory tract infection in the Pakistani community are now required.

New microbiota found in sputum from patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major concern in hospitals and the bacterial community of which has not been systemically discussed yet. Sputum from patients in the acute stages is a kind of accessible sample reflecting its features. In our study, we analyzed 45 sputum samples from 45 patients with CAP. Eighteen sputum samples from healthy people were chosen as the controls. Pyrosequencing of the 16s rDNA V3 hypervariable regions of all the bacteria contained in the sputum was used as a culture-independent method to disclose the community constitution. Also, our published data for hospital-acquired pneumonia (HAP) in sputum was used for comparison. By pyrosequencing, >90,000 DNA reads were detected. After being analyzed by tools in the Ribosomal Database Project, the reads were classified into five main phyla and >100 genera. At the phyla level, the reads' distribution of CAP is similar to that of healthy people and at genera level, the occurrence of each genus possesses their feature in three categories. Genera such as Streptococcus and Neisseria showed stability in their percentages, indicating that such genera are rarely affected by exogenous bacteria or antibiotics. The role of other genera such as Moraxella and Rothia in CAP should be emphasized. According to our analysis, the bacterial communities of CAP are with slight change when compared with those of healthy people, but have a large gap between HAP. Meanwhile, Rothia might be an important endogenous pneumonia-causing factor.

A single dose of azithromycin does not improve clinical outcomes of children hospitalised with bronchiolitis: a randomised, placebo-controlled trial

Objective

Bronchiolitis, one of the most common reasons for hospitalisation in young children, is particularly problematic in Indigenous children. Macrolides may be beneficial in settings where children have high rates of nasopharyngeal bacterial carriage and frequent prolonged illness. The aim of our double-blind placebo-controlled randomised trial was to determine if a large single dose of azithromycin (compared to placebo) reduced length of stay (LOS), duration of oxygen (O₂) and respiratory readmissions within 6 months of children hospitalised with bronchiolitis. We also determined the effect of azithromycin on nasopharyngeal microbiology.

Methods

Children aged ≤18 months were randomised to receive a single large dose (30 mg/kg) of either azithromycin or placebo within 24 hrs of hospitalisation. Nasopharyngeal swabs were collected at baseline and 48hrs later. Primary endpoints (LOS, O₂) were monitored every 12 hrs. Hospitalised respiratory readmissions 6-months post discharge was collected.

Results

97 children were randomised (n = 50 azithromycin, n = 47 placebo). Median LOS was similar in both groups; azithromycin = 54 hours, placebo = 58 hours (difference between groups of 4 hours 95%CI -8, 13, p = 0.6). O₂ requirement was not significantly different between groups; Azithromycin = 35 hrs; placebo = 42 hrs (difference 7 hours, 95%CI -9, 13, p = 0.7). Number of children re-hospitalised was similar 10 per group (OR = 0.9, 95%CI 0.3, 2, p = 0.8). At least one virus was detected in 74% of children. The azithromycin group had reduced nasopharyngeal bacterial carriage (p = 0.01) but no difference in viral detection at 48 hours.

Conclusion

Although a single dose of azithromycin reduces carriage of bacteria, it is unlikely to be beneficial in reducing LOS, duration of O₂ requirement or readmissions in children hospitalised with bronchiolitis. It remains uncertain if an earlier and/or longer duration of azithromycin improves clinical and microbiological outcomes for children. The trial was registered with the Australian and New Zealand Clinical Trials Register. Clinical trials number: ACTRN12608000150347. http://www.anzctr.org.au/TrialSearch.aspx.

Severity scoring systems: are they internally valid, reliable and predictive of oxygen use in children with acute bronchiolitis?

BACKGROUND

Severity scores are commonly used in research and clinically to assess the severity of bronchiolitis. However, there are limitations as few have been validated. The aim of our study was to: (i) determine the validity and reliability of a bronchiolitis scoring system, and (ii) examine if the score predicted the need for oxygen at 12 and 24 hrs. Children aged <24 months presenting to Royal Darwin Hospital with a clinical diagnosis of bronchiolitis were eligible to participate.

STUDY DESIGN

We reviewed published papers that used a bronchiolitis score and summarized the data in a table. We chose the Tal score that was easy to use and encompassed clinically important parameters. Three research nurses, trained to assess children, used two scoring systems (Tal and Modified-Tal; respiratory rate, accessory muscle use, wheezing, cyanosis, and oxygen saturation), blindly evaluated children within 15 min of each other.

