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Palmu S, Mecklin M, Heikkilä P, Backman K, Peltola V, Renko M, Korppi M. National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals. Acta Paediatr 2018; 107:1966-1970. [PMID: 29752817 DOI: 10.1111/apa.14397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIM Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.
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Affiliation(s)
- Sauli Palmu
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Minna Mecklin
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Katri Backman
- Department of Paediatrics; Kuopio University Hospital; University of Eastern Finland; Kuopio Finland
| | - Ville Peltola
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - Marjo Renko
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
- PEDEGO Research Unit; University of Oulu; Oulu University Hospital; Oulu Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Rosati P, Di Salvo V, Crudo S, D'Amico R, Carlino C, Marchili MR, Gonfiantini M, Di Ciommo V. Are parents of children hospitalized with severe community-acquired pneumonia more satisfied with care when physicians allow them to share decisions on the antibiotic route? Health Expect 2015; 18:2278-87. [PMID: 24766676 PMCID: PMC5810709 DOI: 10.1111/hex.12197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 10/25/2022] Open
Abstract
CONTEXT AND OBJECTIVE Despite convincing evidence that oral and injected amoxicillin have equal efficacy in children with severe community-acquired pneumonia (CAP), hospitalized children often receive injected antibiotics. To investigate whether shared decision-making (choosing the antibiotic route) influences parental satisfaction. DESIGN, SETTING AND PARTICIPANTS In a one-year questionnaire-based study, we enrolled consecutive children hospitalized for CAP. At admission, all children's parents received a leaflet on CAP. Parents arriving during the daytime were assigned to a shared group and could choose the antibiotic route, those admitted at other times were assigned to an unshared group for whom physicians chose the antibiotic route. Shared group parents answered anonymous questionnaire investigating why they chose a specific route. Parents in both groups answered another anonymous questionnaire at discharge assessing perceived satisfaction with care. MAIN OUTCOME MEASURE Parents' satisfaction with perceived medical information as assessed by data from a questionnaire. RESULTS Of the 95 children enrolled, more children's parents were assigned to the unshared than the shared group (77 vs. 18). Of the 18 children's parents in the shared group, 14 chose the oral antibiotic route mainly to avoid painful injections. Doctors explanations were considered better in the shared than in the unshared group (P = 0.02). DISCUSSION AND CONCLUSIONS The larger number of children's parents assigned to the unshared group reflects paediatricians' reluctance to offer shared-decision making. Well-informed parents prefer oral antibiotic therapy for children with severe CAP. Allowing parents choose the antibiotic route respects parents' wishes, reduces children's pain and improves satisfaction.
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Affiliation(s)
- Paola Rosati
- Unit of Clinical Epidemiology Bambino Gesù Children's Hospital IRCCSRomeItaly
| | | | | | - Roberto D'Amico
- Italian Cochrane CentreDepartment of DiagnosticClinical and Public Health MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Cecilia Carlino
- Reasearch Training ProgramFacoltà di Medicina e ChirurgiaUniversità La SapienzaRomeItaly
| | | | | | - Vincenzo Di Ciommo
- Unit of Clinical Epidemiology Bambino Gesù Children's Hospital IRCCSRomeItaly
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Elemraid MA, Rushton SP, Thomas MF, Spencer DA, Eastham KM, Gennery AR, Clark JE. Changing clinical practice: management of paediatric community-acquired pneumonia. J Eval Clin Pract 2014; 20:94-9. [PMID: 24118607 PMCID: PMC4291095 DOI: 10.1111/jep.12091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2013] [Indexed: 11/04/2022]
Abstract
RATIONALE AND AIM To compare clinical features and management of paediatric community-acquired pneumonia (PCAP) following the publication of UK pneumonia guidelines in 2002 with data from a similar survey at the same hospitals in 2001-2002 (pre-guidelines). METHODS A prospective survey of 11 hospitals in Northern England was undertaken during 2008-2009. Clinical and laboratory data were recorded on children aged ≤16 years who presented with clinical and radiological features of pneumonia. RESULTS 542 children were included. There was a reduction in all investigations performed (P < 0.001) except C-reactive protein (P = 0.448) between surveys. These included full blood count (76% to 61%); blood culture (70% to 53%) and testing of respiratory secretions for viruses (24% to 12%) and bacteria (18% to 8%). Compared to pre-guidelines, there was a reduction in the use of intravenous antibiotics as a proportion of the total prescribed from 47% to 36% (P < 0.001) and a change in the route of antibiotic administration with increasing preference for oral alone (16% pre-compared to 50% post-guidelines, P < 0.001). CONCLUSION Apart from the acute phase reactants that should not be measured routinely, these changes are in line with the guideline recommendations. Improvements in antibiotic use are possible and have implications for future antimicrobial stewardship programmes. Further work using cost-effectiveness analysis may also demonstrate a financial benefit to health services from adoption of guidelines.
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Affiliation(s)
- Mohamed A Elemraid
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Ross RK, Hersh AL, Kronman MP, Newland JG, Metjian TA, Localio AR, Zaoutis TE, Gerber JS. Impact of Infectious Diseases Society of America/Pediatric Infectious Diseases Society guidelines on treatment of community-acquired pneumonia in hospitalized children. Clin Infect Dis 2014; 58:834-8. [PMID: 24399088 DOI: 10.1093/cid/ciu013] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
We examined the impact of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines that recommend ampicillin or amoxicillin for children hospitalized with community-acquired pneumonia. Prescribing of ampicillin/amoxicillin increased following guideline publication, but remains low. Cephalosporin and macrolide prescribing decreased but remains common. Further studies exploring outcomes of and reasons for compliance with guidelines are warranted.
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Affiliation(s)
- Rachael K Ross
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
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Elemraid MA, Sails AD, Eltringham GJA, Perry JD, Rushton SP, Spencer DA, Thomas MF, Eastham KM, Hampton F, Gennery AR, Clark JE. Aetiology of paediatric pneumonia after the introduction of pneumococcal conjugate vaccine. Eur Respir J 2013; 42:1595-603. [PMID: 23598951 PMCID: PMC3844138 DOI: 10.1183/09031936.00199112] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We describe the aetiology of community-acquired pneumonia in children before and after the introduction of the pneumococcal conjugate vaccination (PCV) programme in 2006. Prospective studies were conducted in 2001–2002 (pre-vaccine) and 2009–2011 (post-vaccine) of children aged 0–16 years with radiologically confirmed pneumonia seen in hospital. Investigations included culture, serology, immunofluorescence antibody and urine antigen testing, with an increased use of PCR assays and expanded panels of pathogens in the post-vaccine study. 241 and 160 children were enrolled in the pre- and post-vaccine studies, respectively (73% aged <5 years). Identification of a causative pathogen was higher post-vaccination (61%) than pre-vaccination (48.5%) (p=0.019). Rates of bacterial infections were not different between post- and pre-vaccine studies (17.5% versus 24%, p=0.258). Viral (31%) and mixed (12.5%) infections were found more often post-vaccination (19.5%, p=0.021) than pre-vaccination (5%, p=0.015). Rates of identified pneumococcal infections were comparable between pre- and post-vaccine studies (14.7% versus 17.4%, p=0.557). Diagnosis of pneumococcal infection post-vaccination improved when PCR was used compared to culture (21.6% versus 6%, p=0.0004). Serotypes included in PCV13 but not PCV7 were identified in 75% (18 out of 24) post-vaccination. Infection with nonvaccine pneumococcal serotypes continues to be a significant cause of pneumonia in children in the UK. Aetiology of community-acquired pneumonia in children following a pneumococcal conjugate vaccination programmehttp://ow.ly/p9Wub
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Elemraid MA, Sails AD, Thomas MF, Rushton SP, Perry JD, Eltringham GJA, Spencer DA, Eastham KM, Hampton F, Gennery AR, Clark JE. Pneumococcal diagnosis and serotypes in childhood community-acquired pneumonia. Diagn Microbiol Infect Dis 2013; 76:129-32. [PMID: 23537785 DOI: 10.1016/j.diagmicrobio.2013.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 02/12/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
Abstract
The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced routinely in the UK from September 2006 and replaced by PCV13 in 2010. In a prospective study from 2009 to 2011 of 160 children aged ≤16 years with radiologically confirmed pneumonia, likely pneumococcal infections were identified in 26%. Detection of pneumococci was improved with polymerase chain reaction compared to culture (21.6% versus 6% of children tested, P = 0.0004). Where serotyping was possible, all (n = 23) were non-PCV7 but PCV13 serotypes; 1 (43.5%), 3 (21.7%), 7A/F, and 19A (17.4% each).
