Factors determining the outcome of children hospitalized with severe pneumonia

Characteristics of children readmitted with severe pneumonia in Kenyan hospitals

BACKGROUND

Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities.

METHODS

We conducted a retrospective cohort study including children aged ≥ 2 months-14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 20 primary referral hospitals in Kenya. Severe pneumonia was defined using the 2013 World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality.

RESULTS

Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% CI 10.6-11.5) were readmitted. Re-admission was independently associated with age (12-59 months vs. 2-11 months: adjusted odds ratio (aOR) 1.70, 1.54-1.87; >5 years vs. 2-11 months: aOR 1.85, 1.55-2.22), malnutrition (weight-for-age-z-score (WAZ) <-3SD vs. WAZ> -2SD: aOR 2.05, 1.84-2.29); WAZ - 2 to -3 SD vs. WAZ> -2SD: aOR 1.37, 1.20-1.57), wheeze (aOR 1.17, 1.03-1.33) and presence of a concurrent neurological disorder (aOR 4.42, 1.70-11.48). Chest radiography was ordered more frequently among those readmitted (540/2,274 [23.7%] vs. 3,102/18,329 [16.9%], p < 0.001). Readmitted patients more frequently received second-line antibiotics (808/2,256 [35.8%] vs. 5,538/18,173 [30.5%], p < 0.001), TB medication (69/2,256 [3.1%] vs. 298/18,173 [1.6%], p < 0.001), salbutamol (530/2,256 [23.5%] vs. 3,707/18,173 [20.4%], p = 0.003), and prednisolone (157/2,256 [7.0%] vs. 764/18,173 [4.2%], p < 0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.93, 95% CI 0.82-1.07). Age (12-59 months vs. 2-11 months: aHR 0.62, 0.57-0.67), male sex (aHR 0.81, 0.75-0.88), malnutrition (WAZ <-3SD vs. WAZ >-2SD: aHR 1.87, 1.71-2.05); WAZ - 2 to -3 SD vs. WAZ >-2SD: aHR 1.46, 1.31-1.63), complete vaccination (aHR 0.74, 0.60-0.91), wheeze (aHR 0.87, 0.78-0.98) and anaemia (aHR 2.14, 1.89-2.43) were independently associated with mortality.

CONCLUSIONS

Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality.

Treatment outcome of pneumonia and its associated factors among pediatric patients admitted to Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia

Background

Pneumonia is the leading cause of morbidity and mortality among children worldwide. Despite its substantial impact, there exists a dearth of evidence regarding treatment outcomes and related factors, particularly within the Ethiopian context. This study endeavors to address these critical gaps by examining the treatment outcome of pneumonia among pediatric patients hospitalized in the Hiwot Fana Comprehensive Specialized University Hospital.

Method

A facility-based cross-sectional study was conducted on 204 children (≤14 years of age) diagnosed with pneumonia and admitted to the Hiwot Fana Comprehensive Specialized University Hospital. An interview using a structured questionnaire accompanied by a review of medical records was used to collect data from the parents/guardians. A binary logistic regression model with an adjusted odds ratio (AOR) and a 95% confidence interval (CI) was used to identify the associated factors with the outcome variable. Statistical significance was set at P < 0.05 in the multivariable analysis.

Result

Among the 204 children (≤14 years) included in the study, 119 (93.6%, 95% CI: 90.2-96.9) patients with pneumonia survived whereas 13 (6.4%, 95% CI: 3.1-9.7) died. Multivariable logistic regression analysis, after adjustments for potential confounders, revealed that children who had malnutrition (AOR = 3.5, 95% CI: 2.37-12.44), were unvaccinated (AOR =  3.41, 95% CI: 2.25-11.87), had altered mental states during admission (AOR = 4.49, 95% CI: 2.28-17.85), and had complicated types of pneumonia (AOR = 5.70, 95% CI: 2.98-15.09) were independently associated with mortality.

Conclusion

Poor treatment outcome was 6.4% among pediatric patients admitted with pneumonia in this study setting. Being unvaccinated, malnourished, and admitted with a complicated type of pneumonia as well as having altered consciousness at the time of admission were significantly associated with poor treatment outcomes. These findings underscore the critical need to prioritize preventative measures against malnutrition and unvaccinated status in children. Early identification of such children and proper interventions are imperative to reducing such outcomes, particularly in resource-constrained settings.

Construction and external validation of a scoring prediction model for mortality risk within 30 days of community-acquired pneumonia in children admitted to the pediatric intensive care unit: A multicenter retrospective case-control study

In this study, we constructed and validated a scoring prediction model to identify children admitted to the pediatric intensive care unit (PICU) with community-acquired pneumonia (CAP) at risk for early death. Children with CAP who were admitted to the PICU were included in the training set and divided into death and survival groups according to whether they died within 30 days of admission. For univariate and multifactorial analyses, demographic characteristics, vital signs at admission, and laboratory test results were collected separately from the 2 groups, and independent risk factors were derived to construct a scoring prediction model. The ability of the scoring model to predict CAP-related death was validated by including children with CAP hospitalized at 3 other centers during the same period in the external validation set. Overall, the training and validation sets included 296 and 170 children, respectively. Univariate and multifactorial analyses revealed that procalcitonin (PCT), lactate dehydrogenase (LDH), activated partial thromboplastin time (APTT), and fibrinogen (Fib) were independent risk factors. The constructed scoring prediction model scored 2 points each for PCT ≥ 0.375 ng/mL, LDH ≥ 490 U/L, and APTT ≥ 31.8 s and 1 point for Fib ≤ 1.78 g/L, with a total model score of 0-7 points. When the score was ≥ 5 points, the sensitivity and specificity of mortality diagnosis in children with CAP were 72.7% and 87.5%, respectively. In the external validation set, the sensitivity, specificity, and accuracy of the scoring model for predicting the risk of CAP-related death were 64.0%, 92.4%, and 88.2%, respectively. Constructing a scoring prediction model is worth promoting and can aid pediatricians in simply and rapidly evaluating the risk of death in children with CAP, particularly those with complex conditions.

Burden, predictors, and outcome of unconsciousness among under-five children hospitalized for community-acquired pneumonia: A retrospective study from a developing country

Despite the reduction of death from pneumonia over recent years, pneumonia has still been the leading infectious cause of death in under-five children for the last several decades. Unconsciousness is a critical condition in any child resulting from any illness. Once it occurs during a pneumonia episode, the outcome is perceived to be fatal. However, data on children under five with pneumonia having unconsciousness are scarce. We've retrospectively analyzed the data of under-five children admitted at the in-patient ward of Dhaka Hospital of icddr,b during 1 January 2014 and 31 December 2017 with World Health Organization classified pneumonia or severe pneumonia. Children presented with or without unconsciousness were considered as cases and controls respectively. Among a total of 3,876 children fulfilling the inclusion criteria, 325 and 3,551 were the cases and the controls respectively. A multivariable logistic regression analysis revealed older children (8 months vs. 7.9 months) (adjusted odds ratio, aOR 1.02, 95% CI: 1.004-1.04, p = 0.015), hypoxemia (aOR 3.22, 95% CI: 2.39-4.34, p<0.001), severe sepsis (aOR 4.46, 95% CI: 3.28-6.06, p<0.001), convulsion (aOR 8.90, 95% CI: 6.72-11.79, p<0.001), and dehydration (aOR 2.08, 95% CI: 1.56-2.76, p<0.001) were found to be independently associated with the cases. The cases more often had a fatal outcome than the controls (23% vs. 3%, OR 9.56, 95% CI: 6.95-13.19, p<0.001). If the simple predicting factors of unconsciousness in children under five hospitalized for pneumonia with different severity can be initially identified and adequately treated with prompt response, pneumonia-related deaths can be reduced more effectively, especially in resource-limited settings.

Prediction of mortality in pneumonia patients with connective tissue disease treated with glucocorticoids or/and immunosuppressants by machine learning

Objectives

The assessment of accurate mortality risk is essential for managing pneumonia patients with connective tissue disease (CTD) treated with glucocorticoids or/and immunosuppressants. This study aimed to construct a nomogram for predicting 90-day mortality in pneumonia patients using machine learning.

Methods

Data were obtained from the DRYAD database. Pneumonia patients with CTD were screened. The samples were randomly divided into a training cohort (70%) and a validation cohort (30%). A univariate Cox regression analysis was used to screen for prognostic variables in the training cohort. Prognostic variables were entered into the least absolute shrinkage and selection operator (Lasso) and a random survival forest (RSF) analysis was used to screen important prognostic variables. The overlapping prognostic variables of the two algorithms were entered into the stepwise Cox regression analysis to screen the main prognostic variables and construct a model. Model predictive power was assessed using the C-index, the calibration curve, and the clinical subgroup analysis (age, gender, interstitial lung disease, diabetes mellitus). The clinical benefits of the model were assessed using a decision curve analysis (DCA). Similarly, the C-index was calculated and the calibration curve was plotted to verify the model stability in the validation cohort.

Results

A total of 368 pneumonia patients with CTD (training cohort: 247; validation cohort: 121) treated with glucocorticoids or/and immunosuppressants were included. The univariate Cox regression analysis obtained 19 prognostic variables. Lasso and RSF algorithms obtained eight overlapping variables. The overlapping variables were entered into a stepwise Cox regression to obtain five variables (fever, cyanosis, blood urea nitrogen, ganciclovir treatment, and anti-pseudomonas treatment), and a prognostic model was constructed based on the five variables. The C-index of the construction nomogram of the training cohort was 0.808. The calibration curve, DCA results, and clinical subgroup analysis showed that the model also had good predictive power. Similarly, the C-index of the model in the validation cohort was 0.762 and the calibration curve had good predictive value.

