Central nervous system infection is an important cause of death in underfives hospitalised with World Health Organization (WHO) defined severe and very severe pneumonia

Spectrum and outcome predictors of central nervous system infections in a neurological critical care unit in India: a retrospective review

BACKGROUND

There are few published studies on the spectrum and outcome of central nervous system (CNS) infection in the neurology intensive care unit (NICU). We report the spectrum of CNS infections in the NICU and the predictors of outcome.

METHODS

During 2011 to 2012, 235 critically ill neurological patients were admitted to a 12-bed NICU in a tertiary-care teaching hospital in Lucknow, northern India; 76 (32.3%) of them had CNS infections and were included in the present study. The patients' demographic and clinical details were noted, together with the underlying aetiology, Glasgow Coma Scale (GCS) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, systemic inflammatory response syndrome (SIRS) and complications during mechanical ventilation. Deaths were recorded, and 3-month functional outcome in the surviving patients assessed by the modified Rankin Scale (mRS).

RESULTS

The median age of the patients was 37.5 (4-75) years and 31 were females; 36/76 (47%) patients had tuberculous meningitis, 28/76 (37%) viral encephalitis, 8/76 (11%) pyogenic meningitis and 4/76 (5%) fungal meningitis. Seven of these patients had AIDS. The median duration of mechanical ventilation was 8 (1-121) days and 39/76 patients (51.3%) died. Duration of hospital stay (OR 1.2, 95% CI 1.05-1.37, p=0.006) and duration of mechanical ventilation (OR 0.81, 95% CI 0.68-0.95, p=0.01) were independent predictors of death. At 3-month follow-up, 23/37 patients (62%) had recovered well, 10/37 (27%) were severely disabled and 4/37 (11%) had died.

CONCLUSION

Of patients admitted to the NICU during the study period, one-third had a CNS infection. Half of those with a CNS infection survived, and predictors of death were prolonged mechanical ventilation and prolonged hospital stay.

Respiratory viruses from hospitalized children with severe pneumonia in the Philippines

BACKGROUND

Pneumonia remains a leading cause of child death in developing countries. The viruses in severe pneumonia remain poorly defined.

METHODS

The study was conducted at the Eastern Visayas Regional Medical Center in Tacloban City, Philippines from May 2008 to May 2009. Patients aged 8 days to 13 years old who were admitted to the Department of Pediatrics with severe pneumonia were enrolled for the study. Upon admission, polymerase chain reaction was performed using nasopharyngeal swabs and blood cultures to detect respiratory viruses and bacteria, respectively.

RESULT

Among the 819 patients enrolled, at least one virus was detected in 501 cases (61.2%). In addition, 423 cases were positive for a single virus while bacteria were detected in the blood culture sample of 31 cases. The most commonly detected viruses were human rhinoviruses (n = 189), including types A (n = 103), B (n = 17), and C (n = 69), and respiratory syncytial virus (RSV) (n = 165). Novel viruses such as human metapneumovirus, human coronavirus NL63, human bocavirus, and human polyomaviruses WU and KI were also detected. There were 70 deaths, and one or more viruses were detected in 35 (50%) of these cases. Positivity only for influenza A virus (OR = 4.3, 95% CI = 1.3-14.6) was significantly associated with fatal outcome. From the blood culture, Burkholderia cepacia group (n = 9), Streptococcus pneumoniae (n = 4), Staphylococcus aureus (n = 4), Haemophilus influenzae (n = 1), and Salmonella C1 (n = 1) were also isolated.

CONCLUSION

Viruses were commonly detected in children with severe pneumonia in the Philippines. Hence, viral etiologies should be considered while developing better effective strategies to reduce child pneumonia-related deaths in developing countries.

Pneumonia among young infants in rural Southeast Asia (Bohol Island, Philippines)

OBJECTIVE

To develop a clinical algorithm that can be used to identify pneumonia deaths in young infants in developing countries and estimate the disease burden in this population.

