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Rees CA, Kuppermann N, Florin TA. Community-Acquired Pneumonia in Children. Pediatr Emerg Care 2023; 39:968-976. [PMID: 38019716 DOI: 10.1097/pec.0000000000003070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
ABSTRACT Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.
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Affiliation(s)
| | - Nathan Kuppermann
- Professor, Departments of Emergency Medicine and Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA
| | - Todd A Florin
- Associate Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Wu Y, Mascaro S, Bhuiyan M, Fathima P, Mace AO, Nicol MP, Richmond PC, Kirkham LA, Dymock M, Foley DA, McLeod C, Borland ML, Martin A, Williams PCM, Marsh JA, Snelling TL, Blyth CC. Predicting the causative pathogen among children with pneumonia using a causal Bayesian network. PLoS Comput Biol 2023; 19:e1010967. [PMID: 36913404 PMCID: PMC10035934 DOI: 10.1371/journal.pcbi.1010967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 03/23/2023] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Pneumonia remains a leading cause of hospitalization and death among young children worldwide, and the diagnostic challenge of differentiating bacterial from non-bacterial pneumonia is the main driver of antibiotic use for treating pneumonia in children. Causal Bayesian networks (BNs) serve as powerful tools for this problem as they provide clear maps of probabilistic relationships between variables and produce results in an explainable way by incorporating both domain expert knowledge and numerical data. METHODS We used domain expert knowledge and data in combination and iteratively, to construct, parameterise and validate a causal BN to predict causative pathogens for childhood pneumonia. Expert knowledge elicitation occurred through a series of group workshops, surveys and one-on-one meetings involving 6-8 experts from diverse domain areas. The model performance was evaluated based on both quantitative metrics and qualitative expert validation. Sensitivity analyses were conducted to investigate how the target output is influenced by varying key assumptions of a particularly high degree of uncertainty around data or domain expert knowledge. RESULTS Designed to apply to a cohort of children with X-ray confirmed pneumonia who presented to a tertiary paediatric hospital in Australia, the resulting BN offers explainable and quantitative predictions on a range of variables of interest, including the diagnosis of bacterial pneumonia, detection of respiratory pathogens in the nasopharynx, and the clinical phenotype of a pneumonia episode. Satisfactory numeric performance has been achieved including an area under the receiver operating characteristic curve of 0.8 in predicting clinically-confirmed bacterial pneumonia with sensitivity 88% and specificity 66% given certain input scenarios (i.e., information that is available and entered into the model) and trade-off preferences (i.e., relative weightings of the consequences of false positive versus false negative predictions). We specifically highlight that a desirable model output threshold for practical use is very dependent upon different input scenarios and trade-off preferences. Three commonly encountered scenarios were presented to demonstrate the potential usefulness of the BN outputs in various clinical pictures. CONCLUSIONS To our knowledge, this is the first causal model developed to help determine the causative pathogen for paediatric pneumonia. We have shown how the method works and how it would help decision making on the use of antibiotics, providing insight into how computational model predictions may be translated to actionable decisions in practice. We discussed key next steps including external validation, adaptation and implementation. Our model framework and the methodological approach can be adapted beyond our context to broad respiratory infections and geographical and healthcare settings.