Conclusion

In this study, the nomogram developed performed well in predicting the 90-day risk of death in pneumonia patients with CTD treated with glucocorticoids or/and immunosuppressants.

Childhood Pneumonia: What's Unchanged, and What's New?

Childhood pneumonia is still a significant clinical and public health problem. India contributes the highest number of deaths due to pneumonia, accounts for about 20% of global mortality among under five children. Various etiologic agents including bacteria, viruses and atypical organism are responsible for childhood pneumonia. Recent studies suggest that viruses are one of the major causes of childhood pneumonia. Among viruses, respiratory syncytial virus has got great attention and several recent studies are reporting it as an important organism for pneumonia. Lack of exclusive breast feeding during first six months, improper timing of start and content of complimentary feeding, anemia, undernutrition, indoor pollution due to tobacco smoking and use of coal and wood for cooking food and lack of vaccinations are important risk factors. X-ray chest is not routinely performed to diagnose pneumonia while use of lung ultrasound is increasing to detect consolidation, pleural effusion, pneumothorax and pulmonary edema (interstitial syndrome). Role of C-reactive protein (CRP) and procalcitonin is similar, to differentiate between viral and bacterial pneumonia, however duration of antibiotics is better guided by procalcitonin. Newer biomarkers like IL-6, presepsin and triggering receptor expressed on myeloid cells 1 are needed to be evaluated for their use in children. Hypoxia is significantly associated with childhood pneumonia. Therefore, use of pulse oximetry should be encouraged for early detection and prompt treatment of hypoxia to prevent adverse outcomes. Among the available tools for risk of mortality assessment in children due to pneumonia, PREPARE score is the best but external validation will be needed.

Pneumonia among under - five children in Ethiopia: a retrospective analysis from an urban hospital

Background

Pneumonia is the leading cause of death in under-five children in low-income countries. However, the burden of pneumonia in hospital admission is not traced systematically. This study was conducted to determine the proportion of under-five pneumonia admissions among children admitted to a hospital in Addis Ababa, Ethiopia between 2017-2021.

Methods

A retrospective record of pediatric admissions to the Yekatit 12 referral hospital in Addis Ababa, Ethiopia was assessed for the period 2017- 2021. The date of admission and discharge, length of stay, and outcome at discharge were collected in accordance with the Ethiopian National Classification of Diseases (NCoD). Descriptive statistics were used to assess the proportion of under-five children with pneumonia. Survival analyses using Log rank test and cox regression analysis were done to assess time to recovery (recovering from illness). Multivariable logistic regression was used to assess the influence of selected factors on pneumonia associated hospital admission.

Results

Between 2017-2021, 2170 children age 1 to 59 months were admitted, 564 (25.99%; 95% confidence interval 24.18% to 27.87%) were diagnosed with pneumonia. Among the sixty children who died during their hospitalization, 15 had been diagnosed with pneumonia. The median time to recover from pneumonia and discharge was 6 days. The odds of pneumonia hospital admission were higher among younger children (4.36 times higher compared to elder children with 95% CI 2.77,6.87)and were increased between the months of September to November.

Conclusions

Pneumonia accounts for more than a quarter of hospital admissions in under-five children and for a quarter of deaths in this urban cohort. Hospital admission due to pneumonia was higher among older children (36-59 months of age) in the months following the heavy rain months (September to November) as compared to younger children. Our data strongly support increase of vaccination to prevent under 5 pneumonia.

Treatment outcomes and its associated factors among pneumonia patients admitted to public hospitals in Harar, eastern Ethiopia: a retrospective follow-up study

OBJECTIVE

Although there is a high risk of drug resistance, empiric treatment is a common approach for pneumonia management. In this respect, it is relevant to know treatment outcomes of patients with pneumonia. This study aimed to assess treatment outcomes and its associated factors among pneumonia patients treated at two public hospitals in Harar, eastern Ethiopia.

DESIGN

Retrospective follow-up study.

SETTING

Jugal General Hospital and Hiwot Fana Specialised University Hospital in Harar, eastern Ethiopia.

PARTICIPANTS

Patients admitted and treated for pneumonia in the two public hospitals in eastern Ethiopia between April 2020 and April 2021.

PRIMARY OUTCOME

The primary outcome was unfavourable treatment outcome (died or transferred to intensive care unit) for pneumonia patients.

RESULTS

A total of 693 patients with pneumonia were included in the study. 88 (12.7%) of these patients had an unfavourable treatment outcome, which included 14 (2%) transfers to the intensive care unit and 74 (10.7%) deaths. Patients with comorbidity (adjusted OR, AOR=2.96; 95% CI: 1.47 to 5.97) and with clinical features including abnormal body temperature (AOR=4.03; 95% CI: 2.14 to 7.58), tachycardia (AOR=2.57; 95% CI: 1.45 to 4.55), bradypnoea or tachypnoea (AOR=3.92; 95% CI:1.94 to 7.92), oxygen saturation below 90% (AOR=2.52; 95% CI:1.37 to 4.64) and leucocytosis (AOR=2.78, 95%, CI:1.38 to 5.58) had a significantly increased unfavourable treatment outcome.

CONCLUSION

We found that nearly one out of eight patients with pneumonia had unfavourable treatment outcomes. It was considerably high among patients with comorbidities and apparent abnormal clinical conditions. Therefore, taking into account regionally adaptable intervention and paying close attention to pneumonia patients admitted with comorbidity and other superimposed abnormal conditions might help improve the treatment outcomes of these populations.

Incidence of recovery from severe pneumonia and its predictors among children 2-59 months admitted to pediatric ward of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia: A retrospective Cohort study

Background

Pneumonia is a major reason for hospital admission among children, particularly in resource-poor areas. A hospital stay (length of stay) alone is found to contribute for 46.8% of a household cost for single episode of severe pneumonia. The aim of this study was to determine the incidence of recovery from severe pneumonia and predictors among children 2-59 months of age admitted to pediatric ward of Ayder Comprehensive Specialized Hospital (ACSH).

Methods

A retrospective facility-based cohort study was conducted among under-five-year-old children admitted in ACSH. Three years medical records from July 7, 2015 to July 6, 2018 were reviewed. A total of 285 children with severe pneumonia admitted to pediatric ward of ACSH were included. Kaplan-Meier Survival Curve was used to estimate recovery time. The independent effects of covariates on recovery time are analyzed using multivariate Cox-proportional adjusted model.

Result

The median survival time was four days (95% CI = 3.732 - 4.268). The incidence of recovery was 92.3%. Co-morbidity (AOR: 3.47, 95%CI, 2.21, 5.4), malnutrition (AOR = 1.9, 95%CI, 1.2, 3.1), duration of chief complaint (AOR = 0.72, 95%CI: 0.54, 0.94), and vaccination (AOR = 0.32, 95% CI, 0.13, 0.81) were significant predictors of time to recovery from severe pneumonia.

Conclusion

High recovery rate and short length of hospital stay was observed in this study. Increased duration of chief complaint, presence of co-morbidity, being malnourished, and vaccination were factors that associated with time to recovery. Therefore focuses have to be given in increasing the community's health seeking behavior to visit health facility early and especial attention should be given for children with co-morbidity, malnutrition, and unvaccinated children.

Time to Recovery from Covid-19 and Its Predictors Among Patients Admitted to Treatment Centers of Southern Nations Nationalities and Peoples Region (SNNPR), ETHIOPIA: Multi-Center Retrospective Cohort Study

Background

The world is currently facing a pandemic of Coronavirus Disease 2019 (Covid-19). It has caused significant morbidity and mortality. So far little is known about recovery time (prolonged hospital stay) from Covid-19 and its determinants in Ethiopia as well as in the study area. Therefore, the aim of this study was to determine time to recovery from Covid-19, and identify predictors of time to recovery among patients admitted to treatment centers of Southern Nations Nationalities and Peoples Region (SNNPR).

Methods and Materials

A facility-based retrospective cohort study was conducted among Covid-19 patients admitted to care centers of SNNPR from May 30, 2020 to October 15, 2021. A sample of 845 patients was included in the study. Summarization of the data was done using mean (standard deviation) and median (inter quartile range). Kaplan–Meier Survival Curve was used to estimate recovery time from Covid-19 and the independent effects of covariates on recovery time was analyzed using multivariable Cox-proportional hazard model.

Results

The incidence density of recovery was 8.24 per 100 person-days (95% CI: 7.67, 8.85). The overall median recovery time was 10 days (IQR: 8–16 days). Critical stage of Covid-19 (aHR = 0.19, 95% CI: 0.12, 0.29), severe stage of Covid-19 (aHR = 0.40, 95% CI: 0.29, 0.56), mechanical ventilation (aHR = 0.20, 95% CI: 0.073, 0.56) and treatment center (aHR = 0.68, 95% CI: 0.51, 0.90) were significant predictors of recovery rate among Covid-19 patients.

Conclusion

The median time to recovery from Covid-19 was relatively short. The incidence density of recovery was 8.24 per 100 person-days. The hazard of recovery was lower for patients at higher levels of Covid-19 severity and for patients in need of mechanical ventilation. Early identification of severity levels of the patients is required at the time of admission. Special attention, critical follow–up and management is warranted for patients at higher levels of Covid-19 severity.

Predicting Mortality and Use of RISC Scoring System in Hospitalized Under-Five Children Due to WHO Defined Severe Community Acquired Pneumonia

BACKGROUND

Pneumonia acquired in the community is a leading cause of hospitalization and death in under-five children. Predicting mortality in children remains a challenge. There is a need of consolidated scoring system to predict mortality in under-five children in developing nations.

