Defining the aetiology of paediatric community-acquired pneumonia: an unsolved problem

Improving effective antimicrobial resistance (AMR) prevention in ambulatory care: lessons from secondary appraisal of Belgian anti-infectious treatment care guidelines

The emergence of antimicrobial resistance (AMR) has been designated as a global threat by the World Health Organization. To combat AMR in Belgium, the Belgian Antibiotic Policy Coordination Committee (BAPCOC) has, among others, developed guidelines for the appropriate use of antimicrobials in the ambulatory practice. We aim to assess the current guidelines from an antimicrobial stewardship perspective and procide suggestions for improving the ambulatory antibiotic guidelines for first-line healthcare providers. The 2022 BAPCOC guidelines were independently evaluated by 7 antimicrobial stewardship experts based on the five "Ds" of antimicrobial stewardship. The results were aggregated, summarized, and consensus was sought. Recommendations improving the guidelines were formulated. A total of 52 recommendations were made, covering 16 different (sub)chapters. The most frequently covered topics were urinary tract infections, followed by skin and soft tissue infections. Among the top five recommendations deemed to have the greatest impact on antimicrobial stewardship outcomes, three were related to the diagnosis or treatment duration of urinary tract infections. Tailoring infectious disease and antibiotic treatment guidelines to antimicrobial stewardship principles and the latest literature is essential in combating antimicrobial resistance. Implementing our proposed recommendations in the Belgian ambulatory treatment guidelines could significantly enhance rational and judicious antibiotic use while minimizing the risk of 'antibiotic undertreatment. The proposed 'Choosing Wisely' recommendations have the potential to be applied to a broader (European) context.

Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection

OBJECTIVES

Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs).

DESIGN

This is an analysis of of a seven-center prospective cohort study.

SETTING

Seven PICUs within academic children's hospitals in the United States.

PATIENTS

Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours.

INTERVENTIONS

We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement.

MEASUREMENTS AND MAIN RESULTS

Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001).

CONCLUSIONS

Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.

Impact on Patient Management of a Novel Host Response Test for Distinguishing Bacterial and Viral Infections: Real World Evidence from the Urgent Care Setting

Antibiotic overuse and underuse are prevalent in urgent care settings, driven in part by diagnostic uncertainty. A host-based test for distinguishing bacterial and viral infections (MeMed BV) has been clinically validated previously. Here we examined how BV impacts antibiotic prescription in a real-world setting. The intention to treat with antibiotics before the receipt of a BV result was compared with practice after the receipt of a BV result at three urgent care centers. The analysis included 152 patients, 57.9% children and 50.7% female. In total, 131 (86.2%) had a bacterial or viral BV result. Physicians were uncertain about prescription for 38 (29.0%) patients and for 30 (78.9%) of these cases, subsequently acted in accordance with the BV result. Physicians intended to prescribe antibiotics to 39 (29.8%) patients, of whom 17 (43.6%) had bacterial BV results. Among the remaining 22 patients with viral BV results, antibiotic prescriptions were reduced by 40.9%. Overall, the physician prescribed in accordance with BV results in 81.7% of all cases (p < 0.05). In total, the physicians reported that BV supported or altered their decision making in 87.0% of cases (p < 0.05). BV impacts patient management in real-world settings, supporting appropriate antibiotic use.

A Retrospective Analysis to Estimate the Burden of Invasive Pneumococcal Disease and Non-Invasive Pneumonia in Children <15 Years of Age in the Veneto Region, Italy

Despite advances in preventative interventions, invasive pneumococcal disease and pneumonia cause significant morbidity and mortality in children. We studied the annual incidence of pneumococcal-specific and syndromic invasive disease and non-invasive pneumonia in children <15 years of age during the early (2010−2013) and late (2014−2017) 13-valent pneumococcal conjugate vaccine (PCV13) periods in Veneto, Italy. In this retrospective observational study, pneumococcal-specific and syndromic invasive disease and non-invasive pneumonia cases were identified from several sources, including the Pedianet database. Interrupted time series analysis and Mann−Kendall tests were conducted to explore trends in incidence rates (IRs). Among 72,570 patients <15 years of age between 2010−2017, 88 episodes of pneumococcal-specific and syndromic invasive disease and 3926 episodes of non-invasive pneumonia were reported. Overall IR of pneumococcal-specific and syndromic invasive disease was 0.4/1000 person-years and did not change significantly (p = 0.46) throughout the study. Overall IR of non-invasive pneumonia was 10/1000 person-years and decreased significantly (−0.64, p = 0.026) over the study period. Following PCV13 introduction, the IRs of non-invasive pneumonia in children <15 years of age declined significantly, with no significant change in the IRs of pneumococcal-specific and syndromic invasive disease. There is a continuing clinical burden associated with pediatric pneumococcal diseases in Veneto, Italy.

The remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia

INTRODUCTION

Despite availability of several official guidelines, not all the problems related to the most effective and safe use of antibiotics in children with community-acquired pneumonia (CAP) have been solved. Presently, too many children receive unneeded antibiotics or, when antibiotics are mandatory, the choice of the drug is not appropriate.

AREAS COVERED

In this paper, the authors discuss the remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia and provide their expert perspectives.

EXPERT OPINION

Further improvement in pediatric CAP management could be derived from physician education on antibiotic use and a larger use, particularly in office practice, of point of care testing or new technologies (i.e. artificial intelligence) to define etiology of a lower respiratory infection. However, recommendations regarding the duration of antibiotic therapy vary largely because of the absence of reliable data on the optimal CAP treatment according to the bacterial etiology of the disease, its severity, and child characteristics. Available evidence seems to confirm that a short course of antibiotics, approximately 5 days, can be effective and lead to results not substantially different from those obtained with prolonged-course antibiotic therapy, at least in patients with mild to moderate disease.

Viruses and Mycoplasma pneumoniae are the main etiological agents of community-acquired pneumonia in hospitalized pediatric patients in Spain

OBJECTIVES

To describe the etiology of community-acquired pneumonia (CAP) in hospitalized children in Spain and analyze the predictors of the etiology.

HYPOTHESIS

The different etiological groups of pediatric CAP are associated with different clinical, radiographic, and analytical data.

DESIGN

Observational, multicenter, and prospective study.

PATIENT SELECTION

This study included children aged 1 month to 17 years with CAP, who were hospitalized between April 2012 and May 2019.

METHODS

An extensive microbiological workup was performed. The clinical, radiographic, and analytical parameters were analyzed for three etiological groups.

RESULTS

Among the 495 children included, at least one causative pathogen was identified in 262 (52.9%): pathogenic viruses in 155/262 (59.2%); atypical bacteria (AB), mainly Mycoplasma pneumonia, in 84/262 (32.1%); and typical bacteria (TyB) in 40/262 (15.3%). Consolidation was observed in 89/138 (64.5%) patients with viral CAP, 74/84 (88.1%) with CAP caused by AB, and 40/40 (100%) with CAP caused by TyB. Para-pneumonic pleural effusion (PPE) was observed in 112/495 (22.6%) patients, of which 61/112 (54.5%) presented a likely causative pathogen: viruses in 12/61 (19.7%); AB in 23/61 (37.7%); and TyB in 26/61 (42.6%). Viral etiology was significantly frequent in young patients and in those with low oxygen saturation, wheezing, no consolidation, and high lymphocyte counts. CAP patients with AB as the etiological agent had a significantly longer and less serious course as compared to those with other causative pathogens.

CONCLUSIONS

Viruses and M. pneumoniae are the main causes of pediatric CAP in Spain. Wheezing, young age, and no consolidation on radiographs are indicative of viral etiology. Viruses and AB can also cause PPE. Since only a few cases can be directly attributed to TyB, the indications for antibiotics must be carefully considered in each patient.

Systematic Review and Meta-Analysis of Diagnostic Biomarkers for Pediatric Pneumonia

BACKGROUND

Pneumonia causes significant morbidity and mortality in children worldwide, especially in resource-poor settings. Accurate identification of bacterial etiology leads to timely antibiotic initiation, minimizing overuse, and development of resistance. Host biomarkers may improve diagnostic sensitivity and specificity. We assessed the ability of biomarkers to correctly identify bacterial pneumonia in children who present with respiratory distress.

METHODS

A librarian-directed search was conducted of MEDLINE, EMBASE, CENTRAL, Global Health, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to May 2020 with no language restriction. Included studies compared a diagnostic biomarker in children with bacterial pneumonia to those with nonbacterial respiratory distress.

RESULTS

There were 31 observational studies of 23 different biomarkers. C-reactive protein (CRP), procalcitonin (PCT), white blood cell (WBC) count, and erythrocyte sedimentation rate (ESR) were the biomarkers with sufficient data for meta-analysis. Meta-analysis revealed that CRP and PCT best differentiated bacterial from viral pneumonia with CRP summary AUROC (area under the receiver operating characteristic curve) 0.71 (0.69-0.73), Youden index 53 mg/L, sensitivity 0.70 (0.68-0.78), and specificity 0.64 (0.58-0.68) and PCT summary AUROC 0.70 (0.67-0.74), Youden index 0.59 ng/mL, sensitivity 0.69 (0.65-0.77), and specificity 0.64 (0.60-0.68). WBC and ESR did not perform as well. Nineteen other inflammatory and immunologic biomarkers were identified including CRP/mean platelet value, neutrophil/leukocyte ratio, interleukin 6, and interferon-alpha, with sensitivities from 60% to 85% and specificities from 76% to 83%.