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Affiliation(s)
- Yue Wu
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Steven Mascaro
- Bayesian Intelligence Pty Ltd, Upwey, Victoria, Australia
- Faculty of Information Technology, Monash University, Clayton, Victoria, Australia
| | - Mejbah Bhuiyan
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Parveen Fathima
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Ariel O Mace
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- Department of General Paediaitrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Department of Paediatrics, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Mark P Nicol
- School of Biomedical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Peter C Richmond
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- Department of General Paediaitrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Lea-Ann Kirkham
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Michael Dymock
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - David A Foley
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- Microbiology, PathWest Laboratory Medicine QEII Medical Centre, Nedlands, Western Australia, Australia
| | - Charlie McLeod
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Meredith L Borland
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
- Emergency Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Andrew Martin
- Department of General Paediaitrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Phoebe C M Williams
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Sydney Children's Hospitals Network, New South Wales, Australia
- School of Women's and Children's Health, The University of New South Wales, Kensington, New South Wales, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Thomas L Snelling
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- Sydney Children's Hospitals Network, New South Wales, Australia
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Christopher C Blyth
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
- Microbiology, PathWest Laboratory Medicine QEII Medical Centre, Nedlands, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Muacevic A, Adler JR, Lala GE, Yar SR, Zaman MB, Afridi BK. Clinical Findings and Radiological Evaluation of WHO-Defined Severe Pneumonia Among Hospitalized Children. Cureus 2023; 15:e33804. [PMID: 36819341 PMCID: PMC9928894 DOI: 10.7759/cureus.33804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The leading infectious cause of death in children worldwide is pneumonia. Pneumonia claimed the lives of 740,180 kids under the age of five in 2019, accounting for 14% of all fatalities and 22% of deaths in kids between the ages of 1 and 5. Children and families worldwide are affected by pneumonia, but South Asia and Africa have the highest fatality rates. OBJECTIVE This study aims to determine the clinical risk factors and radiological assessment of the World Health Organization (WHO)-defined severe pneumonia in Pakistani hospitalized children. MATERIAL AND METHODS This cross-sectional study was carried out in the pediatric department of the Hayatabad Medical Complex between January 2021 and December 2021. The study included kids who had a fever, cough, and fast or difficulty breathing between the ages of 2 and 60 months. All of the included clinical pneumonia cases were acquired in the community. RESULTS A total of 360 clinically confirmed patients with pneumonia who presented with fever, cough, and fast or difficulty breathing were enrolled. Age ranged between 2 and 60 months, with a mean age of ±31 months. There were 168 (46.7%) males and 192 (53.3%) females. About 232 (64.4%) had radiological pneumonia, while the rest of the pneumonia cases 128 (35.5%) were without a radiological diagnosis. The most common presenting complaint was noisy breathing 119 (33%), followed by refusal of feeds 81 (22.5%), lethargy 69 (19.2%), seizure 40 (11.1%), nasal drainage 29 (8%), and abdominal pain 22 (6.1%). CONCLUSION The most specific clinical finding of radiographic pneumonia was bronchial breathing, while tachypnea was the most sensitive sign.
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Esposito S, Argentiero A, Rebecchi F, Fainardi V, Pisi G, Principi N. The remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia. Expert Opin Pharmacother 2022; 23:497-505. [PMID: 35094614 DOI: 10.1080/14656566.2022.2028773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesca Rebecchi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic Pneumonia. Pediatrics 2022; 149:183721. [PMID: 34845493 PMCID: PMC9647527 DOI: 10.1542/peds.2021-051405] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. METHODS We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. RESULTS Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77-0.84). Of 229 children with a predicted risk of <4%, 13 (5.7%) had radiographic CAP (sensitivity of 94.9% at a 4% risk threshold). Conversely, of 229 children with a predicted risk of >39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). CONCLUSIONS A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Address correspondence to Sriram Ramgopal, MD, Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Box 62, Chicago, IL 60611. E-mail:
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado and Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | | | - Richard M. Ruddy
- Emergency Medicine, Cincinnati Children’s Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Todd A. Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Abstract
BACKGROUND The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia. METHODS We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia. RESULTS Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73). CONCLUSIONS In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.
