Aetiology and severity of childhood pneumonia in primary care in Malawi: a cohort study

Respiratory syncytial virus-associated pneumonia in primary care in Malawi

OBJECTIVE

To identify the prevalence of respiratory syncytial virus (RSV) in a cohort of children under 5 years of age with World Health Organization (WHO)-defined pneumonia and the factors associated with developing severe RSV-associated community-acquired pneumonia (CAP) in primary care in a single centre in Northern Malawi.

METHODS

The BIOmarkers TO diagnose PnEumonia (BIOTOPE) study was a prospective cohort study conducted from March to June 2016 that took place in a primary care centre in Northern Malawi. Data from this study was used to identify the characteristics of children under 5 years of age who presented with RSV and WHO-defined CAP. Means, standard deviations, medians and ranges were calculated for continuous variables. A univariate logistic regression was performed to examine the potential predictor variables.

RESULTS

Four hundred and ninety-four infants presented with CAP and were eligible for inclusion in the study; RSV infection was detected in 205 (41.6%) of the infants. Eight factors were associated with increased risk for RSV CAP in the univariate model: age, born at term, presenting for care in June, crowded living environment, not being exclusively breastfed, not having received zinc or vitamin A supplementation in the last six months. Infants with RSV were more likely to have an oxygen saturation ≤92% compared to infants with other causes of pneumonia and more likely to have severe pneumonia as defined by the WHO.

CONCLUSION

This study supports that RSV-associated CAP is linked to modifiable and non-modifiable risk factors; further research is indicated to determine which interventions would be most impactful. Developing and implementing an infant or maternal vaccine could be a cost-effective way to prevent RSV-associated CAP and mortality in developing nations. More research is needed to understand seasonal patterns of CAP and research over extended periods can offer valuable insights on host, environmental and pathogen-specific factors that contribute to RSV-associated CAP.

Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia

OBJECTIVES

Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children.

METHODS

Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included.

RESULTS

Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children.

CONCLUSIONS

Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.

EFFECT OF HIGH-FREQUENCY CHEST WALL OSCILLATION ON CLINICAL INDICES OF COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN

OBJECTIVE

The aim: To study the effect of high-frequency chest wall oscillation (HFCWO) on clinical indices of community-acquired pneumonia (CAP) in children.

PATIENTS AND METHODS

Materials and methods: The main clinical symptoms were assessed in 107 children (girls - 45.79% and boys - 54.21%) aged 6 to 17 years with acute and uncomplicated course of CAP of moderate severity. The main group (MG) consisted of 55 children who were prescribed basic therapy (BT) in combination with HFCWO procedures. The control group (CG) comprised 52 children who received BT exclusively.

RESULTS

Results: In the children of MG, the intensity of cough decreased to 0.28 ± 0.06 points compared with children of CG - 0.5 ± 0.07 points (p <0.05) on the 10th day of treatment. A positive dynamics of CAP in the form of the amount of sputum reduction was revealed in the MG children up to 0.06 ± 0.03 points compared with the CG children - 0.42 ± 0.07 (p <0.05). On the 10th day of therapy the MG children with CAP had decrease in the number of râles in the lungs up to 0.08 ± 0.04 points compared with those of CG - 0.4 ± 0.07 points (p <0.05).

CONCLUSION

Conclusions: High efficacy of HFCWO method in complex treatment of CAP in children is confirmed by the dynamics of the main clinical symptoms, such as reduction of intensity and productivity of cough as well as absence shortness of breath and moist râles in the lungs. The data obtained indicate recovery of mucociliary clearance (MCC) functions and the bronchopulmonary system as a whole.

Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis

BACKGROUND

Pneumonia is a leading cause of mortality in children <5 years globally. Early identification of hospitalized children with pneumonia who may fail antibiotics could improve outcomes. We conducted a secondary analysis from the Malawi CPAP IMPACT trial evaluating risk factors for antibiotic failure among children hospitalized with pneumonia.

METHODS

Participants were 1-59 months old with World Health Organization-defined severe pneumonia and hypoxemia, severe malnutrition, and/or HIV exposure/infection. All participants received intravenous antibiotics per standard care. First-line antibiotics were benzylpenicillin and gentamicin for five days. Study staff assessed patients for first-line antibiotic failure daily between days 3-6. When identified, patients failing antibiotics were switched to second-line ceftriaxone. Analyses excluded children receiving ceftriaxone and/or deceased by hospital day two. We compared characteristics between patients with and without treatment failure and fit multivariable logistic regression models to evaluate associations between treatment failure and admission characteristics.