PATIENTS AND METHODS

Infants younger than 60 days hospitalized with signs of severe pneumonia who underwent clinical, microbiologic and radiological evaluation were the subjects. Stepwise logistic regression and subtractive iterative process were used to derive the algorithm.

RESULTS

Three-hundred and one infants had either clinical or radiographic pneumonia. The case fatality rate for 185 infants with radiographic pneumonia was 21%vs. 5% for clinical pneumonia. Age below 7 days was associated with an increased risk of dying. Among 7- to 59-day-old infants, poor feeding, cyanosis and absence of crackles were predictors of death from pneumonia. Using logistic regression, an algorithm consisting of any one of three clinical signs (cyanosis, poor feeding and abnormally sleepy) was developed in infants aged 7-59 days; 80% of deaths and 50% of those with radiographic pneumonia have at least one of these signs. It performed better than both the WHO case management algorithm and the IMCI algorithm.

CONCLUSION

Radiographic pneumonia is a common and serious infection among infants below 2 months old in the Philippines. Cyanosis, poor feeding and abnormal sleepiness are simple signs that can be used by health workers to identify seriously ill infants who are most likely to die from pneumonia.

Clinical case review: a method to improve identification of true clinical and radiographic pneumonia in children meeting the World Health Organization definition for pneumonia

Background

The World Health Organization's (WHO) case definition for childhood pneumonia, composed of simple clinical signs of cough, difficult breathing and fast breathing, is widely used in resource poor settings to guide management of acute respiratory infections. The definition is also commonly used as an entry criteria or endpoint in different intervention and disease burden studies.

Methods

A group of paediatricians conducted a retrospective review of clinical and laboratory data including C-reactive protein concentration and chest radiograph findings among Filipino children hospitalised in the Bohol Regional Hospital who were enrolled in a pneumococcal vaccine efficacy study and had an episode of respiratory disease fulfilling the WHO case definition for clinical pneumonia. Our aim was to evaluate which disease entities the WHO definition actually captures and what is the probable aetiology of respiratory infections among these episodes diagnosed in this population.

Results

Among the 12,194 children enrolled to the vaccine study we recorded 1,195 disease episodes leading to hospitalisation which fulfilled the WHO criteria for pneumonia. In total, 34% of these episodes showed radiographic evidence of pneumonia and 11% were classified as definitive or probable bacterial pneumonia. Over 95% of episodes of WHO-defined severe pneumonia (with chest indrawing) had an acute lower respiratory infection as final diagnosis whereas 34% of those with non-severe clinical pneumonia had gastroenteritis or other non-respiratory infection as main cause of hospitalisation.

Conclusion

The WHO definition for severe pneumonia shows high specificity for acute lower respiratory infection and provides a tool to compare the total burden of lower respiratory infections in different settings.

Trial registration

ISRCTN62323832

Serious community-acquired paediatric infections in rural Asia (Bohol Island, Philippines): bacterial meningitis in children less than 5 years of age

This paper describes the clinical profile and aetiology of bacterial meningitis in infants and children less than 5 y old admitted to a rural general hospital in the Philippines. A total of 989 infants and children 0-59 months old with suspected meningitis using a standardized guideline based on clinical signs and symptoms were prospectively enrolled from April 1994 to May 2000. Blood and CSF were drawn on admission for culture, antigen testing and cell count. All had blood cultures and 623 (63%) had CSF samples. Bacterial aetiology was found in 54 (5%). The most common bacterial pathogens were H. influenzae type b (Hib) (20, 37%) and S. pneumoniae (Pnc) (10, 18%). All of the Hib infections and 8 (80%) Pnc infections were in infants less than 1 y old. 12 (22%) of the subjects with bacterial meningitis died. All strains of S. pneumoniae and H. influenzae were sensitive to chloramphenicol, cotrimoxazole and ampicillin. In conclusion, S. pneumoniae and H. influenzae type b are the most common aetiological agents of bacterial meningitis in a rural area in the Philippines, and occur especially in infants less than 1 y old. Aetiological agents were susceptible to the currently recommended antimicrobial agents.