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Shrestha S, Chaudhary N, Shrestha S, Pathak S, Sharma A, Shrestha L, Kurmi OP. Clinical predictors of radiological pneumonia: A cross-sectional study from a tertiary hospital in Nepal. PLoS One 2020; 15:e0235598. [PMID: 32702037 PMCID: PMC7377451 DOI: 10.1371/journal.pone.0235598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 06/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Despite readily availability of vaccines against both Hemophilus influenzae and Pneumococcus, pneumonia remains the most common cause of morbidity and mortality in children under the age of five years in Nepal. With growing antibiotic resistance and a general move towards more rational antibiotic use, early identification of clinical signs for the prediction of radiological pneumonia would help practitioners to start the treatment of patients. The main aim of this study was to reassess the clinical predictors of pneumonia in Nepal. Methods This cross-sectional study was conducted between June 2015 and November 2015 at Tribhuvan University Teaching Hospital, a tertiary hospital in Kathmandu, Nepal. Children aged 3–60 months with a clinical diagnosis of pneumonia by a physician were enrolled in the study. Radiological pneumonia was identified and categorized as per World Health Organization guidelines by an experienced radiologist blinded to patient characteristics. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia. Results Out of 1021 children with fever, 160 cases were clinically diagnosed as pneumonia and were enrolled for this study. Among the enrolled patients, 61% had radiological pneumonia. Tachypnea had the highest sensitivity of 99%, while bronchial breathing had the highest specificity of 100%. During univariate analysis, grunting, wheezing, nasal discharge, decreased breath sounds, noisy breathing and hypoxemia were associated with radiological pneumonia. Only hypoxemia remained an independent predictor when adjusted for all the factors. Conclusion Tachypnea was the most sensitive sign, whereas bronchial breathing was most specific sign for radiological pneumonia.
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Affiliation(s)
- Sandeep Shrestha
- Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal
| | - Nagendra Chaudhary
- Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal
- * E-mail:
| | - Saneep Shrestha
- Department of Community Medicine, Universal College of Medical Sciences, Bhairahawa, Nepal
| | - Santosh Pathak
- Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal
| | - Arun Sharma
- Department of Pediatrics, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Laxman Shrestha
- Department of Pediatrics, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Om P. Kurmi
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Canada
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Chan FYY, Lui CT, Tse CF, Poon KM. Decision rule to predict pneumonia in children presented with acute febrile respiratory illness. Am J Emerg Med 2020; 38:2557-2563. [PMID: 32007339 DOI: 10.1016/j.ajem.2019.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph. METHOD This was a multicenter prospective study in 3 emergency departments. Children younger than 6 years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios. RESULTS Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever <3 days (0 points), 3-4 days (2 points), 5-6 days (4 points), ≥7 days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpO2 ≤96% or tachypnea (3 points). The Area under ROC curve of the PAFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. A PAFRI score of ≥0 gives a sensitivity of 91.7% and negative predictive value of 97.7%. CONCLUSION PAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation. WHAT'S KNOWN ON THIS SUBJECT It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients. WHAT THIS STUDY ADDS The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.
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Affiliation(s)
- Fiona Y Y Chan
- Accident & Emergency Department, Tuen Mun Hospital, Hong Kong.
| | - C T Lui
- Accident & Emergency Department, Tuen Mun Hospital, Hong Kong.
| | - C F Tse
- Accident & Emergency Department, Princess Margaret Hospital, Hong Kong.
| | - K M Poon
- Accident & Emergency Department, Pok Oi Hospital, Hong Kong.
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Keitel K, Kilowoko M, Kyungu E, Genton B, D'Acremont V. Performance of prediction rules and guidelines in detecting serious bacterial infections among Tanzanian febrile children. BMC Infect Dis 2019; 19:769. [PMID: 31481123 PMCID: PMC6724300 DOI: 10.1186/s12879-019-4371-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SBI from well-resourced countries at outpatient level may help to improve current guidelines; however, their diagnostic performance has not been evaluated in resource-limited countries, where clinical conditions, access to care, and diagnostic capacity differ. The aim of this study was to estimate the diagnostic accuracy of existing prediction rules and clinical guidelines in identifying children with SBI in a cohort of febrile children attending outpatient health facilities in Tanzania. Methods Structured literature review to identify available prediction rules and guidelines aimed at detecting SBI and retrospective, external validation on a dataset containing 1005 febrile Tanzanian children with acute infections. The reference standard, SBI, was established based on rigorous clinical and microbiological criteria. Results Four prediction rules and five guidelines, including IMCI, could be validated. All examined rules and guidelines had insufficient diagnostic accuracy for ruling-in or ruling-out SBI with positive and negative likelihood ratios ranging from 1.04–1.87 to 0.47–0.92, respectively. IMCI had a sensitivity of 36.7% (95% CI 29.4–44.6%) at a specificity of 70.3% (67.1–73.4%). Rules that use a combination of clinical and laboratory testing had better performance compared to rules and guidelines using only clinical and or laboratory elements. Conclusions Currently applied guidelines for managing children with febrile illness have insufficient diagnostic accuracy in detecting children with SBI. Revised clinical algorithms including simple point-of-care tests with improved accuracy for detecting SBI targeting in tropical resource-poor settings are needed. They should undergo careful external validation against clinical outcome before implementation, given the inherent limitations of gold standards for SBI. Electronic supplementary material The online version of this article (10.1186/s12879-019-4371-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristina Keitel
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland. .,Department of Pediatric Emergency Medicine, University Hospital of Bern, Bern, Switzerland.