RESULTS

The children's (n = 115) median age was 5.4 months (IQR 2.9, 10.4); 65% were male and 64% were Indigenous. Internal consistency was excellent (Tal: Cronbach α = 0.66; Modified-Tal: α = 0.70). There was substantial inter-rater agreement; weighted kappa of 0.72 (95% CI: 0.63, 0.83) for Tal and 0.70 (95% CI: 0.63, 0.76) for Modified-Tal. For predicting requirement for oxygen at 12 and 24 hrs; area under receiver operating curve (aROC) was 0.69 (95% CI: 0.13, 1.0) and 0.75 (95% CI: 0.34, 1.0), respectively.

CONCLUSION

The Tal and Modified-Tal scoring systems for bronchiolitis is repeatable and can reliably be used in research and clinical practice. Its utility for prediction of O2 requirement is limited.

Cord blood 25-hydroxyvitamin D levels and the risk of acute lower respiratory tract infection in early childhood

OBJECTIVE

To determine the relationship between cord blood 25-hydroxyvitamin D [25 (OH) D] concentrations and the subsequent risk of acute lower respiratory tract infection (ALRI) in the first 2 years of life.

PATIENTS AND METHODS

Cord blood from 206 newborns was tested for 25 (OH) D. Medical records covering the first 2 years of life were reviewed, and the diagnosis of ALRI was recorded.

RESULTS

Sixty-two (30.1%) infants developed ALRI in their first 2 years of life, of whom 49 (79%) infants had bronchiolitis and 13 (21%) infants had pneumonia. Concentrations of 25 (OH) D were lower in infants who developed ALRI compared with those did not (p < 0.0001). Vitamin D deficiency was associated with increased risk of ALRI (p = 0.000).

CONCLUSION

Low cord blood 25 (OH) D levels are associated with increased risk of ALRI in the first 2 years of life.

Antibiotics for persistent cough or wheeze following acute bronchiolitis in children

BACKGROUND

Bronchiolitis is a common acute respiratory infectious condition, with a high prevalence worldwide. It is a clinically diagnosed syndrome, manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (< 14 days), antibiotics have only been recommended when a secondary bacterial infection is suspected. Although bronchiolitis is usually a self-limiting condition, a number of children have persistent respiratory symptoms such as cough and wheezing in post-acute bronchiolitis, and they present or re-present to secondary care.

OBJECTIVES

To determine the effectiveness of antibiotics compared to a control (no treatment or placebo) for persistent respiratory symptoms (within six months), following acute bronchiolitis.

SEARCH METHODS

The following databases were searched, The Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid) and ClinicalTrials.gov. We searched all databases from their inception to the present, and did not impose restriction on language of publication. The search was performed in October 2012.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing antibiotics with controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years of age diagnosed with bronchiolitis were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies against pre-defined criteria; and selected, extracted and assessed the data for inclusion. Several subgroup analyses were planned and this included when antibiotics commenced (early commencement classified as preventing; later commencement as treatment for post-bronchiolitis symptoms).

MAIN RESULTS

A single study met the inclusion criteria but had a high attrition rate. Thirty infants with respiratory syncytial virus (RSV)-confirmed bronchiolitis were randomised to receive either a daily dose of oral clarithromycin 15 mg/kg or placebo for three weeks. Using an intention-to-treat (ITT) analysis, there was no significant difference between groups for the proportion of children who had persistent symptoms (odds ratio (OR) 0.20; 95% confidence interval (CI) 0.02 to 2.02) or re-hospitalisation within six months (OR 0.11; 95% CI 0.01 to 1.29). There were no treatment studies of later commencement of antibiotics.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs that evaluate the efficacy of antibiotics to reduce persistent respiratory symptoms are required, especially in areas where both acute and post-bronchiolitis morbidity is high such as in Indigenous communities in the US, New Zealand and Australia.

Trends in lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general US child population

OBJECTIVE

To describe trends in the rate of hospitalization for lower respiratory tract infection (LRTI) among American Indian/Alaska Native (AI/AN) children and the general US population of children aged <5 years.

STUDY DESIGN

This was a retrospective analysis of trends and hospitalization rates for LRTI-associated hospitalizations in 1998-2008 among AI/AN children aged <5 years using the Indian Health Service direct/contract inpatient data, and also among the general population of US children aged <5 years using the Nationwide Inpatient Sample.