METHODS

This is a hospital-based prospective nested case-control study, conducted in a tertiary care teaching hospital of north India. Included were under-five hospitalized children due to WHO defined severe community acquired pneumonia (CAP). Those who did not survive were categorized as cases, while those who were discharged were categorized as controls.

RESULTS

The mortality rate among the recruited 180 hospitalized children with severe CAP was 9.4%. The mortality in under-five children was higher among infants, children who resided in rural areas and were unimmunized or partially immunized for the present age. Mortality was also statistically significantly higher among under-five children with weight for age and weight for length/height below -2Z score; SpO2 < 90% at room air at admission, cyanosis, convulsion, high C-reactive protein (CRP), blood culture positive sepsis and end point consolidation. These predictors were found to be independent risk factors for the mortality after analyzing in multivariate model while presence of wheeze and exclusive breast feeding for first six months of life were found to be protective. The receiver operating characteristic (ROC) curve for respiratory index of severity in children (RISC) score has area under curve (AUC) 0.91 while AUC of RISC score with King George's Medical University (KGMU) modification has 0.88 for prediction of mortality. At the cut-off level of 3, the sensitivity of the RISC score in predicting mortality was 94.1% while the specificity was 73.6%. However, the sensitivity of the RISC score with KGMU modification in predicting mortality at cut-off level of 3 was 88.4% with a specificity of 74.8%.

CONCLUSION

Various predictors for mortality under-five children are young age, malnutrition, cyanosis, high CRP, blood culture positive sepsis and end point consolidation. It is also possible to predict mortality using RISC score which comprises simple variables and can be easily used at centers of periphery. Similar accuracy had been also found through the use of an age independent modified score (RISC score with KGMU modification).Lay summaryPneumonia is a primary cause of hospitalization as well as death among the children under the age of five. A variety of severity or mortality predicting scores have been produced for adults, but such scores for children are scarce. Furthermore, their utility in developing nations has not been proven. This is a hospital-based prospective study. Included were children under five (2 to 59 months) hospitalized due to severe community acquired pneumonia (CAP) defined as per World Health Organization (WHO) and were not hospitalized in last 14 days elsewhere. Those who did not survive were classified as cases while those who were discharged were classified as controls. A total of 200 consecutively hospitalized children with severe CAP based on WHO were screened and 180 children were recruited. Among recruited children, the percentage of mortality was 9.4% while 90.6% were discharged. The mortality was higher among children younger than 12 months, those belonged to rural area and were unimmunized or partially immunized for the present age. Mortality was also higher among under-five children with severe malnutrition, anemia, SpO2 < 90% at room air at admission, cyanosis, convulsion, thrombocytopenia, high CRP, blood culture positive sepsis and end point consolidation. After assessing in a multivariate model, these predictors were determined to be independent risk factor for death, while wheezing and exclusive breast feeding throughout the first six months of life were found to be protective. The receiver operating characteristic (ROC) curve for respiratory index of severity in children (RISC) score has an area under curve (AUC) of 0.91 while AUC of RISC score with King George's Medical University (KGMU) modification was 0.88 for the prediction of death in under-five children hospitalized due to severe CAP.

Barriers to seeking timely treatment for severe childhood pneumonia in rural Bangladesh

OBJECTIVE

Delays in seeking medical attention for childhood pneumonia may lead to increased morbidity and mortality. This study aimed at identifying the drivers of delayed seeking of treatment for severe childhood pneumonia in rural Bangladesh.

METHODS

We conducted a formative study from June to September 2015 in one northern district of Bangladesh. In-depth interviews were conducted with 20 rural mothers of children under 5 years with moderate or severe pneumonia. We analysed the data thematically.

RESULTS

We found that mothers often failed to assess severity of pneumonia accurately due to lack of knowledge or misperception about symptoms of pneumonia. Several factors delayed timely steps that could lead to initiation of appropriate treatment. They included time lost in consultation with non-formal practitioners, social norms that required mothers to seek permission from male household heads (eg, husbands) before they could seek healthcare for their children, avoiding community-based public health centres due to their irregular schedules, lack of medical supplies, shortage of hospital beds and long distance of secondary or tertiary hospitals from households. Financial hardships and inability to identify a substitute caregiver for other children at home while the mother accompanied the sick child in hospital were other factors.

CONCLUSIONS

This study identified key social, economic and infrastructural factors that lead to delayed treatment for childhood pneumonia in the study district in rural Bangladesh. Interventions that inform mothers and empower women in the decision to seek healthcare, as well as improvement of infrastructure at the facility level could lead to improved behaviour in seeking and getting treatment of childhood pneumonia in rural Bangladesh.

Study to evaluate the socio-demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years

Aim: To evaluate the socio demographic and environmental factors affecting morbidity and mortality of community acquired pneumonia in children <5years. Materials and methods: The present Observational longitudinal study was carried in the Department of Paediatrics, Dr. D.Y. Patil Medical College, Pune, among 70 children less than 5 years of age admitted in the In-patient department , Neonatal Intensive Care Unit and Paediatric Intensive Care Unit diagnosed as community acquired pneumonia of either sex in the hospital. The study was carried out from may 2019-september 2021. The children who fulfilled the WHO criteria of Community Acquired Pneumonia were in addition to the Chest x-ray and investigations findings suggestive of CAP were enrolled. The details of the patient's personal and demographic profile, clinical presentation, underlying condition, laboratory investigations, therapy and course in the hospital, and the final outcome were all recorded on a pre-designed proforma. Results: Mean age of children presenting with pneumonia (31.92 months) was approximately similar with those presenting with severe pneumonia (30.37 months).

Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis

Background

Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries.

Methods

We conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO₂ <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia.

Findings

We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ² (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I² value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207.

Interpretation

The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy.

Funding

UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).

Do children with severe acute respiratory infection need cohorting & isolation before screening for COVID-19?

This retrospective analysis was done to ascertain the SARS-CoV-2-positivity rate in children (0-12 yr) with severe acute respiratory infection (SARI) and compare it to those without SARI to determine the need for running a dedicated SARI isolation facility for paediatric COVID-19 care. The case records of 8780 children (0-12 yr) admitted and/or tested for SARS-CoV-2 between June 2020 and May 2021 at a tertiary care centre in north India were analyzed. The overall SARS-CoV-2 reverse transcription (RT)-PCR positivity rate was 3.0 per cent (262/8780). There were 1155 (13.15%) children with SARI. Fifty of these 1155 (4.3%) children with SARI, as against 212 of the 7625 (2.8%) children without SARI, tested positive for COVID-19. The absolute difference in the positivity rate among SARI and non-SARI groups was only 1.54 per cent which translates to cohorting and isolating 65 children with SARI to pick up one extra SARS-CoV-2-positive child (compared to those without SARI). The positive predictive value of SARI as a screening test was 4.3 per cent. Our findings suggest that isolation of children with SARI as a transmission-prevention strategy for COVID-19 may not be required. This is particularly relevant in resource-limited settings.

Prevalence, Predictive Factors, and Outcomes of Respiratory Failure in Children With Pneumonia Admitted in a Developing Country

BACKGROUND

Pneumonia has been the leading infectious cause of morbidity and mortality in children under 5 years of age for the last several decades. Although most of these deaths occur due to respiratory failure, published data are limited regarding predicting factors and outcomes of respiratory failure in children hospitalized with pneumonia or severe pneumonia.

OBJECTIVE

This study aimed to explore the prevalence, predicting factors, and outcomes of respiratory failure in children under-five with pneumonia or severe pneumonia.

METHODS

In this retrospective chart analysis, we enrolled children under 5 years of age hospitalized with pneumonia or severe pneumonia in the Dhaka Hospital of International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) between August 2013 and December 2017. Comparisons were made between children with respiratory failure (n = 212) and those without respiratory failure (n = 4,412). Respiratory failure was defined when the oxygen saturation/fraction of inspired oxygen (SpO₂/FiO₂) was <315.

RESULTS

A total of 4,625 children with pneumonia or severe pneumonia were admitted during this study period. Among them, 212 (4.6%) children developed respiratory failure and formed the case group. A total of 4,412 (95.3%) children did not develop respiratory failure and formed the comparison group. In logistic regression analysis, after adjusting with potential confounders, severe sepsis [adjusted odds ratio (aOR): 12.68, 95% CI: 8.74-18.40], convulsion (aOR: 4.52, 95% CI: 3.06-6.68), anemia (aOR: 1.76, 95% CI: 1.20-2.57), and severe underweight (aOR: 1.97, 95% CI: 1.34-2.89) were found to be independently associated with respiratory failure. As expected, children with respiratory failure more often had fatal outcome than without respiratory failure (74, 1%, p < 0.001).

CONCLUSION

The results of our analyses revealed that prevalence of respiratory failure was 4.6% among under-five children hospitalized for pneumonia or severe pneumonia. Severe sepsis, convulsion, anemia, and severe underweight were the independent predictors for respiratory failure in such children and their case-fatality rate was significantly higher than those without respiratory failure. Early recognition of these predicting factors of respiratory failure may help clinicians imitating prompt treatment that may further help to reduce deaths in such children, especially in resource-limited settings.

Amoxicillin duration and dose for community-acquired pneumonia in children: the CAP-IT factorial non-inferiority RCT

BACKGROUND

Data are limited regarding the optimal dose and duration of amoxicillin treatment for community-acquired pneumonia in children.

OBJECTIVES

To determine the efficacy, safety and impact on antimicrobial resistance of shorter (3-day) and longer (7-day) treatment with amoxicillin at both a lower and a higher dose at hospital discharge in children with uncomplicated community-acquired pneumonia.

DESIGN

A multicentre randomised double-blind 2 × 2 factorial non-inferiority trial in secondary care in the UK and Ireland.