| | | | - Esther Kyungu
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital Lausanne, Lausanne, Switzerland
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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van de Maat J, Nieboer D, Thompson M, Lakhanpaul M, Moll H, Oostenbrink R. Can clinical prediction models assess antibiotic need in childhood pneumonia? A validation study in paediatric emergency care. PLoS One 2019; 14:e0217570. [PMID: 31194750 PMCID: PMC6563975 DOI: 10.1371/journal.pone.0217570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/14/2019] [Indexed: 11/18/2022] Open
Abstract
Objectives Pneumonia is the most common bacterial infection in children at the emergency department (ED). Clinical prediction models for childhood pneumonia have been developed (using chest x-ray as their reference standard), but without implementation in clinical practice. Given current insights in the diagnostic limitations of chest x-ray, this study aims to validate these prediction models for a clinical diagnosis of pneumonia, and to explore their potential to guide decisions on antibiotic treatment at the ED. Methods We systematically identified clinical prediction models for childhood pneumonia and assessed their quality. We evaluated the validity of these models in two populations, using a clinical reference standard (1. definite/probable bacterial, 2. bacterial syndrome, 3. unknown bacterial/viral, 4. viral syndrome, 5. definite/probable viral), measuring performance by the ordinal c-statistic (ORC). Validation populations included prospectively collected data of children aged 1 month to 5 years attending the ED of Rotterdam (2012–2013) or Coventry (2005–2006) with fever and cough or dyspnoea. Results We identified eight prediction models and could evaluate the validity of seven, with original good performance. In the Dutch population 22/248 (9%) had a bacterial infection, in Coventry 53/301 (17%), antibiotic prescription was 21% and 35% respectively. Three models predicted a higher risk in children with bacterial infections than in those with viral disease (ORC ≥0.55) and could identify children at low risk of bacterial infection. Conclusions Three clinical prediction models for childhood pneumonia could discriminate fairly well between a clinical reference standard of bacterial versus viral infection. However, they all require the measurement of biomarkers, raising questions on the exact target population when implementing these models in clinical practice. Moreover, choosing optimal thresholds to guide antibiotic prescription is challenging and requires careful consideration of potential harms and benefits.
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Affiliation(s)
- Josephine van de Maat
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Matthew Thompson
- University of Washington, Department of Family Medicine, Seattle, United States of America
| | - Monica Lakhanpaul
- Population, Policy, Practice Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Henriette Moll
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC–Sophia Children’s Hospital, Rotterdam, The Netherlands
- * E-mail:
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11
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Hirsch AW, Monuteaux MC, Neuman MI, Bachur RG. Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort. J Pediatr 2019; 204:172-176.e1. [PMID: 30293642 DOI: 10.1016/j.jpeds.2018.08.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/17/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To improve the prediction of pediatric pneumonia by developing a series of models based on clinically distinct subgroups. We hypothesized that these subgroup models would provide superior estimates of pneumonia risk compared with a single pediatric model. STUDY DESIGN We conducted a secondary analysis of a prospective cohort being evaluated for radiographic pneumonia in an urban pediatric emergency department (ED). Using multivariate modeling, we created 4 models across subgroups stratified by age and presence of wheezing to predict the risk of pneumonia. RESULTS A total of 2351 patients were included in the study. In this series, the prevalence of pneumonia was 8.5%, and 21.6% were hospitalized. The highest prevalence of pneumonia was in children aged >2 years without wheezing (13.3%). Children aged <2 years with wheezing had the lowest prevalence of pneumonia (4.0%). The most accurate model was for children aged <2 years with wheezing (area under the curve [AUC], 0.80), and the poorest performing model was for those aged <2 years without wheezing (AUC, 0.64). The AUC of a combination of the 4 subgroup models was 0.76 (95% CI, 0.72-0.80). The precision of the models' estimates (expected vs observed) was ± 3.7%. CONCLUSIONS Using 4 complementary prediction models for pediatric pneumonia, an accurate risk of pneumonia can be calculated. These models can provide the basis for clinical decision making support to guide the use of chest radiographs and promote antibiotic stewardship.