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Affiliation(s)
- Mohamed A Elemraid
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK.
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Impact of the 7-valent pneumococcal conjugate vaccine on the incidence of childhood pneumonia. Epidemiol Infect 2012; 141:1697-704. [PMID: 23084696 PMCID: PMC3733065 DOI: 10.1017/s0950268812002257] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
In September 2006, the 7-valent pneumococcal conjugate vaccine (PCV7) was added to the UK immunization programme. We aimed to evaluate the impact of PCV7 on the incidence of all-cause community-acquired pneumonia (CAP) in children. A prospective survey was undertaken in 2008-2009 at 11 hospitals in North East England of children aged 0-16 years with radiologically confirmed pneumonia. Data were compared to those from a similar survey undertaken in the same hospitals in 2001-2002. A total of 542 children were enrolled, of which 74% were aged <5 years. PCV7 uptake was 90∙7%. The incidence of pneumonia was 11∙8/10,000 [95% confidence interval (CI) 10∙9-12∙9], and the hospitalization rate was 9∙9/10,000 (95% CI 9∙0-10∙9). Compared to 2001, there was a 19% (95% CI 8-29) reduction in the rate of CAP in those aged <5 years, and in those <2 years a 33∙1% (95% CI 20-45) reduction in the incidence of CAP and 38∙1% (95% CI 24-50) reduction in hospitalization rates. However, for those unvaccinated aged ≥5 years, there was no difference in the incidence of CAP and hospitalization rate between both surveys. Since 2001, the overall reduction in incidence was 17∙7% (95% CI 8-26) and for hospitalization 18∙5% (95% CI 8-28). For the <5 years age group there was a lower incidence of CAP in PCV7-vaccinated children (25∙2/10,000, 95% CI 22∙6-28∙2) than in those that were not vaccinated (37∙4/10,000, 95% CI 29∙2-47∙1). In conclusion, PCV7 has reduced both incidence and rate of hospitalization of pneumonia in children, particularly in the <2 years age group.
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Rowan-Legg A, Barrowman N, Shenouda N, Koujok K, Le Saux N. Community-acquired lobar pneumonia in children in the era of universal 7-valent pneumococcal vaccination: a review of clinical presentations and antimicrobial treatment from a Canadian pediatric hospital. BMC Pediatr 2012; 12:133. [PMID: 22928588 PMCID: PMC3477073 DOI: 10.1186/1471-2431-12-133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 08/23/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common cause of pediatric admission to hospital. The objectives of this study were twofold: 1) to describe the clinical characteristics of CAP in children admitted to a tertiary care pediatric hospital in the pneumococcal vaccination era and, 2) to examine the antimicrobial selection in hospital and on discharge. METHODS A retrospective review of healthy immunocompetent children admitted to a tertiary pediatric hospital from January 2007 to December 2008 with clinical features consistent with pneumonia and a radiographically-confirmed consolidation was performed. Clinical, microbiological and antimicrobial data were collected. RESULTS One hundred and thirty-five hospitalized children with pneumonia were evaluated. Mean age at admission was 4.8 years (range 0-17 years). Two thirds of patients had been seen by a physician in the 24 hours prior to presentation; 56 (41.5%) were on antimicrobials at admission. 52 (38.5%) of patients developed an effusion, and 22/52 (42.3%) had pleural fluid sampled. Of 117 children who had specimens (blood/pleural fluid) cultured, 9 (7.7%) had pathogens identified (7 Streptococcus pneumoniae, 1 Group A Streptococcus, and 1 Rhodococcus). 55% of patients received 2 or more antimicrobials in hospital. Cephalosporins were given to 130 patients (96.1%) in hospital. Only 21/126 patients (16.7%) were discharged on amoxicillin. The median length of stay was 3 days (IQR 2-4) for those without effusion and 9 (IQR 5-13) for those with effusion. No deaths were related to pneumonia. CONCLUSIONS This study provides comprehensive data on the clinical characteristics of hospitalized children with CAP in the pneumococcal 7-valent vaccine era. Empiric antimicrobial choice at our institution is variable, highlighting a need for heightened antimicrobial stewardship.
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Affiliation(s)
- Anne Rowan-Legg
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada
| | - Nicholas Barrowman
- Clinical Research Unit, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Nazih Shenouda
- Department of Diagnostic Imaging, Children’s Hospital of Eastern Ontario, Ottawa, Canada
| | - Khaldoun Koujok
- Department of Diagnostic Imaging, Children’s Hospital of Eastern Ontario, Ottawa, Canada
| | - Nicole Le Saux
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada
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Affiliation(s)
- Matti Korppi
- Paediatric Research Centre, Tampere University and University Hospital, Finland.
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Rossi A, Cornette J, Johnson MR, Karamermer Y, Springeling T, Opic P, Moelker A, Krestin GP, Steegers E, Roos-Hesselink J, van Geuns RJM. Quantitative cardiovascular magnetic resonance in pregnant women: cross-sectional analysis of physiological parameters throughout pregnancy and the impact of the supine position. J Cardiovasc Magn Reson 2011; 13:31. [PMID: 21708015 PMCID: PMC3148552 DOI: 10.1186/1532-429x-13-31] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 06/27/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are physiological reasons for the effects of positioning on hemodynamic variables and cardiac dimensions related to altered intra-abdominal and intra-thoracic pressures. This problem is especially evident in pregnant women due to the additional aorto-caval compression by the enlarged uterus. The purpose of this study was to investigate the effect of postural changes on cardiac dimensions and function during mid and late pregnancy using cardiovascular magnetic resonance (CMR). METHODS Healthy non-pregnant women, pregnant women at 20th week of gestation and at 32nd week of gestation without history of cardiac disease were recruited to the study and underwent CMR in supine and left lateral positions. Cardiac hemodynamic parameters and dimensions were measured and compared between both positions. RESULTS Five non-pregnant women, 6 healthy pregnant women at mid pregnancy and 8 healthy pregnant women at late pregnancy were enrolled in the study. In the group of non-pregnant women left ventricular (LV) cardiac output (CO) significantly decreased by 9% (p=0.043) and right ventricular (RV) end-diastolic volume (EDV) significantly increased by 5% (p=0.043) from the supine to the left lateral position. During mid pregnancy LV ejection fraction (EF), stroke volume (SV), left atrium lateral diameter and left atrial supero-inferior diameter increased significantly from the supine position to the left lateral position: 8%, 27%, 5% and 11%, respectively (p<0.05). RV EDV, SV and right atrium supero-inferior diameter significantly increased from the supine to the left lateral position: 25%, 31% and 13% (p<0.05), respectively. During late pregnancy a significant increment of LV EF, EDV, SV and CO was observed in the left lateral position: 11%, 21%, 35% and 24% (p<0.05), respectively. Left atrial diameters were significantly larger in the left lateral position compared to the supine position (p<0.05). RV CO was significantly increased in the left lateral position compared to the supine position (p<0.05). CONCLUSIONS During pregnancy positional changes affect significantly cardiac hemodynamic parameters and dimensions. Pregnant women who need serial studies by CMR should be imaged in a consistent position. From as early as 20 weeks the left lateral position should be preferred on the supine position because it positively affects venous return, SV and CO.