SETTING

Paediatric emergency departments, paediatric assessment/observation units and inpatient wards.

PARTICIPANTS

Children aged > 6 months, weighing 6-24 kg, with a clinical diagnosis of community-acquired pneumonia, in whom treatment with amoxicillin as the sole antibiotic was planned on discharge.

INTERVENTIONS

Oral amoxicillin syrup at a dose of 35-50 mg/kg/day compared with a dose of 70-90 mg/kg/day, and 3 compared with 7 days' duration. Children were randomised simultaneously to each of the two factorial arms in a 1 : 1 ratio.

MAIN OUTCOME MEASURES

The primary outcome was clinically indicated systemic antibacterial treatment prescribed for respiratory tract infection (including community-acquired pneumonia), other than trial medication, up to 28 days after randomisation. Secondary outcomes included severity and duration of parent/guardian-reported community-acquired pneumonia symptoms, drug-related adverse events (including thrush, skin rashes and diarrhoea), antimicrobial resistance and adherence to trial medication.

RESULTS

A total of 824 children were recruited from 29 hospitals. Ten participants received no trial medication and were excluded. Participants [median age 2.5 (interquartile range 1.6-2.7) years; 52% male] were randomised to either 3 (n = 413) or 7 days (n = 401) of trial medication at either lower (n = 410) or higher (n = 404) doses. There were 51 (12.5%) and 49 (12.5%) primary end points in the 3- and 7-day arms, respectively (difference 0.1%, 90% confidence interval -3.8% to 3.9%) and 51 (12.6%) and 49 (12.4%) primary end points in the low- and high-dose arms, respectively (difference 0.2%, 90% confidence interval -3.7% to 4.0%), both demonstrating non-inferiority. Resolution of cough was faster in the 7-day arm than in the 3-day arm for cough (10 days vs. 12 days) (p = 0.040), with no difference in time to resolution of other symptoms. The type and frequency of adverse events and rate of colonisation by penicillin-non-susceptible pneumococci were comparable between arms.

LIMITATIONS

End-of-treatment swabs were not taken, and 28-day swabs were collected in only 53% of children. We focused on phenotypic penicillin resistance testing in pneumococci in the nasopharynx, which does not describe the global impact on the microflora. Although 21% of children did not attend the final 28-day visit, we obtained data from general practitioners for the primary end point on all but 3% of children.

CONCLUSIONS

Antibiotic retreatment, adverse events and nasopharyngeal colonisation by penicillin-non-susceptible pneumococci were similar with the higher and lower amoxicillin doses and the 3- and 7-day treatments. Time to resolution of cough and sleep disturbance was slightly longer in children taking 3 days' amoxicillin, but time to resolution of all other symptoms was similar in both arms.

FUTURE WORK

Antimicrobial resistance genotypic studies are ongoing, including whole-genome sequencing and shotgun metagenomics, to fully characterise the effect of amoxicillin dose and duration on antimicrobial resistance. The analysis of a randomised substudy comparing parental electronic and paper diary entry is also ongoing.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76888927, EudraCT 2016-000809-36 and CTA 00316/0246/001-0006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 60. See the NIHR Journals Library website for further project information.

Risk factors for childhood pneumonia: a case-control study in a high prevalence area in Indonesia

BACKGROUND

Acute respiratory infections (ARIs), especially pneumonia, remain a major cause of infant mortality worldwide. In Indonesia, pneumonia is the second most common cause of infant and toddler deaths. Exclusive breastfeeding and basic immunization can protect infants and children from contracting pneumonia.

PURPOSE

Our goal was to assess the risk factors for childhood pneumonia in regions with a high prevalence of pneumonia in Indonesia.

METHODS

This case-control study was conducted between March and April 2019. A total of 176 infants and toddlers aged 10-59 months were enrolled and selected from among patients who visited the community health center. Cases of pneumonia were diagnosed clinically based on the World Health Organization guidelines, and the control was nonpneumonia.

RESULTS

The risk factors for the diagnosis of pneumonia included no or nonexclusive breastfeeding (odds ratio [OR], 7.95; 95% confidence interval [CI], 3.52-17.94), incomplete basic immunizations (OR, 4.47; 95% CI, 2.22-8.99), indoor air pollution (OR, 7.12; 95% CI, 3.03-16.70), low birth weight (OR, 3.27; 95% CI, 1.19-8.92), and a high degree of wasting (OR, 2.77; 95% CI, 1.06-7.17). Other variables such as nutritional status (height-for-age z score), age, sex, and educational status of the mother were not risk factors for pneumonia.

CONCLUSION

No or nonexclusive breastfeeding, incomplete basic immunizations, indoor air pollution, a history of low birth weight, and severe malnutrition were risk factors for childhood pneumonia. Breastfeeding was the dominant factor, while sex modified the relationship between exclusive breastfeeding and the incidence of pneumonia.

Sentinel surveillance for bacterial pneumonia and meningitis in children under the age of 5 in a tertiary pediatric hospital in Colombia - 2016

Introduction:

Bacterial pneumonia and meningitis are vaccine-preventable diseases. Sentinel surveillance provides relevant information about their behavior.

Objective:

To present the data from sentinel surveillance carried out at the Fundación HOMI, Fundación Hospital Pediátrico La Misericordia in 2016.

Materials and methods:

We conducted a descriptive study from January 1 to December 31, 2016, on the daily surveillance of patients under 5 years of age diagnosed with pneumonia or bacterial meningitis according to PAHO's definitions. We identified the microorganisms using the automated VITEK^TM 2 system. Bacterial isolates were sent to the Microbiology Group at the Colombian Instituto Nacional de Salud for confirmation, serotyping, phenotypic, and genotypic characterization. Antimicrobial susceptibility profiles were established.

Results:

From 1,343 suspected cases of bacterial pneumonia, 654 (48.7%) were probable, 84% had complete Hib vaccination schedules, and 87% had complete pneumococcal vaccination schedules for age. Blood culture was taken in 619 (94.6%) and 41 (6.6%) were positive while S. pneumoniae was isolated in 17 (41%) of them. The most frequent serotype was 19A in five cases (29.4%), and four 19A serotypes were associated with the reference isolate ST320. The incidence rate of probable bacterial pneumonia was 7.3 cases/100 hospitalized patients, and lethality was 2.1%. As for bacterial meningitis, 22 suspected cases were reported, 12 (54%) were probable, four (33%) were confirmed: two by Escherichia coli and two by group C N. meningitidis. The incidence of probable bacterial meningitis was 0.14 cases/100 hospitalized patients.

Conclusion:

Streptococcus pneumoniae serotypes 19A and 3 were the most frequent cause of pneumonia. Spn19A is related to the multi-resistant clone ST320. Strengthening and continuing this strategy will allow understanding the impact of vaccination.

Time to Recovery from Severe Pneumonia and Its Predictors Among Children 2-59 Months of Age Admitted to Pediatric Ward of Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital, Hossana, Ethiopia: Retrospective Cohort Study

Background

Severe pneumonia is still the greatest infectious cause of morbidity and mortality in children under the age of five around the world. Each night spent in the hospital raises the chance of bad drug responses, infections, and ulcers by 0.5%, 1.6%, and 0.5%, respectively. In Southern Ethiopia, as well as the research area, little is known regarding death and recovery time from severe pneumonia and their determinants.

Objective

To determine time to recovery from severe pneumonia and its predictors among children 2–59 months of age admitted to pediatric ward of Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital.

Methods

A facility-based retrospective cohort study was conducted among children 2–59 months of age. Three years’ medical records, from January 2017 to December 2020, were reviewed. A total of 280 children with severe pneumonia were included. In the case of survival time, median was calculated. Kaplan Meier survival curve was used to estimate recovery time from severe pneumonia, and the independent effects of covariates on recovery time were analyzed using multivariable Cox-proportional hazard model.

Results

The median time to recovery was 4 days (interquartile range = 3, 5). The incidence rate of recovery was 24.16 per 100 person-days. Underweight (adjusted hazard ratio = 0.56, 95% CI = 0.38–0.80), age group 12–35 months (adjusted hazard ratio= 2.0, 95% CI=1.30–3.30), treatment with ampicillin and gentamicin (adjusted hazard ratio= 0.35, 95% CI: 0.13–0.80), and antibiotic change (adjusted hazard ratio= 0.34, 95% CI = 0.21–0.53) were statistically significant predictors of time to recovery from severe pneumonia.

Conclusion

The median length of stay in the hospital was short (4 days [interquartile range =3, 5]). Time to recover from severe pneumonia was significantly influenced by being underweight, age, antibiotics administered first, and antibiotic change. Measures such as providing nutritious meals to children and ensuring that underweight children are properly managed should be bolstered.

Vitamin D deficiency and severity of pneumonia in Indonesian children

Objective

To determine the prevalence of vitamin D deficiency in Indonesian children hospitalized with pneumonia and evaluate the association between vitamin D status and severity of pneumonia.

Methods

A hospital-based cross-sectional study was conducted from February 2016 to July 2017 in two district hospitals in Yogyakarta province, Indonesia. Infants and young children aged 2–59 months hospitalized with pneumonia were recruited. Serum blood samples were collected on admission and analyzed for total serum 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 concentrations using liquid chromatography-tandem mass spectrometry. Vitamin D deficiency was defined as a level of serum vitamin D <50 nmol/L. The association between vitamin D deficiency and severity of hospitalized pneumonia according to WHO criteria, including the presence of danger signs, hypoxemia (SpO2 in air below 90%), duration of hospitalization, and admission to Intensive Care Unit (ICU), was analyzed using logistic regression.