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Affiliation(s)
- Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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12
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Pervaiz F, Chavez MA, Ellington LE, Grigsby M, Gilman RH, Miele CH, Figueroa-Quintanilla D, Compen-Chang P, Marin-Concha J, McCollum ED, Checkley W. Building a Prediction Model for Radiographically Confirmed Pneumonia in Peruvian Children: From Symptoms to Imaging. Chest 2018; 154:1385-1394. [PMID: 30291926 PMCID: PMC6335257 DOI: 10.1016/j.chest.2018.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/18/2018] [Accepted: 09/05/2018] [Indexed: 11/30/2022] Open
Abstract
Background Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru. Methods Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo2), and addition of lung ultrasound. Results Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo2 than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve [AUC] = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo2 did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo2 ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%). Conclusions The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.
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Affiliation(s)
- Farhan Pervaiz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Miguel A Chavez
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD; Biomedical Research Unit, A.B. PRISMA, Lima, Peru
| | - Laura E Ellington
- Department of Pulmonary and Sleep Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Matthew Grigsby
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Robert H Gilman
- Biomedical Research Unit, A.B. PRISMA, Lima, Peru; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | | | | | - Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, School of Medicine Johns Hopkins University, Baltimore, MD
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD; Biomedical Research Unit, A.B. PRISMA, Lima, Peru.
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13
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Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children-a systematic review. Eur J Pediatr 2018; 177:337-344. [PMID: 29387980 DOI: 10.1007/s00431-018-3098-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/19/2017] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). Our aim was to systematically review if children suffering from high fever are at high risk for SBI. Our data sources were Embase, Medline, and Pubmed; from their inception until the last week of March 2017. The study selection were of cohort and case control studies comparing the incidence of SBI in children with hyperpyrexia with children with fever of 41 °C or less, and children with a temperature higher than 40 °C, with children with fever of 40 °C or less. Two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted. In our results, 11 studies met the inclusion criteria. Two studies showed that children with hyperpyrexia are at higher risk for SBI (OR 1.96 95% CI 1.3-1.97). An increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67; 6.22). SBI in infants with temperature over 40 °C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44; 8.95). On older children, the risk for SBI was only slightly higher in children with fever above 40 °C. The limitation of the study is the small amount of studies and that the heterogeneity of the studies was very high. CONCLUSION Young infants with temperature higher than 400 °C are at increased risk for SBI. Risk of SBI in older children with temperature > 400C is minimal. What is known: • An association between high fever and increased risk for SBI was reported in young infants. • Based on only two studies from the 1970s and 1980s, hyperpyrexia is associated with increased risk for SBI. What is new: • Infants under the age of 3 months with fever > 40 °C were found to have increased risk for SBI. • Risk of SBI in older children with temperature > 40 °C is minimal.
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14
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Florin TA, Ambroggio L, Brokamp C, Rattan MS, Crotty EJ, Kachelmeyer A, Ruddy RM, Shah SS. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics 2017; 140:peds.2017-0310. [PMID: 28835381 PMCID: PMC5574720 DOI: 10.1542/peds.2017-0310] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP. METHODS This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate. CONCLUSIONS In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.