CONCLUSION

CRP and PCT performed better than WBC and ESR but had suboptimal sensitivity. Some less well-studied novel biomarkers appear to have promise particularly in combination.

Pediatricians' Compliance to the Clinical Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children in Pakistan

Community-acquired pneumonia (CAP) is among the most commonly prevailing acute infections in children that may require hospitalization. Inconsistencies among suggested care and actual management practices are usually observed, which raises the need to assess local clinical practices. The current study was conducted to evaluate pediatricians' compliance with the standard clinical practice guidelines and their antibiotic-prescribing behavior for the management of CAP in children. Methods: A descriptive cross-sectional study was conducted using a self-administered questionnaire; which was provided to pediatricians by the researchers. Statistical analysis was performed with SPSS 25 Statistics; χ2 tests (or Fisher-exact tests) with the p-value set at < 0.05 as the threshold for statistical significance. Results: The overall response rate was 59.2%. Male respondents were (n = 101; 42.6%), and the respondents (n = 163; 68.7%) were under 30 years of age. Amoxicillin (n = 122; 51.5%) was considered as the most commonly used first-line treatment for non-severe pneumonia, whereas a smaller proportion (n = 81; 34.2%) of respondents selected amoxicillin-clavulanate. Likewise, amoxicillin (n = 100; 42.2%) was the most popular choice for non-severe pneumonia in hospitalized children; however, if children had used antibiotics earlier to admission, respondents showed an inclination to prescribe a macrolide (n = 95; 40.0%) or second-generation cephalosporin (n = 90; 37.9%). More than 90% responded that children <6 months old with suspected bacterial CAP will probably receive better therapeutic care by hospitalization. Restricting exposure to the antibiotic as much as possible (n = 71; 29.9%), improving antibiotic prescribing (n = 59; 24.8%), and using the appropriate dose of antimicrobials (n = 29; 12.2%) were considered the major factors by the respondents to reduce antimicrobials resistance. Conclusions: The selection of antibiotics and diagnostic approach was as per the recommendations, but indication, duration of treatment, and hospitalization still can be further improved.

Complications in community acquired pneumonia: magnitude of problem, risk factors, and management in pediatric age

Introduction: In the last decades, the large use of several effective vaccines has dramatically reduced the incidence of community acquired pneumonia (CAP) in infants and children. Moreover, the availability of new antibiotics effective against emerging resistant strains of bacteria has greatly improved the early and long-term prognosis of this disease.Areas covered: The aim of this manuscript is to evaluate the burden of complicated CAP in pediatric age and to discuss its appropriate management.Expert opinion: Complicated CAP remains a problem for children in industrialized and developing countries. A larger use of lung ultrasonography (US) as first diagnostic approach could significantly improve early identification of cases at higher risk of complications. Difficult to solve, is the problem of the use of an antibiotic therapy able to assure adequate control in all the CAP cases, including those at high risk of or with already established complications. All these findings reveal that control of the incidence of complicated CAP remains difficult and will not be significantly changed in the next few years. Any attempt to improve complicated CAP management must be made. Consensus documents on better definition of the use of corticosteroids, fibrinolytic agents, and interventional procedures (including surgery) can allow us to reach this goal.

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

How does one choose the appropriate pharmacotherapy for children with lower respiratory tract infections?

INTRODUCTION

The definition of acute lower respiratory tract infection (LRTI) includes any infection involving the respiratory tract below the level of the larynx. In children, the most common acute LRTIs, and those with the greatest clinical relevance, are community-acquired pneumonia (CAP), bronchiolitis, bronchitis and tuberculosis (TB). The clinical relevance of LRTIs implies that they must be addressed with the most effective therapy. Antibiotics and antivirals play an essential role in this regard.

AREAS COVERED

In this paper, the most recent advances in the drug treatment of LRTIs in children are discussed.

EXPERT OPINION

Although LRTIs are extremely common and one of the most important causes of hospitalization and death in children, anti-infective therapy for these diseases remains unsatisfactory. For CAP and BR, the most important problem is the overuse and misuse of antibiotics; for BCL, the lack of drugs with demonstrated efficacy, safety and tolerability; for TB, the poor knowledge on the true efficacy and safety of the new drugs specifically planned to overcome the problem of MDR M. tuberculosis strains. There is still a long way to go for the therapy of pediatric LRTIs to be considered satisfactory.