Results

133 children with WHO-defined pneumonia were enrolled in the study and 127 (96%) had their vitamin D status determined. The mean vitamin D concentration was 67 (± 24 SD) nmol/L and 19% of participants were vitamin D deficient. Age younger than 6 months was associated with prolonged hospitalization (> 5 days) and low birth weight and poor nutritional status on admission were risk factors for hypoxemia. However, vitamin D status was not associated with the presence of danger signs, duration of hospitalization, or hypoxemia.

Conclusions

One in every five children hospitalized with pneumonia was vitamin D deficient. Vitamin D status was not associated with the severity of pneumonia.

Predictors of Treatment Outcomes among Pediatric Patients Hospitalized with Pneumonia in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background

Pneumonia remains the leading cause of hospitalization and mortality in young children in low- and middle-income countries. This study is aimed to assess predictors of treatment outcomes among pediatric patients hospitalized with pneumonia in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A facility-based retrospective cross-sectional study was conducted among pediatric patients admitted with pneumonia, considering patient medical charts recorded for a 1-year period from February 2017 to February 2018. The sample size was computed based on a single population proportion formula and giving a total sample size of 207. The systematic random sampling method was employed to select patient cards from the sampling frame. The data extraction format was used to extract any relevant information from patient chart. The processed data were analyzed by using Statistical Package for Social Sciences (SPSS, version 21). Descriptive statistics were used to summarize the patients' baseline characteristics and related information. The logistic regression model was fitted to determine factors associated with treatment outcomes. To identify predictors of poor treatment outcome, the level of significance was set at P < 0.05.

Results

From a total of 207 patient charts reviewed, more than half (55.6%) of the study participants were males. Majority of patients, 130 (62.8%), were in the age range of 1 month–11 months. Furthermore, 191 (92.3%) patients had good treatment outcome. Patients who treated with ceftriaxone + azithromycin were less likely to have poor treatment outcome compared with patients who were placed on crystalline penicillin (AOR = 0.86, 95% CI 0.01–0.83). On the contrary, patients who stayed ≥ 8 days were about 14.3 times more likely to have poor treatment outcome compared with patients who stayed ≤ 3 days (AOR = 14.3, 95% CI 1.35–151.1).

Conclusion

Even though the study revealed good treatment outcome among the pediatric patients, particular consideration should be given to children in need of other interventions.

Vitamin D supplementation and improvement of pneumonic children at a tertiary pediatric hospital in Egypt: A randomized controlled trial

BACKGROUND

Despite the well-recognized effect of vitamin D in metabolism and homeostasis, there is now growing interest in its probable association with pneumonia. This study aims to supply vitamin D3 (Cholecalciferol) (100,000 IU) to pneumonic children to minimize the duration of illness and improve their outcome.

METHODS

A double-blinded, randomized, placebo-controlled trial was conducted in a Pediatric Cairo University affiliated hospital. An intervention arm (93 children) and a control arm (98 children), who had pneumonia with an insufficient or deficient level of vitamin D and whose parental permission was obtained, were enrolled in the trial. All children were treated with antibiotics according to WHO guidelines. Children were given a single injection of 1 mL of 100,000 IU of vitamin D3 or placebo. Clinical data were recorded every eight hours for all children. Outcomes were assessed 7 days after vitamin D injection.The primary outcome variable was the change in serum level of 25(OH)D, while the secondary outcomes were the medical state of the assigned cases (improvement or death) and duration between enrollment and hospital discharge for improved cases.

RESULTS

In the supplementation group, the percentage of patients who suffered either deficient (38.7%) or insufficient levels (61.3%) of 25 (OH)D at day one had significantly decreased in the seventh day to (11.8%) and (52.7%), respectively. Kaplan--Meier plots highlighted that the median time to recover of the placebo group was significantly longer than that of the supplementation group (Log Rank P value < .001).

CONCLUSION

VDD was detected in pediatric critical care children. In pneumonic children with high VDD, it is illustrated that Vitamin D supplementation is accompanied by lowered mortality risk and pSOFA scores, reduced time to recover, and improved PaO2/FiO2.

TRIAL REGISTRATION

Trial Identifier number: NCT04244474. Registered on 27 January 2020- Retrospectively registered at ClinicalTrials.gov https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JXO&selectaction=Edit&uid=U0004UO8&ts=152&cx=9cceq6.

Viral causes of severe acute respiratory infection in hospitalized children and association with outcomes: A two-year prospective surveillance study in Suriname

BACKGROUND

Viruses are the most frequent cause of severe acute respiratory infection (SARI) in children. It is currently unknown whether presence of a virus, the number of viruses, or type of virus, are associated with clinical outcomes of pediatric SARI in developing countries.

METHODS

Between 2012 and 2014 nasopharyngeal swabs and demographic and clinical variables were prospectively collected for surveillance of viral causes of SARI in Surinamese children within 48 hours after hospitalization. These swabs were tested for 18 respiratory viruses using a multiplex polymerase chain reaction (PCR) panel to identify the specific viral causes of SARI, unknown to the treating physicians. In post hoc analyses we evaluated if the PCR results, and demographic and clinical characteristics, were associated with course of disease, duration of respiratory support, and length of stay (LOS).

RESULTS

Of a total of 316 analyzed children, 290 (92%) had one or more viruses. Rhinovirus/enterovirus (43%) and respiratory syncytial virus (34%) were most prevalent. Course of disease was mild in 234 (74%), moderate in 68 (22%), and severe in 14 (4%) children. Neither presence of a single virus, multiple viruses, or the type of virus, were different between groups. Prematurity and lower weight-for-age-z-score were independent predictors of a severe course of disease, longer duration of respiratory support, and longer LOS.

CONCLUSIONS

Viruses are common causes of pediatric SARI in Suriname, yet not necessarily associated with clinical outcomes. In developing countries, demographic and clinical variables can help to identify children at-risk for worse outcome, while PCR testing may be reserved to identify specific viruses, such as influenza, in specific patient groups or during outbreaks.

Clinical profile of acute lower respiratory tract infections in children aged 2-60 months: An observational study

Background:

Assessment of risk factors and clinical profile for acute lower respiratory tract infections (ALRIs) with severe and very severe pneumonia in children <5 years age is obligatory.

Objective:

To study the clinical profile, risk factors, and clinical outcomes associated with ALRIs in children aged 2–60 months.

Methodology:

In total, 130 children of either gender, diagnosed with ALRIs, admitted in a tertiary care hospital were enrolled. Demographic data and clinical history was collected. Clinical profile data such as respiratory and heart rate, oxygen supplementation, ventilator use, and lab investigation such as erythrocyte sedimentation rate, hemoglobin, total leucocyte count, differential leucocytes count, and blood culture were analyzed and noted.

Results:

The study findings demonstrated male gender predominance for ALRIs with 1.3:1 male to female ratio. Around 16% of them had pneumonia, 61% had severe pneumonia, and 23% had very severe pneumonia. The birth weight of child, maternal and paternal literacy, socioeconomic status, overcrowding at home, immunization status of children, type of kitchen and fuel used for cooking, malnutrition, anemia, and need for oxygen supplementation were found to be associated with the occurrence of ALRIs (P < 0.05). Most of the presented symptoms were cough (100%), breathlessness (96.92%), and fever (92.31%). Bronchiolitis (63%), bronchopneumonia (27%), and lobar pneumonia (25%) were the major clinical outcomes.

Conclusion:

The study identified various sociodemographic, environmental, and nutritional risk factors for ALRIs along with the clinical profile, which can be managed by effective peripheral health personnel's training and persuasive community health education.

Predictors and outcome of first line treatment failure among under-five children with community acquired severe pneumonia at Bugando Medical Centre, Mwanza, Tanzania: A prospective cohort study

Background

Despite recent advances in management and preventive strategies, high rates of first line antibiotics treatment failure and case fatality for Severe Community Acquired Pneumonia (SCAP) continue to occur in children in low and middle-income countries. This study aimed to identify the predictors and outcome of first line antibiotics treatment failure among children under-five years of age with SCAP admitted at Bugando Medical Centre (BMC) in Mwanza, Tanzania.

Methods

The study involved under-five children admitted with SCAP, treated with first line antibiotics as recommended by WHO. Patients with treatment failure at 48 hours were shifted to second line of antibiotics treatment and followed up for 7 days. Generalized linear model was used to determine predictors of first line antibiotics treatment failure for SCAP.

Results

A total of 250 children with SCAP with a median age of 18 [IQR 9–36] months were enrolled, 8.4% had HIV infection and 28% had acute malnutrition. The percentage of first line antibiotics treatment failure for the children with SCAP was 50.4%. Predictors of first line treatment failure were; presentation with convulsion (RR 1.55; 95% CI [1.11–2.16]; p-value 0.009), central cyanosis (RR 1.55; 95% CI [1.16–2.07]; p-value 0.003), low oxygen saturation (RR 1.28; 95% CI [1.01–1.62]; p-value 0.04), abnormal chest X-ray (RR 1.71; 95% CI [1.28–2.29]; p-value <0.001), HIV infection (RR 1.80; 95% CI [1.42–2.27]; p-value 0.001), moderate acute malnutrition (RR 1.48; 95% CI [1.04–2.12]; p-value = 0.030) and severe acute malnutrition (RR 2.02; 95% CI [1.56–2.61]; p-value<0.001). Mortality in children who failed first line treatment was 4.8%.

Conclusion

Half of the children with SCAP at this tertiary center had first line antibiotics treatment failure. HIV infection, acute malnutrition, low oxygen saturation, convulsions, central cyanosis, and abnormal chest X-ray were independently predictive of first line treatment failure. We recommend consideration of second line treatment and clinical trials for patients with SCAP to reduce associated morbidity and mortality.