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Affiliation(s)
- Todd A. Florin
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Biostatistics and Epidemiology,,Hospital Medicine, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Mantosh S. Rattan
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric J. Crotty
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Divisions of Emergency Medicine,,Hospital Medicine, and,Infectious Diseases, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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15
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Mace SE, Gemme SR, Valente JH, Eskin B, Bakes K, Brecher D, Brown MD, Brown MD, Brecher D, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Ingalsbe GS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah K, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Wolf SJ, Cantrill SV, O’Connor RE, Whitson RR, Mitchell MA. Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever. Ann Emerg Med 2016; 67:625-639.e13. [DOI: 10.1016/j.annemergmed.2016.01.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Rambaud-Althaus C, Althaus F, Genton B, D'Acremont V. Clinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2015; 15:439-50. [PMID: 25769269 DOI: 10.1016/s1473-3099(15)70017-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pneumonia is the biggest cause of deaths in young children in developing countries, but early diagnosis and intervention can effectively reduce mortality. We aimed to assess the diagnostic value of clinical signs and symptoms to identify radiological pneumonia in children younger than 5 years and to review the accuracy of WHO criteria for diagnosis of clinical pneumonia. METHODS We searched Medline (PubMed), Embase (Ovid), the Cochrane Database of Systematic Reviews, and reference lists of relevant studies, without date restrictions, to identify articles assessing clinical predictors of radiological pneumonia in children. Selection was based on: design (diagnostic accuracy studies), target disease (pneumonia), participants (children aged <5 years), setting (ambulatory or hospital care), index test (clinical features), and reference standard (chest radiography). Quality assessment was based on the 2011 Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. For each index test, we calculated sensitivity and specificity and, when the tests were assessed in four or more studies, calculated pooled estimates with use of bivariate model and hierarchical summary receiver operation characteristics plots for meta-analysis. FINDINGS We included 18 articles in our analysis. WHO-approved signs age-related fast breathing (six studies; pooled sensitivity 0·62, 95% CI 0·26-0·89; specificity 0·59, 0·29-0·84) and lower chest wall indrawing (four studies; 0·48, 0·16-0·82; 0·72, 0·47-0·89) showed poor diagnostic performance in the meta-analysis. Features with the highest pooled positive likelihood ratios were respiratory rate higher than 50 breaths per min (1·90, 1·45-2·48), grunting (1·78, 1·10-2·88), chest indrawing (1·76, 0·86-3·58), and nasal flaring (1·75, 1·20-2·56). Features with the lowest pooled negative likelihood ratio were cough (0·30, 0·09-0·96), history of fever (0·53, 0·41-0·69), and respiratory rate higher than 40 breaths per min (0·43, 0·23-0·83). INTERPRETATION Not one clinical feature was sufficient to diagnose pneumonia definitively. Combination of clinical features in a decision tree might improve diagnostic performance, but the addition of new point-of-care tests for diagnosis of bacterial pneumonia would help to attain an acceptable level of accuracy. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Clotilde Rambaud-Althaus
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Fabrice Althaus
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland; Infectious Disease Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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17
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Räsänen J, Gavriely N. Childhood Pneumonia Screener: a concept. Pneumonia (Nathan) 2014; 5:52-58. [PMID: 31641574 PMCID: PMC5922325 DOI: 10.15172/pneu.2014.5/515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 12/01/2014] [Indexed: 12/02/2022] Open
Abstract
Childhood pneumonia continues to be the number one cause of death in children under five years of age in developing countries. In addition to mortality, pneumonia constitutes an enormous economic and social burden because late diagnosis is associated with high cost of treatment and often leads to chronic health problems. There are several bottlenecks in developing countries in the case flow of a child with lung infection: 1) recognising the symptoms as a reason to seek care, 2) getting the patient to a first-tier health facility, 3) scarcity of trained healthcare personnel who can diagnose the condition and its severity, 4) access to a second-tier facility in severe cases. These factors are commonly present in rural areas but even in more urban settings, access to a physician is often delayed. The Childhood Pneumonia Screener project aims at bridging the diagnostic gap using emerging technology. Mobile “smart” phone communication with several inexpensive dedicated sensors is proposed as a rapid data-collection and transmission unit that is connected to a central location where trained personnel assisted by sophisticated signal processing algorithms, evaluate the data and determine if the child is likely to have pneumonia and what the level and urgency of care should be.
