Improving diagnosis of childhood pneumonia

Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients

OBJECTIVES

Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients.

DESIGN

We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined.

SETTING

We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023.

PATIENTS OR SUBJECTS

Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (Fio2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H2O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus.

INTERVENTIONS

All 83 eligible patients were enrolled and underwent concurrent EA and NBBL.

MEASUREMENTS AND MAIN RESULTS

More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL.

CONCLUSIONS

NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.

Vitamin D3 in acute respiratory infections in patients under five years old (Cartagena de Indias, Colombia)

Background and Aim. Low serum levels of 25-hydroxyvitamin D3 are associated with an increased risk of Acute Respiratory Infection (ARI) that is among the most important causes of morbidity and mortality in children under 5 years old. We describe the clinical behavior of acute respiratory infections in patients under five years ago in one sanitary institution in Colombia after VD3 supplementation. Material and Methods. A case series was conducted on 38 patients of both genders aged less to 5 years ago was included. Participants were supplied 50,000 units of VD3 orally each month for three months. The number of events, consultations for emergency services, and hospitalization due to acute respiratory infections (ARIs) before and after VD3 administration were described. Results. The average age of the participants was 25.81 ± 17.50 months. The average clinical ARIs per month was 4.02 (95% CI 3.64-4.40) before VD3 administration. Fewer episodes at the end of the three cycles was found at 2.23/month (95% CI 1.81-2.65; p=0.0230). The average consultations for emergency services during the three months before VD3 administration was 2.15 (95% CI 1.77-2.53). After three months of treatment, the average use of emergency services decreased to 0.52 (95% CI 0.37-0.72; p=0.0180). After the administration of the three doses of VD3, only one patient required hospitalization (2.63%; : 0.026 (IC95% 0.02-0.03; p=0.0368)). Conclusions. The administration of vitamin D3 could have a benefit in decreasing the number of episodes, emergencies, and hospitalization for ARI in children under five years old. Trial studies are required to determine this potential benefit.

Should fast breathing pneumonia cases be treated with antibiotics? The scientific rationale for revisiting management in Low and Middle income countries

BACKGROUND

Pneumonia is the largest single contributor to child mortality and the problem is more acute in low and middle income countries. The World Health Organization (WHO) currently recommends oral antibiotic treatment for all children with fast breathing pneumonia without danger signs. It is, however, widely acknowledged that most such infections are viral and self-limiting and that the evidence for the guidance is weak.

RATIONALE

Overuse of antibiotics exposes children to adverse events, increases cost for families, burdens already stretched health care resources and may contribute to development of antibiotic resistance.

CONCLUSION

There is equipoise regarding utility of antibiotic in case of fast breathing pneumonia and no high quality trial evidence exists. This paper provides further information behind the rationale for conducting non-inferiority trials to test the hypothesis that antibiotics may not be necessary for children with fast breathing as the sole symptomatology.

DOENÇAS RESPIRATÓRIAS AGUDAS EM CRIANÇAS BRASILEIRAS: OS CUIDADORES SÃO CAPAZES DE DETECTAR OS PRIMEIROS SINAIS DE ALERTA?

RESUMO Objetivo: Avaliar o nível de conhecimento do cuidador em relação aos sinais e sintomas respiratórios de Infecções Respiratórias Agudas (IRA) e a percepção dos mesmos em relação às crianças que necessitam de assistência médica. Métodos: Estudo prospectivo e transversal, no qual um questionário padronizado com itens relacionados à percepção da gravidade dos sinais e sintomas de IRA foi administrado a cuidadores de pacientes pediátricos admitidos no serviço de emergência de um hospital universitário no período de agosto de 2011 a maio de 2012. A análise estatística foi realizada com os testes do qui-quadrado e t-Student para determinar quais variáveis contribuíram para o reconhecimento pelos cuidadores da gravidade das doenças respiratórias agudas. Resultados: Foram entrevistados 499 cuidadores. As causas de IRA mais citadas foram Síndrome gripal (78,6%), Resfriado comum (73,9%), Faringites (64,1%) e Pneumonia (54,5%). Febre (34,1%) e Tosse (15,8%) foram as principais razões para a procura de atendimento. Os sinais de gravidade mais citados pelos cuidadores foram: febre (99,6%), dispneia (91,4%), sibilância (86,4%), adinamia (80,2%), tosse (79,8%) e taquipneia (78,6%). O histórico de doença respiratória anterior do paciente (p=0,002), a idade (p=0,010) e o estado civil do cuidador (p=0,014) foram as variáveis significativamente associadas com taquipneia, o sintoma mais grave de IRA. Conclusões: Embora cuidadores pediátricos possam perceber os principais sinais de IRA, eles não são capazes de reconhecer a gravidade destes, o que pode atrasar os cuidados médicos e impedir o tratamento precoce.