Characterization of children younger than 5 Years of age with severe community-acquired alveolar pneumonia (CAAP) requiring Pediatric Intensive Care Unit (PICU) admission

BACKGROUND

The purpose of this study was to determine factors characterizing children admitted to the Pediatric Intensive Care Unit (PICU) with community-acquired alveolar pneumonia (CAAP) to help clinicians assess disease severity upon initial assessment in the emergency department.

METHODS

We prospectively collected demographic, clinical, and laboratory data of children <5 years with radiologically confirmed CAAP referred to the Soroka University Medical Center during 2001-2011. Three groups of children were compared: 1) those hospitalized in the PICU (PICU-CAAP); 2) those treated in the emergency department and discharged (ED-CAAP); and 3) those hospitalized in a pediatric ward (Hosp-CAAP).

RESULTS

Of 9722 CAAP episodes, 367 (3.8%) were PICU-CAAP, 5552 (57.1%) Hosp-CAAP and 3803 (39.1%) ED-CAAP. In a univariate analysis, respiratory syncytial virus (RSV) was detected more commonly among PICU-CAAP than in Hosp-CAAP (P = 0.02) and ED-CAAP patients (P < 0.001). In a multivariate analysis, several factors were associated with PICU hospitalization versus ED-CAAP and Hosp-CAAP: Younger age (ORs: 1.04, [95%CI: 1.02-1.05] and 0.97 [0.96-0.98], respectively); prematurity (ORs: 2.16 [1.28-3.64] and 1.61 [1.15-2.26], respectively), lower O₂ saturation (ORs: 1.32 [1.25-1.41] and 0.94[0.92-0.96]), higher respiratory rate (ORs: 1.06 [1.04-1.07] and 1.00 [1-1.01], respectively).

CONCLUSION

Children admitted to PICU were younger, had more respiratory syncytial virus (RSV) detection, were premature, had lower O₂ saturation, and had a higher respiratory rate than those admitted to the general ward or those visiting the emergency department and subsequently discharged.

Influenza epidemiology and risk factors for severe acute respiratory infection in Morocco during the 2016/2017 and 2017/2018 seasons

Introduction

in order to implement an influenza vaccination program for high-risk-groups in Morocco, as recommended by the World Health Organization, an epidemiological study indicating the influenza virus effect in the development of complicated influenza for subjects with co-morbidity was required. The present study aims to evaluate the risk factors for severe acute respiratory infections caused by influenza in risk groups.

Methods

this research is based on the epidemiological and virological surveillance data of severe acute respiratory infections and influenza-like illness during the 2016/2017 and 2017/2018 seasons. It was realized using a retrospective series study with a descriptive and analytical purpose.

Results

the over-recruitment of pediatric cases with a severe acute respiratory infection has been significantly rectified because cases of severe acute respiratory infections under 15 years old in the 2017/2018 season represent only 57.9%, whereas they represented 75.9% of the total cases of severe acute respiratory infections during the 2016/2017 season. The influenza positivity rate has increased globally and specifically by age group, clinical service and co-morbidity. The risk factors considered were significantly associated with hospitalization for influenza-associated severe acute respiratory infections. The multivariate logistic regression analysis considers male sex (OR=2.1), age ≥65 years (OR=5.4), presence of influenza cases in the surroundings (OR=0.1), diabetes (OR=7.5) and chronic respiratory disease (OR=10.9) as risk factors influenza-associated severe acute respiratory infections.

Conclusion

the risk assessment of influenza-associated severe acute respiratory infections in high-risk groups revealed national epidemiological findings, particularly for diabetics and the elderly. An influenza vaccination program for these high-risk-groups becomes much recommended in Morocco.

Incidence and Risk Factors for Severe Pneumonia in Children Hospitalized with Pneumonia in Ujjain, India

Childhood pneumonia is a major public health problem. The aim of this prospective hospital-based study is to determine the incidence and risk factors for community-acquired severe pneumonia in children in Ujjain, India. The study includes 270 children, 161 (60%) boys and 109 (40%) girls, aged between 2 months and 5 years with World Health Organization defined and radiologically confirmed severe pneumonia. Considering the 270 children, 64% (95% confidence interval (CI) 57.9–69.4) have severe pneumonia. The following are identified as risk factors for severe pneumonia from the generalized logistic regression model: Born premature (adjusted odds ratio (AOR) 7.50; 95% CI 2.22–25.31; p = 0.001); history of measles (AOR 6.35; 95% CI 1.73–23.30; p = 0.005); incomplete vaccination (AOR 2.66; 95% CI 1.09–6.48; p = 0.031); acyanotic congenital heart disease (AOR 9.21; 95% CI 2.29–36.99; p = 0.002); home treatment tried (AOR 3.84; 95% CI 1.42–10.39; p = 0.008); living in a kuchha house (AOR 3.89; 95% CI 1.51–10.01; p = 0.027); overcrowding (AOR 4.50; 95% CI 1.75–11.51; p = 0.002);poor ventilation in living area (AOR 16.37; 95% CI 4.67–57.38; p < 0.001); and practicing open defecation (AOR 16.92; 95% CI 4.95–57.85; p < 0.001). Awareness of these risk factors can reduce mortality due to severe pneumonia.

Evaluating the Usefulness of Lab-Based Test for the Diagnosis of Pneumonia in Children

Objective

The aim of this study is to determine the distribution of the results of routine laboratory tests for the diagnosis of pneumonia in children in Khorramabad.

Methods

This is a cross-sectional study and was performed on 650 children with pneumonia who were referred to Shahid Madani Hospital. From patients' test results, the following data were recorded: whether the results were normal or not, age, sex, serotype, history of diabetes mellitus, and the presence of urinary and digestive tract symptoms.

Results

There was no difference in the prevalence of pneumonia, gender-wise, whereas 40% of the patients were under 2 years. In addition, 53.7% of the patients were presented with leukocytosis. From the blood test, blood urea nitrogen, creatinine, sodium, and potassium were normal in most of the patients. Stool examination, urine analysis, urine culture, erythrocyte sedimentation rate, C-reactive protein, and blood sugar were also normal in these patients.

Conclusion

Children under the age of 2 years are more susceptible to lung infections. Findings from blood tests such as leukocytosis are useful for making initial diagnosis other than computed tomography scan. Other lab tests might not give any useful results. In addition, a closer examination of the urinary system and digestive tract involvement is recommended, prior to urine or stool analysis.

Continuous positive airway pressure in children with severe pneumonia and hypoxaemia in Papua New Guinea: an evaluation of implementation

Aim

To prospectively evaluate the use of bubble continuous positive airway pressure (CPAP) in children with very severe pneumonia and other acute lower respiratory infections, during its trial introduction in a low resource hospital in Papua New Guinea.

Methods

Prospective observational study of children treated with CPAP who had severe pneumonia and severe respiratory distress with hypoxaemia (SpO₂ <90%). CPAP was driven by oxygen concentrators in which the fraction of inspired oxygen could be adjusted, and using low‐resistance tubing and nasal oxygen prongs.

Results

A total of 64 children were commenced on CPAP: 29 (45.3%) survived and were discharged well, 35 (54.7%) died. Prior to commencing CPAP, the median SpO2 was 78% (IQR 53.3–86.8%), at one hour SpO₂ was 92% (IQR 80–97.75%, n = 64), and at 84 hours (3½ days) 98% (IQR 93–98%, n = 29), in survivors at each of these time points. A higher SpO₂ at one hour after commencement of CPAP predicted survival (p = 0.013), and human immunodeficiency virus infection was an independent predictors of death (p = 0.017). Technical and clinical problems encountered are described.

Conclusion

Bubble CPAP improved oxygenation and reduced the severity of respiratory distress in some children with severe pneumonia; however, mortality was high reflecting high severity of illness and comorbidities. CPAP requires a quality system to be safe and effective.

The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children

Background

Although breastfeeding is touted as providing many health benefits to infants, some aspects of this relationship remain poorly understood.

Methods

The Environmental Determinants of Diabetes in the Young (TEDDY) is a prospective longitudinal study that follows children from birth through childhood, and collects data on illness events, breastfeeding duration, and time to introduction of formula or foods at 3 month intervals up until 4 years of age and at 6 months intervals thereafter. Exclusive and non-exclusive breastfeeding is examined in relation to the 3-month odds of a respiratory or gastrointestinal infection for 6861 children between the ages of 3–18 months, and 5666 children up to the age of 4 years. Analysis was performed using logistic regression models with generalized estimating equation methodology. All models were adjusted for potential confounding variables.

Results

At 3–6 months of age, breastfeeding was found to be inversely associated with the odds of respiratory infections with fever (OR = 0.82, 95% CI = 0.70–0.95), otitis media (OR = 0.76, 95% CI = 0.62–0.94), and infective gastroenteritis (OR = 0.55, 95% CI = 0.46–0.70), although the inverse association with respiratory illnesses was observed only for girls during the winter months. Between 6 and 18 months of age, breastfeeding within any 3 month period continued to be inversely associated with the odds of ear infection and infective gastroenteritis, and additionally with the odds of conjunctivitis, and laryngitis and tracheitis, over the same 3 month period within this age range. However, breastfeeding in this group was associated with increased reports of common cold. Duration of exclusive breastfeeding was inversely associated with the odds of otitis media up to 48 months of age (OR = 0.97, 95% CI = 0.95–0.99) after breastfeeding had stopped.

Conclusions

This study demonstrates that breastfeeding can be protective against multiple respiratory and gastrointestinal acute illnesses in some children up to at least 6 months of age, with duration of exclusive breastfeeding being somewhat protective of otitis media even after breastfeeding has stopped.

Trial registration

ClinicalTrials.gov Identifier: NCT00279318.

Date of registration: January 17, 2006 (proactively registered).