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Affiliation(s)
- Jukka Räsänen
- 17Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612 USA
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18
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Torres FA, Pasarelli I, Cutri A, Ossorio MF, Ferrero F. Impact assessment of a decision rule for using antibiotics in pneumonia: a randomized trial. Pediatr Pulmonol 2014; 49:701-6. [PMID: 24039234 DOI: 10.1002/ppul.22849] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 06/12/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although more than half of the cases of pneumonia in children can be due to virus, most of them receive antibiotic treatment. A previously published clinical prediction rule bacterial pneumonia score (BPS) allows the identification of children with pneumonia who do not require antibiotics, but its impact has not been evaluated. We assessed whether the use of the BPS for the initial management of patients with pneumonia results in decreasing the use of antibiotics than under standard management of this condition without increasing patients' risks. METHODS This was a randomized, parallel-group, observer-blind, controlled clinical trial comparing the use of antibiotics in children aged 3-60 months treated for pneumonia in an outpatient setting, according to two methods of initial management. Patients were assigned randomly to management according to the BPS (antibiotic indication with a BPS ≥ 4 points) or routine management (antibiotic indication based on the institutional guidelines). We calculated the proportion of the use of antibiotics in each group and evaluated each patient's clinical outcome. RESULTS We included 120 patients (60 BPS and 60 controls) with a mean age of 24.2 ± 14.1 months. The use of antibiotics was significantly lower in the BPS group (46.6% vs. 86.6; OR 0.13; 95% CI: 0.05-0.35; P < 0.001). We observed an unfavorable outcome in 10 patients (8.3%), 5 in each group (P = 1.0; OR: 1.0 95% CI: 0.2-3.6). CONCLUSION The use of antibiotics was significantly lower in the group managed according to the BPS compared to the conventionally treated group, without increasing the rate of treatment failure.
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Affiliation(s)
- Fernando A Torres
- Departamento de Consultorios Externos, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
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19
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Chiappini E, Venturini E, Galli L, Novelli V, de Martino M. Diagnostic features of community-acquired pneumonia in children: what's new? Acta Paediatr 2013; 102:17-24. [PMID: 24330269 DOI: 10.1111/apa.12502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM To critically summarise the available data on diagnosis of CAP in children, focusing on the newest findings and on the need for new studies. METHODS Eighty studies on the diagnosis of paediatric community-acquired pneumonia were scrutinised. RESULTS We found no significant associations between the signs or symptoms and aetiology of pneumonia and concluded that chest radiographs remain controversial and real-time polymerase chain reaction appears more sensitive than blood cultures. CONCLUSION Antibiotic overuse could make it difficult to differentiate viral and bacterial causes. Molecular methods provide promising tools for diagnosing infection by atypical bacteria, but are expensive and should be used selectively.
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Affiliation(s)
- Elena Chiappini
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Elisabetta Venturini
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Luisa Galli
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Vas Novelli
- Department of Infectious Diseases; Great Ormond Street Hospital for Children NHS Trust; London UK
| | - Maurizio de Martino
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
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20
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Wang LJ, Mu SC, Lin CH, Lin MI, Sung TC. Fatal community-acquired pneumonia: 18 years in a medical center. Pediatr Neonatol 2013; 54:22-7. [PMID: 23445739 DOI: 10.1016/j.pedneo.2012.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 02/09/2012] [Accepted: 05/21/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) remains a significant cause of childhood morbidity worldwide. We analyzed the etiologies and the clinical characteristics of children who died from CAP. This study aimed at early identification of the poor prognostic factors in order to improve the efficiency of pneumonia management and prevent deaths. METHODS A retrospective chart review was performed for children younger than 18 years admitted to Shin Kong Wu Ho-Su Memorial Hospital between September 1992 and August 2010 with a diagnosis of pneumonia on admission. Twenty-one patients who died with the diagnosis of pneumonia and its complications were included in the study, along with 63 age- and year-matched survival controls. RESULTS Twelve patients (57.1%) were younger than 2 years. Gram-negative bacteria (7 patients) were the most frequently identified pathogen, followed by Mycoplasma pneumoniae (6 patients). Four of these six M. pneumoniae infected patients were co-infected with other pathogens. Among the clinical characteristics, fatal CAP was associated mainly with initial presentations of anemia, lymphopenia, thrombocytopenia, bandemia, hyponatremia, sepsis, meningitis, metabolic acidosis, disseminated intravenous coagulopathy, and underlying congenital diseases. In multivariate logistic regression analysis, metabolic acidosis (odds ratio = 8.50; 95% confidence interval = 2.82-25.60; p < 0.001) was a prognostic risk factor for fatality. CONCLUSION For patients with CAP, blood gas should be included in the routine blood test on admission. Once the initial blood test associated with the aforementioned poor prognostic factors has been identified, an immediate treatment including Gram-negative bacilli antibiotics should be started aggressively in order to prevent deaths.