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Affiliation(s)
- Alexia Rossi
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Jerome Cornette
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, the Netherlands
| | - Mark R Johnson
- Department of Obstetrics and Gynaecology, Imperial College of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Yusuf Karamermer
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Tirza Springeling
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Petra Opic
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Gabriel P Krestin
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Eric Steegers
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, the Netherlands
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Robert-Jan M van Geuns
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
- Department of Radiology, Erasmus University Medical Center, 's Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
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Almasri M, Diza E, Papa A, Eboriadou M, Souliou E. Mycoplasma pneumoniae respiratory tract infections among Greek children. Hippokratia 2011; 15:147-52. [PMID: 22110297 PMCID: PMC3209678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND M. pneumoniae is a common cause of respiratory tract infections (RTIs) of variable severity especially in children. New diagnostic techniques offered more reliable information about the epidemiology of infection by this pathogen. AIM The aim of this study was to investigate the prevalence and epidemiology of acute M. pneumoniae infections among Greek children hospitalized for RTIs using more advanced techniques. MATERIAL AND METHODS The study included 225 Greek children hospitalized for RTIs during a 15-month period. Throat swab specimens were tested by PCR for the detection of M. pneumoniae, while IgG and IgM antibodies were determined by ELISA and, in certain cases, also by western-blot. In parallel, specimens were tested for the presence of additional respiratory pathogens. RESULTS M. pneumoniae infection was diagnosed as the only pathogen in 25 (11.1%) cases, being the second (after respiratory syncytial virus- RSV) most often detected pathogen. The proportion of cases with M. pneumoniae infection in age group 8-14 years (23.3%) was significantly higher than that in <3 years age group. CONCLUSION During our study period, M. pneumoniae was the second causative agent of RTIs after RSV. The proportion of children with M. pneumoniae RTIs increased with age, while most cases were reported during summer and autumn.
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Abstract
In this paper, we review the literature on the management of pneumonia in the developed world setting. Pneumonia is usually diagnosed on the basis of a cough, respiratory distress, a fever, and chest X-ray changes. Pneumonia affects all paediatric age groups, though the highest incidence is in the under 5s. There is a significant burden of primary and secondary care illness, although mortality is low. Inpatient admission rates for pneumonia may have increased in recent years in some regions. Pneumonia is unlikely if a child presents with solely wheeze. In routine clinical practice, a microbiological diagnosis is often not made, because current tests are insensitive. Aetiology varies with geographical location, but approximately half of cases are viral. The mainstay of management of moderate pneumonia (the commonest group presenting to secondary care) is careful assessment, and oral antibiotics, followed by early discharge when the patient shows signs of improvement. We summarise the available clinical trial data from the developed world; most of these trials are not adequately powered. Patients with moderately severe pneumonia do not require invasive investigation, but clinical judgement should be used to identify and investigate more complex cases. We discuss several pathogens that have gained importance as causal agents, including non-vaccinated strains of S. pneumoniae, Panton Valentine leucocidin S. aureus, H1N1 Influenza A and Human Bocavirus. The importance of antimicrobial resistance is considered, and we review recent data on long term effects of pneumonia in childhood. By reviewing the available literature, we demonstrate that there are clear evidence gaps, and we suggest future areas for clinical research.
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Affiliation(s)
- Andrew Prayle
- University of Nottingham, Child Health, E Floor East Block, Queens Medical Centre, Nottingham, NG7 2UH.
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Abstract
Community-acquired pneumonia (CAP) still remains a significant cause for childhood morbidity worldwide. Streptococcus pneumoniae is the most important causative agent at all ages. Respiratory syncytial virus is common in young children, and Mycoplasma pneumoniae in schoolchildren. Paediatric CAP is universally treated with antibiotics; amoxicillin is the drug of choice for presumably pneumococcal and a macrolide for presumably atypical bacterial cases. Because of globally increased resistances, macrolides are not safety for pneumococcal CAP. At present, available prospective research data on the epidemiology of paediatric CAP in western countries are from 1970s to 1980s; correspondingly, data on bacterial aetiology are mainly from 1980s to 1990s. Current concepts on pneumococcal aetiology are mostly based on poorly validated antibody assays. Most data on clinical characteristics in children's CAP, as well as on antibiotic treatment come from developing countries, thus not being directly applicable in western communities. Recent viral studies have revealed the role of rhinoviruses, metapneumovirus and bocavirus in the aetiology of paediatric CAP. This review critically summarizes the available data on epidemiology, aetiology, clinical presentation, treatment and outcome of CAP in children, with special focus on the newest microbial findings, the age and applicability of the data and the need of new studies.
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Affiliation(s)
- Massimiliano Don
- Pediatric Department, School of Medicine, DPMSC, University of Udine, Udine, Italy.
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Prediction of delayed recovery from pediatric community-acquired pneumonia. Ital J Pediatr 2010; 36:51. [PMID: 20670443 PMCID: PMC2920270 DOI: 10.1186/1824-7288-36-51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 07/29/2010] [Indexed: 11/10/2022] Open
Abstract
Background If children with community-acquired pneumonia (CAP) do not recover within 48 hours after starting antibiotic therapy, complications are possible and a checkup must be ensured. Aim of the present study was to evaluate the improvement of pediatric CAP, within 48 hours after starting therapy, in relation to age, etiology, clinical/laboratory characteristics and selected antibiotics. Methods Ninety-four children were treated for radiologically confirmed CAP, 64 by oral amoxicillin, 23 by intravenous ampicillin and 7 by other antibiotics. The etiology of CAP was studied by serology, data on more than 20 clinical characteristics were collected retrospectively, and antibiotics were selected on clinical grounds. Results After starting of antibiotics, the mean duration of fever was higher in children ≥5 than <2 or 2-4 years of age (p = 0.003). Fever continued >48 hours in 4 (4.3%) children and 2 additional children had empyema. Clinical, radiological and laboratory characteristics and serological findings were not significantly associated with the duration of fever. Fever continued >24 hours in 1 (4.8%) child treated with ampicillin and in 2 (8%) inpatients compared with 19 (28.8%) children treated with amoxicillin (p = 0.007) and 23 (33%) outpatients (p = 0.0012), respectively. Conclusions Respiratory rate and erythrocyte sedimentation rates were associated with rapid decrease of fever. Anyway, none of the reported characteristics was able to predict treatment failures or delayed fever decrease in children suffering from CAP.