First Posted: January 19, 2006.

Burden of respiratory illnesses in pediatric intensive care unit and predictors of mortality: Experience from a low resource country

INTRODUCTION AND OBJECTIVES

Acute respiratory infections (ARI), a major cause of childhood mortality and morbidity, place substantial burden on health services worldwide. Due to scarce data regarding respiratory illnesses requiring Pediatric intensive care unit (PICU) admissions (especially in low income/developing countries), we studied the burden of respiratory illnesses in the PICU and the risk factors contributing to mortality.

METHODS

This prospective observational study was conducted over 18 months. Children (aged 1 month to 12 years) admitted to the PICU for acute respiratory/cardiorespiratory illnesses were enrolled. Demographic and clinical details of the study population were recorded and tabulated. Risk factors contributing to mortality (severity of illness [PRISM III score], diagnosis/etiology, need for mechanical ventilation, immunocompromised status, malnutrition, and length of stay [LOS]) were analyzed (using the χ² test or Fischer Exact test).

RESULTS

Two hundred and ninety-three children were enrolled (median age: 5 months; range, 1-132 months; male/female: 181/112). Mean LOS in PICU was 5.25 ± 5.48 days and mean length of hospital stay of 14.82 ± 13.35 days. Mechanical ventilation was required in 62.8% cases. Pneumonia contributed to 66.89% of respiratory admissions and 91% of mortality. Ninety patients (30.7%) died; mortality being higher in cardiorespiratory cases (52.7%). PRISM III score and shock (respiratory cases) and age below 1 year (cardiorespiratory group) were significantly associated with higher mortality ( P < 0.05).

CONCLUSIONS

Respiratory illnesses are a significant contributor to PICU admissions and are associated with significant mortality risk in presence of high PRISM III score and shock (respiratory group); and age below 1 year (cardiorespiratory group).

Geographically linked risk factors for enrolment into a fast breathing child pneumonia trial in Lilongwe, Malawi: an Innovative Treatments in Pneumonia (ITIP) secondary analysis

Background

Pneumonia is the leading infectious killer of children less than 5 years of age worldwide. In addition to vaccines that help prevent pneumonia, understanding the environmental and socioeconomic risk factors for child pneumonia is critical to further prevention.

Methods

Data from children with fast breathing pneumonia enrolled in a non-inferiority clinical trial assessing the effectiveness of 3-day placebo versus antibiotic treatment in Lilongwe, Malawi were used to examine environmental and socioeconomic characteristics within the study population. Location of residence was collected for enrolled children, and spatial enrolment rates were compared across Lilongwe using a spatial scan statistic.

Results

Data from 1101 children were analysed. Three urban subdistricts (locally known as ‘Areas’) (Areas 24, 36 and 38) out of 51 were identified with higher than expected enrolment. These three areas were associated with higher rates of poverty (37.8% vs 23.9%) as well as informal settlements and poorer sanitation (42.4% vs 7.4%) than other areas. Parents of enrolled children from these areas also had lower rates of secondary education compared with parents of children enrolled from other areas (55% vs 67% (p<0.01) among fathers; 47% vs 54% (p<0.01) among mothers).

Conclusion

In Lilongwe, areas with higher rates of poverty, informal settlements and poor sanitation contributed higher than expected enrolment of children to our fast breathing child pneumonia clinical trial when compared with other areas. Additional research is needed to evaluate the impact of environmental and socioeconomic risk factors, along with vaccination status, on the incidence of fast breathing pneumonia in children living in this region.

Disparities by sex in care-seeking behaviors and treatment outcomes for pneumonia among children admitted to hospitals in Bangladesh

Background

Incidence of community acquired pneumonia is high globally. In Bangladesh, more male children than female children are brought to hospitals for pneumonia. We examined if there was disparities in the severity of illness and outcome by sex among children who were admitted with pneumonia to hospitals in Bangladesh.

Methods

Hospitalized children, aged 2 to 59 months, meeting a case definition of pneumonia were recruited in seven hospitals following parental consent. At baseline, study doctors obtained socio-demographic characteristics and care seeking behaviors for pneumonia, and then clinical data were collected throughout the hospital stay. Multivariate analysis was performed to determine if the sex of the child had a relationship with either illness severity on admission or outcome in the hospital.

Results

Between May 2004 and December 2008, 6,856 children, including 35% females, were recruited. A total of 1,371 (19.9%) children had non-severe pneumonia, 4,118 (60.0%) had severe pneumonia, and 1,367 (19.9%) had very severe pneumonia. A higher proportion of hospitalized females had very severe pneumonia as compared to males (21.5% versus 19.1%; P = 0.01), but there was no difference by sex in the proportion of children with severe or non-severe pneumonia. There was no difference by sex observed in the clinical management provided in the hospital, but a greater proportion of females (4.7%) as compared to males (3.6%) died in hospitals (P = 0.04). In multivariate analyses, female sex was associated with very severe pneumonia on admission (OR: 1.26, 95% CI: 1.09–1.47) and fatal outcome in the hospitals (OR: 1.31, 95% CI: 1.01–1.71). Death in female children admitted with very severe pneumonia was 4 times higher than that reported in males (OR: 4.37, 95% CI: 3.24–5.89).

Conclusion

Our data demonstrates a sex-based disparity in the severity of pneumonia and deaths among children admitted to hospitals in Bangladesh, despite no existing disparity by sex in hospital treatment. These findings call for further investigations to explore the determinants of health seeking behavior by parents with children with pneumonia in a community that favors males to females, and to understand the role of differences by sex in childhood pneumonia outcomes in Bangladesh.

Clinical Features and Outcome of Children with Severe Lower Respiratory Tract Infection Admitted to a Pediatric Intensive Care Unit in South Africa

AIM

Severe acute lower respiratory tract infection (ALRTI) remains an important cause of childhood morbidity and mortality.

METHODS

This is a 12-month retrospective cohort study of children (0-12 years) admitted to a pediatric intensive care unit (PICU) with ALRTI to investigate risk factors, clinical course and in-hospital survival.

RESULTS

In total, 265 patients (median age = 4 months [2-12 months]) were identified. In all,102 (38.5%) had co-morbid disease. Twenty-seven (10.2%) were HIV-infected and 87 (32.8%) were HIV-exposed. In-hospital mortality was 34 (12.8%)-24 (9.1%) in PICU and 10 in the wards. Median duration of intensive care unit was 4.0 days (2.0-8.0) and hospital stay was 12.5 days (7.9-28.0). In total, 192 (72.5%) children required invasive ventilation and 42 (15.8%) required inotropic support. Risk factors for mortality included severe malnutrition (odds ratio [OR] = 8.25; 95% confidence interval [CI] = 1.47-46.21), informal housing (OR = 11.87; CI = 1.89-20.81) or inotropic support (OR = 44.35; CI = 8.20-239.92). HIV exposure or infection was associated with a longer duration of hospital stay (OR = 4.41; CI = 2.44-6.39).

CONCLUSION

Severe ALRTI is associated with a high mortality with several factors impacting on in-hospital survival.

Factors Associated With Pneumonia Severity in Children: A Systematic Review

Community-acquired pneumonia in children is associated with significant morbidity and mortality; however, data are limited in predicting which children will have negative outcomes, including clinical deterioration, severe disease, or development of complications. The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) pediatric pneumonia guideline includes criteria that were modified from adult criteria and define pneumonia severity to assist with resource allocation and site-of-care decision-making. However, the PIDS/IDSA criteria have not been formally developed or validated in children. Definitions for mild, moderate, and severe pneumonia also vary across the literature, further complicating the development of standardized severity criteria. This systematic review summarizes (1) the current state of the evidence for defining and predicting pneumonia severity in children as well as (2) emerging evidence focused on risk stratification of children with pneumonia.

Streptococcus pneumoniae's Virulence and Host Immunity: Aging, Diagnostics, and Prevention

Streptococcus pneumoniae is an infectious pathogen responsible for millions of deaths worldwide. Diseases caused by this bacterium are classified as pneumococcal diseases. This pathogen colonizes the nasopharynx of its host asymptomatically, but overtime can migrate to sterile tissues and organs and cause infections. Pneumonia is currently the most common pneumococcal disease. Pneumococcal pneumonia is a global health concern and vastly affects children under the age of five as well as the elderly and individuals with pre-existing health conditions. S. pneumoniae has a large selection of virulence factors that promote adherence, invasion of host tissues, and allows it to escape host immune defenses. A clear understanding of S. pneumoniae's virulence factors, host immune responses, and examining the current techniques available for diagnosis, treatment, and disease prevention will allow for better regulation of the pathogen and its diseases. In terms of disease prevention, other considerations must include the effects of age on responses to vaccines and vaccine efficacy. Ongoing work aims to improve on current vaccination paradigms by including the use of serotype-independent vaccines, such as protein and whole cell vaccines. Extending our knowledge of the biology of, and associated host immune response to S. pneumoniae is paramount for our improvement of pneumococcal disease diagnosis, treatment, and improvement of patient outlook.

Etiology and Risk Factors Determining Poor Outcome of Severe Pneumonia in Under-Five Children

OBJECTIVES

To determine the etiology of severe pneumonia (pneumonia with chest indrawing) in under-five children, and to study the risk factors for poor outcomes viz., 'treatment failure', 'need for change in antibiotics', 'prolonged hospital stay', 'need for mechanical ventilation' and 'mortality.'