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Affiliation(s)
- Ling-Jen Wang
- Department of Pediatric, Shin Kong WHS Memorial Hospital, Taipei, Taiwan
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21
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Williams DJ, Shah SS. Community-Acquired Pneumonia in the Conjugate Vaccine Era. J Pediatric Infect Dis Soc 2012; 1:314-28. [PMID: 26619424 PMCID: PMC7107441 DOI: 10.1093/jpids/pis101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/05/2012] [Indexed: 12/27/2022]
Abstract
Community-acquired pneumonia (CAP) remains one of the most common serious infections encountered among children worldwide. In this review, we highlight important literature and recent scientific discoveries that have contributed to our current understanding of pediatric CAP. We review the current epidemiology of childhood CAP in the developed world, appraise the state of diagnostic testing for etiology and prognosis, and discuss disease management and areas for future research in the context of recent national guidelines.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, The Monroe Carell Jr Children's Hospital at Vanderbilt, and,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Divisions of,Corresponding Author: Derek J. Williams, MD, MPH, 1161 21st Ave. South, CCC 5311 Medical Center North, Nashville, TN 37232. E-mail: derek.
| | - Samir S. Shah
- Infectious Diseases and,Hospital Medicine, Cincinnati Children's Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
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Abstract
PURPOSE OF REVIEW This review discusses unsolved problems concerning pediatric community-acquired pneumonia (CAP) and identifies the areas of research that need to be developed. RECENT FINDINGS Diagnosing pediatric CAP and the required hospitalization are difficult problems especially in the presence of mild signs and symptoms. It is frequently not possible to identify the cause of this disease, and this explains why antibiotics are unnecessarily prescribed in some cases. The treatment recommendations for severe CAP are better defined than those for mild and moderate CAP. SUMMARY It is possible to prepare recommendations for most of the problems that emerge in severe cases of pediatric CAP even though its cause can also be difficult to identify. However, the recommended approach to mild or moderate cases is always based on mainly moderate or poor quality evidence. There is an urgent need for further studies aimed at defining first-line and second-line antibiotic therapy for mild and moderate CAP. In the absence of new data, it is necessary to be aware that a substantial number of patients will not be optimally treated.
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Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC. Clinical prediction rules for children: a systematic review. Pediatrics 2011; 128:e666-77. [PMID: 21859912 DOI: 10.1542/peds.2011-0043] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear. OBJECTIVE To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology. METHODS Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards. RESULTS Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower. CONCLUSIONS Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.
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Affiliation(s)
- Jonathon L Maguire
- Department of Pediatrics, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
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Neuman MI, Monuteaux MC, Scully KJ, Bachur RG. Prediction of pneumonia in a pediatric emergency department. Pediatrics 2011; 128:246-53. [PMID: 21746723 DOI: 10.1542/peds.2010-3367] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography. METHODS We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis. RESULTS Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O₂ saturation >92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4). CONCLUSION Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, 300 Longwood Ave, Boston, MA 02115.
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25
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To give or not to give antibiotics to children with pneumonia. Pediatr Emerg Care 2010; 26:870. [PMID: 21057289 DOI: 10.1097/pec.0b013e3181f9dc57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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