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Calado C, Nunes P, Pereira L, Nunes T, Barreto C, Bandeira T. Estarão diferentes as pneumonias agudas adquiridas na comunidade com internamento hospitalar em idade pediátrica na última década? REVISTA PORTUGUESA DE PNEUMOLOGIA 2010. [DOI: 10.1016/s0873-2159(15)30027-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Naidoo RV, Bryant PA. Not every cough in bronchiolitis season is bronchiolitis. BMJ Case Rep 2009; 2009:bcr04.2009.1780. [PMID: 21874140 DOI: 10.1136/bcr.04.2009.1780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 2-month-old male infant presented to hospital for the third time in late autumn with a 4 week history of cough and respiratory distress. He had presented to hospital on two occasions during the previous two weeks, and had twice been discharged with a diagnosis of bronchiolitis, based on clinical findings and the season. That the nasopharyngeal aspirate (NPA) was negative for respiratory viruses did not alter the diagnosis as this was felt to be a common false negative finding. However his cough worsened and on his third presentation he had respiratory distress with bilateral crackles and wheeze. The C reactive protein was 121 mg/l but the NPA was again negative for viruses. He was investigated for atypical causes of lower respiratory tract infection and the NPA was positive for Chlamydia trachomatis by polymerase chain reaction. He was treated with a 5 day course of azithromycin and made a full recovery.
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Affiliation(s)
- Ronelle Vanessa Naidoo
- St Georges Hospital, Paediatric Infectious Diseases, Blackshaw Road, Tooting, London SW17 0QT, UK
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Al-Sonboli N, Al-Aghbari N, Al-Aryani A, Atef Z, Brabin B, Shenkin A, Roberts E, Harper G, Hart CA, Cuevas LE. Micronutrient concentrations in respiratory syncytial virus and human metapneumovirus in Yemeni children. ACTA ACUST UNITED AC 2009; 29:35-40. [PMID: 19222932 DOI: 10.1179/146532809x402015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute respiratory infections (ARI) cause significant childhood mortality. Nutritional homeostasis, particularly micronutrient levels, is important in modulating response to infection. More information is required regarding micronutrient levels in ARI viral infections, especially newly identified viruses such as human metapneumovirus (HMPV). AIM To describe zinc, copper, selenium and vitamins A and E concentrations in children with respiratory syncytial virus (RSV) and/or HMPV in relation to levels of C-reactive protein (CRP). METHODS The presence of RSV/HMPV in nasopharyngeal aspirates (NPA) was identified in 246 children using RTPCR. Zinc, copper, selenium and vitamins A and E concentrations were measured using inductive coupled plasma mass spectrometry and high performance liquid chromatography. RESULTS 183 children had RSV, 39 had HMPV and 24 were co-infected. Zinc concentrations were lower in children with HMPV than in children with RSV or RSV/HMPV co-infection. Copper concentrations were lower in children with RSV than in children with RSV/HMPV or HMPV and zinc/copper ratios were lower in children with HMPV/RSV or RSV than in children with HMPV alone. Retinol and a alpha-tocopherol were lower in children with RSV than in children with HMPV. Most children had low selenium concentrations. Children with RSV and raised CRP (>5 mg/L) had higher copper and lower zinc/copper ratios than those with low CRP (< or =5 mg/L). Children with HMPV and raised CRP had higher copper and lower zinc concentrations than children with low CRP. Children with RSV/HMPV and raised CRP had higher copper concentrations. Children with RSV/HMPV and raised CRP had higher a alpha-tocopherol concentrations. CONCLUSION The profiles of micronutrients differ in children with RSV and HMPV and are confounded by CRP. These results may guide strategies for micronutrient supplementation in ARI.
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Affiliation(s)
- N Al-Sonboli
- Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Place, Liverpool, UK
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Évaluation de la qualité des prescriptions d’antibiotiques dans le service d’accueil des urgences d’un CHU en région parisienne. Med Mal Infect 2009; 39:48-54. [DOI: 10.1016/j.medmal.2008.09.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 06/12/2008] [Accepted: 09/17/2008] [Indexed: 11/18/2022]
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Abstract
Community-acquired pneumonia (CAP) is a significant cause of childhood morbidity and mortality worldwide. Viral etiology is most common in young children and decreases with age. Streptococcus pneumoniae is the single most common bacterial cause across all age groups. Atypical organisms present similarly across all age groups and may be more common than previously recognized.A bacterial pneumonia should be considered in children presenting with fever >38.5 degrees C, tachypnea, and chest recession. Oxygen therapy is life saving and should be given when oxygen saturation is <92%. For non-severe pneumonia, oral amoxicillin is the antibacterial of choice with low failure rates reported. Severely ill children are traditionally treated with parenteral antibacterials. Penicillin non-susceptible S. pneumoniae prevalence rates are increasing and have been linked to community antibacterial prescribing. Most pneumococci remain sensitive to high-dose penicillin-based antibacterials but macrolide resistance is also a problem in some communities. However, primary combination treatment with macrolides is indicated in areas where there is a high prevalence of atypical organisms. The most common complications in CAP are parapneumonic effusions and empyema. The use of ultrasonography combined with intercostal drainage augmented with the use of fibrinolytic therapy has significantly reduced the morbidity associated with these complications. There is increasing evidence that a preventative strategy with the 7-valent pneumococcal conjugate vaccine (PCV-7) results in a significant fall in CAP in early childhood.
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Affiliation(s)
- Krishne Chetty
- Department of Paediatrics, John Radcliffe Hospital, Headington, Oxford, UK
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Brouard J, Vabret A, Bach N, Toutain F, Duhamel JF, Freymuth F. [Adenoviral respiratory diseases in healthy children: a study of 116 hospital cases]. ACTA ACUST UNITED AC 2008; 6:97-102. [PMID: 32288527 PMCID: PMC7146831 DOI: 10.1016/s1294-5501(04)94248-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Adenoviruses most commonly cause respiratory illness; however, depending on the infecting serotype, they may also cause various other diseases. Diagnosis may be difficult to achieve.The clinical findings for 116 children hospitalised with adenoviral infection were studied retrospectively. In 71 children, the diagnosis was based on detection of adenovirus antigen in the nasopharyngeal specimens and in 71 children on viral culture. The clinical picture of adenoviral infection was characterised by high-grade (mean 39°1C) and prolonged fever (mean duration 4,3 days). Upper respiratory and lower respiratory symptoms were the most common infections. Twelve had been admitted to the hospital due to febrile convulsions, 6 had meningitis. Laboratory findings varied from normal values to values seen in bacterial infections. Thus it was difficult to distinguish adenoviral disease from a bacterial disease. Fifty-nine children were referred to the hospital due to infection unresponsive to antimicrobial therapy.Symptoms of respiratory infection caused by adenovirus may range from the common cold syndrome to pneumonia, croup and bronchiolitis. Adenoviruses can be responsible for severe consequences, even in previously healthy children. Studies of the molecular mechanisms of viral infections of the airways could provide important insights into the nature of the inflammatory process involved in asthma and chronic obstructive pulmonary disease. Most infections are mild and require no therapy or only symptomatic treatment. There are at present time no recognised antiviral agents that are effective in treating serious adenovirus disease. The rapid detection of adenovirus antigen in nasopharygeal specimens proved to have a great clinical value in the diagnosis.