RESULTS

The 2006-2008 LRTI-associated hospitalization rate for AI/AN children aged <5 years (21.8 per 1000/year) was 32% lower than the 1998-1999 rate, and 1.6-fold higher than the general US children rate (13.8 per 1000/year; 95% CI, 12.8-14.8). Higher rates were seen in AI/AN children aged <5 years in the Alaska and the Southwest regions of the United States (41.2 and 28.0 per 1000/year, respectively). In infants, these rates were 136.4 and 82.4 per 1000/year, respectively, exceeding the rate in the general US infant population (37.1 per 1000/year; 95% CI, 34.3-40.0). The greatest disparity in the LRTI-associated hospitalization rate between AI/AN infants and the general US infant population was seen for pneumonia, with a 3-fold higher rate in AI/AN infants (36.2 per 1000/year vs 12.7 per 1000/year; 95% CI, 11.8-13.6).

CONCLUSION

The LRTI-associated hospitalization rate is higher in AI/AN children, particularly infants from Alaska and the American Southwest, compared with the general US child population. Closing this gap will require addressing housing and sanitation inequities and ensuring high immunization rates and access to care.

Influence of air pollutants on allergic sensitization: the paradox of increased allergies and decreased resistance to infection

Air pollution has long been associated with health risks such as increased susceptibility to respiratory infections and potentiation of asthmatic-type responses. Experimental evidence in rodents indicates that air pollutants including diesel exhaust particles (DEPs), gases, and metals cause lung injury, inflammation, reduce aspects of host defense, and may potentiate allergic airway responses. Here we present evidence that diesel exhaust particles delivered by inhalation or aspiration can exacerbate allergic lung disease depending on the material's chemical properties. Genomic analysis of mouse lungs following instillation or inhalation of DEPs shows an alteration spectrum of pathways associated with immune signaling, cell metabolism, and oxidative stress. Diesel exposure also may worsen respiratory infections through depression of protective immune responses. Here we show that mice exposed to diesel and co-infected with influenza had increased influenza virus titers as well as higher levels of lung injury and inflammation in association with increased Th2 cytokines, and a concomitant decrease in Th1 polarization. A simplified model explains how the potentiation of the Th2 arm of immunity by diesel exhaust results in increased allergic sensitization, whereas cell-mediated (protective) immunity against viral infections is simultaneously reduced.

Analysis of the microbiota of sputum samples from patients with lower respiratory tract infections

Sputum is the most common sample collected from patients suffering from lower respiratory tract infections and it is crucial for the bacterial identification of these infections. In this study, we enrolled 101 sputum samples from 101 patients with lower respiratory tract infections. Initially, pyrosequencing of the 16S rDNA V3 hypervariable regions of the bacteria contained in the sputum was utilized as a culture-independent approach for microbiota analysis. For comparison, clinical laboratory tests using a culture-dependent automated bacterial identification system for the same cohort of sputum samples were also done. By pyrosequencing, >70,000 DNA fragments were found and classified into 129 bacterial genera after being analyzed by the Ribosomal Database Project (RDP) process. Most sequences belonged to several predominant genera, such as Streptococcus and Staphylococcus, indicating that these genera play an important role in lower respiratory tract infections. In addition, some sequences belonging to potential causative agents, such as Mycoplasma, Haemophilus, and Moraxella, were also found, but these sequences were not found by clinical laboratory tests. For the nine genera detected by both methods, the methods' sensitivities were compared and the results showed that pyrosequencing was more sensitive, except for Klebsiella and Mycobacterium. Significantly, this method revealed much more complicated bacterial communities and it showed a promising ability for the detection of bacteria.

Lower respiratory infections in Australian Indigenous children

Despite Australia being one of the wealthiest countries of the world, Australian Indigenous children have a health status and social circumstance comparable to developing countries. Indigenous infants have 10 times the mortality rate for respiratory conditions. The lower respiratory infection (LRI) rate in Australian Indigenous children is at least as high as that of children in developing countries; the frequency of hospitalisations of Indigenous infants is triple that of non-Indigenous Australian infants (201.7 vs. 62.6/1000, respectively). While Indigenous Australian children have many risk factors for LRIs described in developing countries, there is little specific data, and hence, evidence-based intervention points are yet to be identified. Efficacy of conjugate vaccines for common bacterial causes of pneumonia has been less marked in Indigenous children than that documented overseas. Gaps in the management and prevention of disease are glaring. Given the burden of LRI in Indigenous children and the association with long-term respiratory dysfunction, LRIs should be addressed as a matter of priority.