RESULTS

From June 2015-March 2018, 644 children were enrolled and 538 analyzed. Antibiotic failure was identified in 251 (46.7%) participants, and 19/251 (7.6%) died. Treatment failure occurred more frequently with severe malnutrition (50.2% (126/251) vs 28.2% (81/287), p<0.001) and amongst those dwelling ≥10km from a health facility (22.3% (56/251) vs 15.3% (44/287), p = 0.026). Severe malnutrition occurred more frequently among children living ≥10km from a health facility than those living <10km (49.0% (49/100) vs 35.7% (275/428), p = 0.014). Children with severe malnutrition (adjusted odds ratio (aOR) 2.2 (95% CI 1.52, 3.24), p<0.001) and pre-hospital antibiotics ((aOR 1.47, 95% CI 1.01, 2.14), p = 0.043) had an elevated aOR for antibiotic treatment failure.

CONCLUSION

Severe malnutrition and pre-hospital antibiotic use predicted antibiotic treatment failure in this high-risk severe pneumonia pediatric population in Malawi. Our findings suggest addressing complex sociomedical conditions like severe malnutrition and improving pneumonia etiology diagnostics will be key for better targeting interventions to improve childhood pneumonia outcomes.

Avenanthramide C from Oats Protects Pyroptosis through Dependent ROS-Induced Mitochondrial Damage by PI3K Ubiquitination and Phosphorylation in Pediatric Pneumonia

Oat containing rich β-glucan, polyphenols, flavonoids, saponins, alkaloids, and other substances shows good biological activities. Therefore, the present study aimed to uncover the possible mechanism and therapeutic effect of Avenanthramide C in lessening inflammatory responses in pediatric pneumonia. Pediatric pneumonia was induced by liposaccharide (LPS) for vivo model and vitro model. Macrophage was performed to determine the mechanism and effects of Avenanthramide C in pediatric pneumonia. NLRP3 activity participated in the effects of Avenanthramide C in pediatric pneumonia. Avenanthramide C induced p-PI3K and p-Akt expressions and reduced ubiquitination of PI3K expression in pediatric pneumonia. On the other hand, Avenanthramide C integrated serine at 821 sites of the PI3K protein function. Avenanthramide C reduced ROS (reactive oxygen species)-induced mitochondrial damage by PI3K/AKT function in a model of pediatric pneumonia. Avenanthramide C protects pyroptosis in a model of pediatric pneumonia by PI3K/AKT/Nrf2/ROS signaling. Taken together, our results demonstrated that Avenanthramide C protects pyroptosis through dependent ROS-induced mitochondrial damage by PI3K ubiquitination and phosphorylation in a model of pediatric pneumonia, suggesting its potential use for the treatment of pediatric pneumonia and other inflammatory diseases.

Does procalcitonin have clinical utility in the management of paediatric community-acquired pneumonia? A PRO/CON debate

Although the overwhelming majority of community-acquired pneumonia (CAP) in children is caused by viral infections, treatment of CAP is among the most common indications for antibiotic use in children. This is largely driven by the imprecision of clinical diagnostic tools to differentiate viral from bacterial pneumonia and highlights the need for improved approaches to optimizing management of CAP in children. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate that discusses the clinical utility of procalcitonin in children with CAP.

A Systematic Review of Clinical Prediction Rules to Predict Hospitalisation in Children with Lower Respiratory Infection in Primary Care and their Validation in a New Cohort

Background: Our goal was to identify existing clinical prediction rules for predicting hospitalisation due to lower respiratory tract infection (LRTI) in children in primary care, guiding antibiotic therapy. A validation of these rules was then performed in a novel cohort of children presenting to primary care in Malawi with World Health Organisation clinically defined pneumonia. Methods: MEDLINE & EMBASE databases were searched for studies on the development, validation and clinical impact of clinical prediction models for hospitalisation in children with lower respiratory tract infection between January 1^st1946-June 30^th 2021. Two reviewers screened all abstracts and titles independently. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews & Meta-Analyses guidelines. The BIOTOPE cohort (BIOmarkers TO diagnose PnEumonia) recruited children aged 2-59 months with WHO-defined pneumonia from two primary care facilities in Mzuzu, Malawi. Validation of identified rules was undertaken in this cohort. Findings: 1023 abstracts were identified. Following the removal of duplicates, a review of 989 abstracts was conducted leading to the identification of one eligible model. The CHARMS checklist for prediction modelling studies was utilized for evaluation. The area under the curve (AUC) of the STARWAVe rule for hospitalisation in BIOTOPE was found to be 0.80 (95% C.I of 0.75-0.85). The AUC of STARWAVe for a confirmed diagnosis of bacterial pneumonia was 0.39 (95% C.I 0.25-0.54). Interpretation: This review highlights the lack of clinical prediction rules in this area. The STARWAVe rule identified was useful in predicting hospitalisation from bacterial infection as defined. However, in the absence of a gold standard indicator for bacterial LRTI, this is a reasonable surrogate and could lead to reductions in antibiotic prescription rates, should clinical impact studies prove its utility. Further work to determine the clinical impact of STARWAVe and to identify diagnostic tests for bacterial LRTI in primary care is required.