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Affiliation(s)
- J Brouard
- Service de Pédiatrie A, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
| | - A Vabret
- Laboratoire de Virologie Humaine et Moléculaire, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
| | - N Bach
- Service de Pédiatrie A, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
| | - F Toutain
- Service de Pédiatrie A, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
| | - J F Duhamel
- Service de Pédiatrie A, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
| | - F Freymuth
- Laboratoire de Virologie Humaine et Moléculaire, CHU de Caen avenue Georges Clémenceau, 14033 Caen cedex
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Atkinson M, Lakhanpaul M, Smyth A, Vyas H, Weston V, Sithole J, Owen V, Halliday K, Sammons H, Crane J, Guntupalli N, Walton L, Ninan T, Morjaria A, Stephenson T. Comparison of oral amoxicillin and intravenous benzyl penicillin for community acquired pneumonia in children (PIVOT trial): a multicentre pragmatic randomised controlled equivalence trial. Thorax 2007; 62:1102-6. [PMID: 17567657 PMCID: PMC2094276 DOI: 10.1136/thx.2006.074906] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 05/19/2007] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To ascertain whether therapeutic equivalence exists for the treatment of paediatric community acquired pneumonia by the oral and intravenous (IV) routes. METHODS A multicentre pragmatic randomised controlled non-blinded equivalence trial was undertaken in eight paediatric centres in England (district general and tertiary hospitals). Equivalence was defined as no more than a 20% difference between treatments of the proportion meeting the primary outcome measure at any time. 246 children who required admission to hospital and had fever, respiratory symptoms or signs and radiologically confirmed pneumonia were included in the study. Exclusion criteria were wheeze, oxygen saturations <85% in air, shock requiring >20 ml/kg fluid resuscitation, immunodeficiency, pleural effusion at presentation requiring drainage, chronic lung condition (excluding asthma), penicillin allergy and age <6 months. The patients were randomised to receive oral amoxicillin for 7 days (n = 126) or IV benzyl penicillin (n = 120). Children in the IV group were changed to oral amoxicillin after a median of six IV doses and received 7 days of antibiotics in total. The predefined primary outcome measure was time for the temperature to be <38 degrees C for 24 continuous hours and oxygen requirement to cease. Secondary outcomes were time in hospital, complications, duration of oxygen requirement and time to resolution of illness. RESULTS Oral amoxicillin and IV benzyl penicillin were shown to be equivalent. Median time for temperature to settle was 1.3 days in both groups (p<0.001 for equivalence). Three children in the oral group were changed to IV antibiotics and seven children in the IV group were changed to different IV antibiotics. Median time to complete resolution of symptoms was 9 days in both groups. CONCLUSION Oral amoxicillin is effective for most children admitted to hospital with pneumonia (all but those with the most severe disease who were excluded from this study). Prior to this study, the British Thoracic Society guidelines on childhood pneumonia could not draw on evidence to address this issue. This will spare children and their families the trauma and pain of cannulation, and children will spend less time in hospital.
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Affiliation(s)
- Maria Atkinson
- Division of Child Health, University of Nottingham, University Hospital Queen's Medical Centre, Nottingham, UK.
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Nakayama E, Hasegawa K, Morozumi M, Kobayashi R, Chiba N, Iitsuka T, Tajima T, Sunakawa K, Ubukata K. Rapid optimization of antimicrobial chemotherapy given to pediatric patients with community-acquired pneumonia using PCR techniques with serology and standard culture. J Infect Chemother 2007; 13:305-13. [PMID: 17982719 PMCID: PMC7087912 DOI: 10.1007/s10156-007-0535-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 05/14/2007] [Indexed: 11/28/2022]
Abstract
Children (n = 117; mean age 2.4 ± 2.9 years) were diagnosed as having community-acquired pneumonia (CAP) using clinical symptoms, chest X-rays, and hematological data. The causative pathogen was determined using real-time polymerase chain reaction (PCR) (6 bacteria), multiple reverse transcription-PCR (MPCR; 11 viruses), bacterial culture, and serology. The initial chemotherapy was evaluated based on the pathogens identified using PCR. We found 27 viral cases (23.1%), 25 bacterial cases (21.4%), 45 mixed infections with virus and bacteria (38.5%), 10 Mycoplasma pneumoniae (8.5%), 7 mixed infections with M. pneumoniae and another pathogen (6.0%), 1 Chlamydophila pneumoniae (0.9%), and 2 unknown pathogens (1.7%). Streptococcus pneumoniae and Haemophilus influenzae accounted for 58 (49.5%) and 27 (23.0%) of the cases, respectively. The median values (50%) of the white blood cell count (WBC) and C-reactive protein (CRP) using the box-and-whisker and plot method, respectively, were 11.7 × 103 mm−3 and 1.4 mg/dl in viral infections, 15.6 × 103 mm−3 and 4.8 mg/dl in mixed infections with virus and bacteria, 17.8 × 103 mm−3 and 6.3 mg/dl in bacterial infections, 6.7 × 103 mm−3 and 1.4 mg/dl in M. pneumoniae infections, and 21.5 × 103 mm−3 and 6.4 mg/dl in mixed infections with M. pneumoniae and other bacterial infections. Sulbactam/ampicillin (n = 61), carbapenems (n = 12), and ceftriaxone (n = 7) were selected for the patients suspected of having bacterial infections alone or mixed infections with bacterial and viruses in accordance with our criteria defined tentatively. For those with M. pneumoniae and C. pneumoniae infections, azithromycin or minocycline was initially used. Treatments averaged 3–5 days. The empirical chemotherapy was improper in 9.4% of cases in relation to the etiologic agents finally identified. We conclude that rapid and comprehensive identification using PCR can provide optimal antimicrobial chemotherapy for CAP patients.
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Affiliation(s)
- Eiichi Nakayama
- Laboratory of Molecular Epidemiology for Infectious Agents, Kitasato Institute for Life Sciences, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8641, Japan.
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Odièvre MH, Sanni E, de Broucker F, Bonnet E, Michot AS, Laurent C, Valdès L, Weil-Olivier C. [Pneumococcal infection among community-acquired pneumonia. A retrospective study of 230 hospitalized children]. Arch Pediatr 2007; 14:1290-7. [PMID: 17920252 DOI: 10.1016/j.arcped.2007.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 06/09/2007] [Accepted: 08/09/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To find arguments in favour of pneumococcal origin in community-acquired pneumonia. POPULATION AND METHODS A retrospective analysis of the files of 230 children hospitalized between January 1st 1999 and June 30th 2001 for community acquired pneumonia was performed. The files were classified into 3 subgroups: I (N=7), confirmed (positive blood culture); II (N=134), probable (biological arguments); III (N=89), possible pneumococcal infection. Age of the children was also taken into consideration. RESULTS All children in the subgroup I had fever>39 degrees C at admission and at least 1 of the 3 criteria (WBC> or=20.10(9)/l, neutrophils > or =10.10(9)/l, C-reactive protein level> or =60 mg/l). Dyspnea was more frequently asthmatiform in the subgroup III. Chest X-ray was not contributive. Before admission, 39% of the children were given one or several antibiotics, and so some of patients belonging to the subgroups II and III could have been infected by pneumococcus without possibility to confirm that. CONCLUSION Results of this analysis suggest that some criteria may be useful for selecting initial antibiotherapy even though systematic early specific antipneumococcal immunization should reduce the frequency of this infection.