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia is a leading cause of childhood mortality from infectious disease, responsible for an estimated 1.3 million deaths annually in children under five years of age, many of which are in low-income countries. The World Health Organization recommends intravenous antibiotics for five days as first-line treatment for children with severe pneumonia. Although controversy exists regarding the specific clinical features used to diagnose pneumonia, the criteria for diagnosis of severe pneumonia are better defined and are widely used to triage children for referral and second-line therapy.In 2011 it was estimated that approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million become severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine, and decrease in quality of life. By reducing the duration of hospital treatment, healthcare burdens could potentially be reduced and treatment compliance may improve.This is an update of a review published in 2015.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy (alone or in combination with oral antibiotics) with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 12), MEDLINE (1966 to December week 3, 2016), Embase (1974 to 22 December 2016), and four trials registers (23 August 2017), together with reference checking of all relevant trials and reviews.

SELECTION CRITERIA

Randomised controlled trials evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy (alone or in combination with oral antibiotics) for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV. We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose, or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Our searches identified 4295 records, however no studies met our predefined inclusion criteria.

AUTHORS' CONCLUSIONS

We identified no randomised controlled trials comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two months to 59 months that met our inclusion criteria.

Exhaustive mathematical analysis of simple clinical measurements for childhood pneumonia diagnosis

BACKGROUND

Pneumonia is the leading cause of mortality for children below 5 years of age. The majority of these occur in poor countries with limited access to diagnosis. The World Health Organization (WHO) criterion for pneumonia is the de facto method for diagnosis. It is designed targeting a high sensitivity and uses easy to measure parameters. The WHO criterion has poor specificity.

METHODS

We propose a method using common measurements (including the WHO parameters) to diagnose pneumonia at high sensitivity and specificity. Seventeen clinical features obtained from 134 subjects were used to create a series of logistic regression models. We started with one feature at a time, and continued building models with increasing number of features until we exhausted all possible combinations. We used a k-fold cross validation method to measure the performance of the models.

RESULTS

The sensitivity of our method was comparable to that of the WHO criterion but the specificity was 84%-655% higher. In the 2-11 month age group, the WHO criteria had a sensitivity and specificity of 92.0%±11.6% and 38.1%±18.5%, respectively. Our best model (using the existence of a runny nose, the number of days with runny nose, breathing rate and temperature) performed at a sensitivity of 91.3%±13.0% and specificity of 70.2%±22.80%. In the 12-60 month age group, the WHO algorithm gave a sensitivity of 95.7%±7.6% at a specificity of 9.8%±13.1%, while our corresponding sensitivity and specificity were 94.0%±12.1% and 74.0%±23.3%, respectively (using fever, number of days with cough, heart rate and chest in-drawing).

CONCLUSIONS

The WHO algorithm can be improved through mathematical analysis of clinical observations and measurements routinely made in the field. The method is simple and easy to implement on a mobile phone. Our method allows the freedom to pick the best model in any arbitrary field scenario (e.g., when an oximeter is not available).

Paediatric respiratory infections

Pulmonary infections remain a major cause of infant and child mortality worldwide and are responsible for a substantial burden of morbidity. During the 2015 European Respiratory Society International Congress in Amsterdam, some of the main findings from peer-reviewed articles addressing this topic that were published in the preceding 12 months were reviewed in a Paediatric Clinical Year in Review session. The following article highlights some of the insights provided by these articles into the complex interactions of the human host with the extensive and dynamic populations of microorganisms that call an individual "home".

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia remains the single leading cause of childhood mortality, causing an estimated 1.3 million childhood deaths each year in children under the age of five years. The greater burden of disease occurs in low-income countries, where medical resources and hospital-based management are poor. The World Health Organization (WHO) current evidence summaries recommend intravenous antibiotics for five days as first-line treatment for severe pneumonia. Although there is controversy around the specificity of clinical features in the diagnosis of pneumonia, the criteria for the diagnosis of severe pneumonia are better defined and widely used to triage children for referral and second-line therapy.Approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million progress to severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine and decrease in quality of life. By reducing the duration of treatment in the hospital, this burden could potentially be lessened and possibly lead to better treatment compliance.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy with the same antibiotic for severe community-acquired pneumonia (CAP) in children aged two months to 59 months.

SEARCH METHODS

We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015) and EMBASE (1974 to February 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV and we excluded children with signs and symptoms of very severe pneumonia (i.e. unable to drink or breast feed, vomiting, lethargic, unconscious, convulsing, central cyanosis, severe respiratory distress or clinically severe malnutrition). We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 2352 studies, however none fulfilled our pre-defined inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify any RCTs comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two to 59 months.