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Affiliation(s)
- M-H Odièvre
- Service de pédiatrie, hôpital Louis-Mourier, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France.
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Pandemic flu. Clinical management of patients with an influenza-like illness during an influenza pandemic. J Infect 2007; 53 Suppl 1:S1-58. [PMID: 17376371 PMCID: PMC7133687 DOI: 10.1016/s0163-4453(07)60001-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Atkinson M, Yanney M, Stephenson T, Smyth A. Effective treatment strategies for paediatric community-acquired pneumonia. Expert Opin Pharmacother 2007; 8:1091-101. [PMID: 17516873 PMCID: PMC7103692 DOI: 10.1517/14656566.8.8.1091] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pneumonia is the leading cause of death in children under 5 years of age worldwide and a cause of morbidity in a considerable number of children. A number of studies have sought to identify the ideal choice of antibiotics, route of administration and optimum duration of treatment based on the most likely aetiological agents. Emerging bacterial resistance to antibiotics is also an important consideration in treatment. However, inconsistent clinical and radiological definitions of pneumonia make comparison between studies difficult. There is also a lack of well designed adequately powered randomised controlled trials. This review describes the difficulties encountered in diagnosing community-acquired pneumonia, aetiology, treatment strategies with recommendations and highlights areas for further research.
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Affiliation(s)
- Maria Atkinson
- Specialist Registrar, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael Yanney
- Specialist Registrar, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Terence Stephenson
- Professor of Child Health, Division of Child Health, University of Nottingham, Nottingham, UK
| | - Alan Smyth
- Senior Lecturer in Child Health, Division of Respiratory Medicine, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
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Abstract
OBJECTIVE To describe the spectrum of clinical features and management of community acquired pneumonia in the UK. DESIGN Prospectively recorded clinical details for all children with possible pneumonia and chest x ray (CXR) changes in 13 hospitals in the North of England between 2001 and 2002. RESULTS 89% of 711 children presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia and dyspnoea all correlated with each other and prompted appropriate interventions. Admission in children, not infants, was independently associated with RR, oxygen saturation, lobar CXR changes and pyrexia. Neither C-reactive protein, lobar CXR changes or pyrexia were associated with severity. Children over 1 year old with perihilar CXR changes more often had severe disease (p = 0.001). Initial intravenous antibiotics were associated with lobar CXR changes in infants and children and with dyspnoea, pyrexia and pleural effusion in children. The presence of pleural effusion increased duration of antibiotic treatment (p<0.001). Cefuroxime was the most often used intravenous antibiotic in 61%. Oral antibiotics included a penicillin in 258 (46%), a macrolide in 192 (34%) and a cephalosporin in 117 (21%). Infants stayed significantly longer (p<0.001) as did children with severe disease (p<0.01), effusions (p = 0.005) or lobar CXR changes (p< or =0.001). CONCLUSIONS There is a high rate of intravenous antibiotic administration in hospital admissions for pneumonia. Despite lobar CXR changes not being independently associated with severe disease, initial lobar CXR changes and clinical assessment in children independently influenced management decisions, including admission and route of antibiotics.
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Affiliation(s)
- Julia E Clark
- Department of Paediatric Infectious Disease, Newcastle General Hospital, Newcastle, UK.
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Affiliation(s)
- V Marchac
- Necker Enfants Malades, Paris, France
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Pandemic flu: clinical management of patients with an influenza-like illness during an influenza pandemic. Provisional guidelines from the British Infection Society, British Thoracic Society, and Health Protection Agency in collaboration with the Department of Health. Thorax 2007; 62 Suppl 1:1-46. [PMID: 17202446 PMCID: PMC2223144 DOI: 10.1136/thx.2006.073080] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Pneumonia is one of the most common global childhood illnesses. The diagnosis relies on a combination of clinical judgement and radiological and laboratory investigations. Streptococcus pneumoniae remains the most important cause of childhood community-acquired pneumonia. In addition, viruses (including respiratory syncytial virus) and atypical bacteria (Mycoplasma and Chlamydia) are likely pathogens in younger and older children in developed countries. In the minority of cases only, the actual organism is isolated to guide treatment. Antibiotics effective against the expected bacterial pathogens should be instituted where necessary. The route and duration of antibiotic therapy, the role of emerging pathogens and the impact of pneumococcal resistance and conjugate pneumococcal vaccines are also discussed.
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Affiliation(s)
- Katherine A Hale
- Department of Allergy, The Children's Hospital at Westmead, Australia.
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Somer A, Salman N, Yalçin I, Ağaçfidan A. Role of Mycoplasma pneumoniae and Chlamydia pneumoniae in children with community-acquired pneumonia in Istanbul, Turkey. J Trop Pediatr 2006; 52:173-8. [PMID: 16627487 DOI: 10.1093/tropej/fml017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND To investigate the role of Mycoplasma pneumoniae and Chlamydia pneumoniae infection in pediatric pneumonia, in Istanbul, Turkey, we conducted a prospective study covering all the children between 2 months and 15 years hospitalized for community-acquired pneumonia. METHODS A total of 140 children (85 males, median age 2.5 years) with community-acquired pneumonia were enrolled. Acute and convalescent sera were tested for IgM and IgG antibodies to M. pneumoniae (enzyme-linked immunosorbent assay, Serion ELISA classic) and for IgM and IgG antibodies to C. pneumoniae (microimmunofluorescence, Savyon, Israel). RESULTS Mycoplasma pneumoniae infection was diagnosed in 38 patients (27%) and C. pneumoniae infection in 7 (5%). In 2 children M. pneumoniae and C. pneumoniae co infection was observed. The average age of the M. pneumoniae cases was 5.3 years and that of the C. pneumoniae was 1.5 years. The average age of pneumonia cases caused by other pathogens was 3.4 years (p<0.05). No significant difference was observed in clinical onset, signs, symptoms and laboratory parameters in children with M. pneumoniae and C. pneumoniae infection and in those without M. pneumoniae and C. pneumoniae infection. CONCLUSIONS The results of this study suggest a remarkable role for M. pneumoniae and C. pneumoniae in childhood community-acquired pneumonia, and the knowledge of the true prevalence of these two types of infections discovered in the community might lead to modifications in the present empirical treatment of bacterial pneumonia.
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Affiliation(s)
- Ayper Somer
- Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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Moreno L, Krishnan JA, Duran P, Ferrero F. Development and validation of a clinical prediction rule to distinguish bacterial from viral pneumonia in children. Pediatr Pulmonol 2006; 41:331-7. [PMID: 16493666 DOI: 10.1002/ppul.20364] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Distinguishing bacterial from viral pneumonia on admission to the hospital could guide the decision of whether or not to use antibiotics. We developed and validated a clinical prediction rule to distinguish bacterial from viral pneumonia in hospitalized children. METHODS We enrolled consecutive children, aged 1 month to 5 years, admitted to two tertiary children's hospitals in whom a bacterial or viral etiology for pneumonia was identified. Data from 175 children at one hospital were used to develop a clinical prediction rule or Bacterial Pneumonia Score (BPS). Data from 136 children at the second hospital were used to validate it. Based on receiver operating characteristic (ROC) curve analyses and multivariable logistic regression, significant clinical and laboratory predictors, along with the radiographic score for each participant, were included as factors in the BPS. The main outcome measure was the sensitivity and specificity of the BPS for bacterial pneumonia. RESULTS The BPS (possible range: -3 to 15; auROCc = 0.996, 95%CI: 0.99-1.0) was developed by attributing 3 points for axillary temperature > or = 39.0 degrees C, 2 points for age > or equal to 9 months, 2 points for absolute neutrophil count > or = [corrected] 8,000 cells/mm3, 1 point for bands > or = 5%, and -3 to 7 points for the chest X-ray findings. A BPS > or = 4 predicted bacterial pneumonia with a sensitivity of 100%, specificity of 93.8%, positive predictive value of 75.8%, and negative predictive value of 100%. CONCLUSIONS The BPS accurately identifies hospitalized children's risk of bacterial pneumonia, helping clinicians determine those not likely to benefit from antibiotic therapy.
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Affiliation(s)
- Laura Moreno
- Division of Pulmonology, Hospital de Niños de la Santísima Trinidad, Universidad Nacional de Córdoba, Córdoba, Argentina
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Abstract
There are few comprehensive epidemiological studies of pneumonia in the developed world. Ascertainment and definition are important variables in the estimation of pneumonia incidence both in primary care and from hospital data. The available figures suggest a burden of disease in the order of 10-15 cases/1000 children per year and a hospital admission rate of 1-4/1000 per year. Both incidence and hospital admission are greatest in the youngest children and rapidly fall after the age of 5 years. In a majority of cases of community acquired pneumonia an organism is not identified. Viral infections are common and influenza A, B, respiratory syncitial virus (RSV) and parainfluenza 1, 2 and 3 are the most common viruses identified. Streptococcus pneumoniae is the most common bacterial cause. Broad brush calculations suggest that the NHS cost of childhood pneumonia in England is 6-8 million pound sterling per annum. This does not include family and social costs. There is potential for new vaccine strategies to decrease childhood pneumonia.
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Affiliation(s)
- Talal Farha
- The John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
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Michelow IC, Olsen K, Lozano J, Rollins NK, Duffy LB, Ziegler T, Kauppila J, Leinonen M, McCracken GH. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics 2004; 113:701-7. [PMID: 15060215 DOI: 10.1542/peds.113.4.701] [Citation(s) in RCA: 458] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The precise epidemiology of childhood pneumonia remains poorly defined. Accurate and prompt etiologic diagnosis is limited by inadequate clinical, radiologic, and laboratory diagnostic methods. The objective of this study was to determine as precisely as possible the epidemiology and morbidity of community-acquired pneumonia in hospitalized children. METHODS Consecutive immunocompetent children hospitalized with radiographically confirmed lower respiratory infections (LRIs) were evaluated prospectively from January 1999 through March 2000. Positive blood or pleural fluid cultures or pneumolysin-based polymerase chain reaction assays, viral direct fluorescent antibody tests, or viral, mycoplasmal, or chlamydial serologic tests were considered indicative of infection by those organisms. Methods for diagnosis of pneumococcal pneumonia among study subjects were published by us previously. Selected clinical characteristics, indices of inflammation (white blood cell and differential counts and procalcitonin values), and clinical outcome measures (time to defervescence and duration of oxygen supplementation and hospitalization) were compared among groups of children. RESULTS One hundred fifty-four hospitalized children with LRIs were enrolled. Median age was 33 months (range: 2 months to 17 years). A pathogen was identified in 79% of children. Typical respiratory bacteria were identified in 60% (of which 73% were Streptococcus pneumoniae), viruses in 45%, Mycoplasma pneumoniae in 14%, Chlamydia pneumoniae in 9%, and mixed bacterial/viral infections in 23%. Preschool-aged children had as many episodes of atypical bacterial LRIs as older children. Children with typical bacterial or mixed bacterial/viral infections had the greatest inflammation and disease severity. Multivariate logistic-regression analyses revealed that high temperature (> or = 38.4 degrees C) within 72 hours after admission (odds ratio: 2.2; 95% confidence interval: 1.4-3.5) and the presence of pleural effusion (odds ratio: 6.6; 95% confidence interval: 2.1-21.2) were significantly associated with bacterial pneumonia. CONCLUSIONS This study used an expanded diagnostic armamentarium to define the broad spectrum of pathogens that cause pneumonia in hospitalized children. The data confirm the importance of S pneumoniae and the frequent occurrence of bacterial and viral coinfections in children with pneumonia. These findings will facilitate age-appropriate antibiotic selection and future evaluation of the clinical effectiveness of the pneumococcal conjugate vaccine as well as other candidate vaccines.
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Affiliation(s)
- Ian C Michelow
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Abstract
The treatment of community-acquired pneumonia (CAP) in children is empirical, being based on the knowledge of the etiology of CAP at different ages. As a result of currently available methods in everyday clinical practice, a microbe-specific diagnosis is not realistic in the majority of patients. Even the differentiation between viral, 'atypical' bacterial (Mycoplasma pneumoniae or Chlamydia pneumoniae) and 'typical' bacterial (Streptococcus pneumoniae) CAP is often not possible. Moreover, up to one-third of CAP cases seem to be mixed viral-bacterial or dual bacterial infections. Recent serologic studies have confirmed that S. pneumoniae is an important causative agent of CAP at all ages. M. pneumoniae is common from the age of 5 years onwards, and C. pneumoniae is common from the age of 10 years onwards. In addition to age, the etiology and treatment of CAP are dependent on the severity of the disease. Pneumococcal infections are predominant in children treated in hospital, and mycoplasmal infections are predominant in children treated at home.In ambulatory patients with CAP, amoxicillin (or penicillin V [phenoxymethylpenicillin]) is the drug of choice from the age of 4 months to 4 years, and at all ages if S. pneumoniae is the presumptive causative organism. Macrolides, preferably clarithromycin or azithromycin, are the first-line drugs from the age of 5 years onwards. In hospitalized patients who need parenteral therapy for CAP, cefuroxime (or penicillin G [benzylpenicillin]) is the drug of choice. Macrolides should be administered concomitantly if M. pneumoniae or C. pneumoniae infection is suspected. Radiologic findings and C-reactive protein (CRP) levels offer limited help for the selection of antibacterials; alveolar infiltrations and high CRP levels indicate pneumococcal pneumonia, but the lack of these findings does not rule out bacterial CAP. Most guidelines recommend antibacterials for 7-10 days (except azithromycin, which has a recommended treatment duration of 5 days). If no improvement takes place within 2 days, therapy must be reviewed.
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Affiliation(s)
- Matti Korppi
- Department of Paediatrics, Kuopio University and University Hospital, Kuopio, Finland.
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37
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Babyn PS, Chu WCW, Tsou IYY, Wansaicheong GKL, Allen U, Bitnun A, Chee TSG, Cheng FWT, Chiu MC, Fok TF, Hon EKL, Gahunia HK, Kaw GJL, Khong PL, Leung CW, Li AM, Manson D, Metreweli C, Ng PC, Read S, Stringer DA. Severe acute respiratory syndrome (SARS): chest radiographic features in children. Pediatr Radiol 2004; 34:47-58. [PMID: 14624321 PMCID: PMC7080132 DOI: 10.1007/s00247-003-1081-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2003] [Revised: 08/18/2003] [Accepted: 08/21/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome (SARS) is a recently recognized condition of viral origin associated with substantial morbidity and mortality rates in adults. Little information is available on its radiologic manifestations in children. OBJECTIVE The goal of this study was to characterize the radiographic presentation of children with SARS. MATERIALS AND METHODS We abstracted data (n=62) on the radiologic appearance and course of SARS in pediatric patients with suspect (n=25) or probable (n=37) SARS, diagnosed in five hospital sites located in three cities: Toronto, Singapore, and Hong Kong. Available chest radiographs and thoracic CTs were reviewed for the presence of the following radiographic findings: airspace disease, air bronchograms, airways inflammation and peribronchial thickening, interstitial disease, pleural effusion, and hilar adenopathy. RESULTS A total of 62 patients (suspect=25, probable=37) were evaluated for SARS. Patient ages ranged from 5.5 months to 17 years and 11.5 months (average, 6 years and 10 months) with a female-to-male ratio of 32:30. Forty-one patients (66.1%) were in close contact with other probable, suspect, or quarantined cases; 10 patients (16.1%) had recently traveled to WHO-designated affected areas within 10 days; and 7 patients (11.2%) were transferred from other hospitals that had SARS patients. Three patients, who did not have close/hospital contact or travel history to affected areas, were classified as SARS cases based on their clinical signs and symptoms and on the fact that they were living in an endemic area. The most prominent clinical presentations were fever, with a temperature over 38 degrees C (100%), cough (62.9%), rhinorrhea (22.6%), myalgia (17.7%), chills (14.5%), and headache (11.3%). Other findings included sore throat (9.7%), gastrointestinal symptoms (9.7%), rigor (8.1%), and lethargy (6.5%). In general, fever and cough were the most common clinical presentations amongst younger pediatric SARS cases (age<10 years), whereas, in addition to these symptoms, headache, myalgia, sore throat, chills, and/or rigor were common in older patients (age>/=10 years). The chest radiographs of 35.5% of patients were normal. The most prominent radiological findings that were observed in the remaining patients were areas of consolidation (45.2%), often peripheral with multifocal lesions in 22.6%. Peribronchial thickening was noted on chest radiographs of 14.5% of patients. Pleural effusion was observed only in one patient (age 17 years and 11.5 months), whereas interstitial disease was not observed in any patient. CONCLUSION In pediatric cases, SARS manifests with nonspecific radiographic features making radiological differentiation difficult, especially from other commonly encountered childhood respiratory viral illnesses causing airspace disease. The radiographic presentation of suspected SARS cases ranged from normal to mild perihilar peribronchial thickening. The radiographic presentations, as expected, were relatively more pronounced in the SARS probable cases.
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Affiliation(s)
- Paul S Babyn
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada.
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38
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David-Ouaknine F, Kinoo J, Echard Y, Hacquard B, Decazes JM. Impact de recommandations sur la pertinence des prescriptions d’antibiotiques. Med Mal Infect 2003. [DOI: 10.1016/s0399-077x(03)00005-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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39
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Affiliation(s)
- A J Cant
- Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Daulby Street, Liverpool L69 3GA, *Liverpool School of Tropical Medicine, University of Liverpool L69 3GA and †Department of Medical Microbiology and PHL, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
| | - S B Gordon
- Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Daulby Street, Liverpool L69 3GA, *Liverpool School of Tropical Medicine, University of Liverpool L69 3GA and †Department of Medical Microbiology and PHL, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
| | - R C Read
- Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Daulby Street, Liverpool L69 3GA, *Liverpool School of Tropical Medicine, University of Liverpool L69 3GA and †Department of Medical Microbiology and PHL, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
| | - C A Hart
- Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Daulby Street, Liverpool L69 3GA, *Liverpool School of Tropical Medicine, University of Liverpool L69 3GA and †Department of Medical Microbiology and PHL, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
| | - C Winstanley
- Department of Medical Microbiology and Genito-Urinary Medicine, University of Liverpool, Daulby Street, Liverpool L69 3GA, *Liverpool School of Tropical Medicine, University of Liverpool L69 3GA and †Department of Medical Microbiology and PHL, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
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40
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Di Ciommo V, Russo P, Attanasio E, Di Liso G, Graziani C, Caprino L. Clinical and economic outcomes of pneumonia in children: a longitudinal observational study in an Italian paediatric hospital. J Eval Clin Pract 2002; 8:341-8. [PMID: 12164981 DOI: 10.1046/j.1365-2753.2002.00351.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Antibiotic prescription for acute lower respiratory infections (ALRI) in hospitalized children can have a major impact on cure and costs. We performed a longitudinal study to explore the appropriateness of prescriptions, the predictors of therapeutic patterns, and the main outcomes: readmission, length of stay (LOS) and costs. METHODS Ninety-nine children who were inpatients of a paediatric hospital receiving antibiotic treatment for community acquired ALRI were consecutively enrolled. To calculate the costs of pneumonia treatment, we collected data on clinical presentation and resources consumption. We used multiple regression analysis to identify predictors of LOS and choice of therapy, and one-way ANOVA to evaluate cost differences among treatment groups. RESULTS Parenteral antibiotics were administered in 64.6% of cases, whereas 35.4% received oral antibiotic therapy by itself (OAT). Switch therapy (SWT) was performed in 43.4% of cases. The most frequently prescribed antibiotic for parenteral therapy was ceftriaxone (58.3%), and for oral therapy cefprozil (58.1%). The median LOS was 3 days and the cure rate 99% (95%CI: 97-100%). SWT and OAT were significantly associated with a shorter LOS. The clinical variables were not significantly associated with SWT or OAT. The average costs per patient in the management of pneumonia were Euro 1435. SWT or OAT were associated with significant lower costs: Euro 1487 per patient (95%CI: 1395-1580) and Euro 1335 per patient (95%CI: 1233-1437), respectively. CONCLUSIONS The hospital management of paediatric pneumonia was more influenced by the early discharge policy than by clinical variables without under-cure.
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Affiliation(s)
- V Di Ciommo
- Epidemiology Unit, Ospedale Pediatrico Bambino Gesù, Rome, Italy.
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41
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Dirlewanger M, Krahenbuhl JD, Fanconi S, Vaudaux B, Gehri M. Community-acquired pneumonia in children aged 2 months to 5 years: application of the WHO guidelines in a developed country setting (Switzerland). Eur J Pediatr 2002; 161:460-1. [PMID: 12269258 DOI: 10.1007/s00431-002-0993-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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42
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British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax 2002; 57 Suppl 1:i1-24. [PMID: 11994552 PMCID: PMC1765993 DOI: 10.1136/thorax.57.90001.i1] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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43
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Abstract
Most children presenting with pneumonia in the industrialised world will have a viral or 'atypical' organism. The clinical features of these 'atypical' pneumonias may be indistinguishable from bacterial pneumonia. New diagnostic techniques such as the polymerase chain reaction may help in diagnosis and choice of treatment, where appropriate. The pathological and clinical features of infection with each agent are discussed, together with their sequelae.
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MESH Headings
- Adenoviridae Infections/diagnosis
- Adenoviridae Infections/drug therapy
- Adenoviridae Infections/virology
- Anti-Bacterial Agents/therapeutic use
- Child
- Child, Preschool
- Humans
- Infant
- Influenza, Human/diagnosis
- Influenza, Human/drug therapy
- Influenza, Human/virology
- Macrolides
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/virology
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/virology
- Ureaplasma Infections/diagnosis
- Ureaplasma Infections/drug therapy
- Ureaplasma Infections/virology
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Affiliation(s)
- Alan Smyth
- Department of Paediatric Respiratory Medicine, Nottingham City Hospital, Nottingham, UK
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