METHODS

Children (age 2 mo to 5 y) with pneumonia and chest drawing were enrolled prospectively from October 2012 through September 2013. Clinical history was recorded, and examination, anthropometry and investigations (including chest X-ray, blood culture and nasopharyngeal swab culture) were performed. Children were managed as per standard guidelines, and recovery outcomes were recorded in form of 'treatment failure' (defined as persistence of features of severe pneumonia after 72 h or worsening of clinical condition before 72 h), need for change of antibiotics and prolonged (>5 d) hospital stay. The associations between the clinical, anthropometric and diagnostic risk factors and the recovery outcomes were evaluated by univariate and multivariate logistic regression analysis.

RESULTS

Out of 120 children enrolled in the study, 36 (42%) were culture positive (nasopharyngeal/blood); most common bacteria isolated were Streptococcal pneumoniae and Staphylococcal aureus, respectively. Treatment failure was seen in 15 (12.5%), 34 (28.3%) needed change of antibiotics, and 50 (41.6%) children required prolonged hospitalization. Low birth weight, overcrowding, general danger signs (lethargy/unable to drink), clinical rickets, crepitation, leukocytosis and positive blood culture were significant risk factors for treatment failure, prolonged hospital stay and antibiotics change. On multivariate logistic regression analysis, respiratory rate of >70/min (OR 19.94, 95%CI 1.42-280.29), lethargy/unconsciousness (OR 114.2, 95%CI 3.14-4147.92), and positive blood culture (OR 15.24, 95%CI 2.53-91.67) had more chances of treatment failure. Duration of hospital stay was prolonged in those who had inability to drink (OR 3.89, CI 1.37-10.99) or abnormal chest X-ray (OR 8.45, CI 3.56-20.04). Children with rickets (OR 3.69, CI 1.14-11.96), and those with abnormal chest X-ray (OR 9.66, CI 2.62-35.53) had a higher odds of change in antibiotics. Presence of wheeze was a protective factor for treatment failure (OR 0.03, CI 0.00-0.37) and change of antibiotics (OR 0.24, CI 0.07-0.74).

CONCLUSIONS

Staphylococcus aureus and Streptococcus pneumoniae are the predominant organisms causing severe pneumonia in our setting. Children with risk factors such as respiratory rate >70/min, rickets, lethargy/unconsciousness, not able to drink, abnormal chest X-ray or positive blood culture are likely to have a delayed recovery or need of change of antibiotics, whereas those with wheeze are likely to recover faster with less chances of treatment failure.

An exploration of mortality risk factors in non-severe pneumonia in children using clinical data from Kenya

BACKGROUND

Childhood pneumonia is the leading infectious cause of mortality in children younger than 5 years old. Recent updates to World Health Organization pneumonia guidelines recommend outpatient care for a population of children previously classified as high risk. This revision has been challenged by policymakers in Africa, where mortality related to pneumonia is higher than in other regions and often complicated by comorbidities. This study aimed to identify factors that best discriminate inpatient mortality risk in non-severe pneumonia and explore whether these factors offer any added benefit over the current criteria used to identify children with pneumonia requiring inpatient care.

METHODS

We undertook a retrospective cohort study of children aged 2-59 months admitted with a clinical diagnosis of pneumonia at 14 public hospitals in Kenya between February 2014 and February 2016. Using machine learning techniques, we analysed whether clinical characteristics and common comorbidities increased the risk of inpatient mortality for non-severe pneumonia. The topmost risk factors were subjected to decision curve analysis to explore if using them as admission criteria had any net benefit above the current criteria.

RESULTS

Out of 16,162 children admitted with pneumonia during the study period, 10,687 were eligible for subsequent analysis. Inpatient mortality within this non-severe group was 252/10,687 (2.36%). Models demonstrated moderately good performance; the partial least squares discriminant analysis model had higher sensitivity for predicting mortality in comparison to logistic regression. Elevated respiratory rate (≥70 bpm), age 2-11 months and weight-for-age Z-score (WAZ) < -3SD were highly discriminative of mortality. These factors ranked consistently across the different models. For a risk threshold probability of 7-14%, there is a net benefit to admitting the patient sub-populations with these features as additional criteria alongside those currently used to classify severe pneumonia. Of the population studied, 70.54% met at least one of these criteria. Sensitivity analyses indicated that the overall results were not significantly affected by variations in pneumonia severity classification criteria.

CONCLUSIONS

Children with non-severe pneumonia aged 2-11 months or with respiratory rate ≥ 70 bpm or very low WAZ experience risks of inpatient mortality comparable to severe pneumonia. Inpatient care is warranted in these high-risk groups of children.

Risk factors for mortality in children with pneumonia admitted to the pediatric intensive care unit

AIMS

To describe the epidemiology of children with severe pneumonia and identify risk factors for poor outcomes.

METHODS

We conducted a retrospective study of children admitted to pediatric intensive care unit (PICU) from 2010 to 2014 with a diagnosis of pneumonia. Clinical microbiological, ventilation and other pertinent PICU data were collected. Primary outcome was PICU mortality. Univariate and multivariate logistic regression model were used to identify risk factors for mortality.

RESULTS

Severe pneumonia consisted of 237/3539 (6.7%) of PICU admissions. Of these, 162/237 (68.4%) required mechanical ventilation. 32/237 (13.5%) patients died. The majority of patients had no organisms identified 82/237 (34.6%). A sole bacterial or viral pathogen was identified in 48/237 (20.1%) and 41/237 (17.9%) patients, respectively. Patients with viral pneumonias were more likely to develop acute respiratory distress syndrome compared to other etiologies (7/41[17.1%] vs 8/196 [4.0%]; P = 0.006). Bacterial pneumonias were associated with lung abscess (4/48 [8.3%] vs 2/189 [1.5%]; P = 0.016) and necrotizing pneumonia (18/48 [37.5%] vs 15/189 [7.9%]; P < 0.001) compared to other etiologies. Co-detections (>1 respiratory pathogens isolated) occurred in 62/237 (26.2%) patients and were associated a higher rate of mechanical ventilation, and decreased ventilator and PICU free days. After adjusting for severity of illness, risk factors for mortality were: hospital acquired pneumonia (HAP) (aOR: 2.92 [95%CI 1.15, 7.40]; P = 0.024) and bacteremia (aOR: 5.03 [95%CI 1.77, 14.35]; P = 0.003).

CONCLUSIONS

Severe pediatric pneumonia accounts for a significant number of PICU admissions and is associated with significant mortality risk. The presence of co-morbidities, HAP and bacteremia were early prognostic variables independently associated with poor clinical outcomes.

Etiology of severe pneumonia in Ecuadorian children

BACKGROUND

In Latin America, community-acquired pneumonia remains a major cause of morbidity and mortality among children. Few studies have examined the etiology of pneumonia in Ecuador.

METHODS

This observational study was part of a randomized, double blind, placebo-controlled clinical trial conducted among children aged 2-59 months with severe pneumonia in Quito, Ecuador. Nasopharyngeal and blood samples were tested for bacterial and viral etiology by polymerase chain reaction. Risk factors for specific respiratory pathogens were also evaluated.

RESULTS

Among 406 children tested, 159 (39.2%) had respiratory syncytial virus (RSV), 71 (17.5%) had human metapneumovirus (hMPV), and 62 (15.3%) had adenovirus. Streptococcus pneumoniae was identified in 37 (9.2%) samples and Mycoplasma pneumoniae in three (0.74%) samples. The yearly circulation pattern of RSV (P = 0.0003) overlapped with S. pneumoniae, (P = 0.03) with most cases occurring in the rainy season. In multivariable analysis, risk factors for RSV included younger age (adjusted odds ratio [aOR] = 1.9, P = 0.01) and being underweight (aOR = 1.8, P = 0.04). Maternal education (aOR = 0.82, P = 0.003), pulse oximetry (aOR = 0.93, P = 0.005), and rales (aOR = 0.25, P = 0.007) were associated with influenza A. Younger age (aOR = 3.5, P = 0.007) and elevated baseline respiratory rate were associated with HPIV-3 infection (aOR = 0.94, P = 0.03).

CONCLUSION

These results indicate the importance of RSV and influenza, and potentially modifiable risk factors including undernutrition and future use of a RSV vaccine, when an effective vaccine becomes available.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 00513929.

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

BACKGROUND

Pneumonia is the leading infectious cause of under-5 mortality in sub-Saharan Africa. Clinical prediction tools may aide case classification, triage, and allocation of hospital resources. We performed an external validation of two published prediction tools and compared this to a locally developed tool to identify children admitted with pneumonia at increased risk for in-hospital mortality in Malawi.

METHODS

We retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011-2014. RISC has both an HIV-infected and HIV-uninfected tool. A local score (RISC-Malawi) was developed using multivariable logistic regression with missing data multiply imputed using chained equations. Score performances were assessed using c-statistics, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood statistics.

RESULTS

16,475 in-patient pneumonia episodes were recorded (case-fatality rate (CFR): 3.2%), 9,533 with complete data (CFR: 2.0%). The c-statistic for the RISC (HIV-uninfected) score, used to assess its ability to differentiate between children who survived to discharge and those that died, was 0.72. The RISC-Malawi score, using mid-upper arm circumference as an indicator of malnutrition severity, had a c-statistic of 0.79. We were unable to perform a comprehensive external validation of RISC (HIV-infected) and mRISC as both scores include parameters that were not routinely documented variables in our dataset.

CONCLUSION

In our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality. However the refinement of parameters and resultant creation of RISC-Malawi improved performance. Next steps include prospectively studying both scores to determine if incorporation into routine care delivery can have a meaningful impact on in-hospital CFRs of children with WHO-defined pneumonia.

The balance between the serum levels of IL-6 and IL-10 cytokines discriminates mild and severe acute pneumonia

BACKGROUND

To identify markers for earlier diagnosis of severe pneumonia, we assess the correlation between serum cytokine profile of children with different pneumonia severity.

METHODS

In 25 hospitalized children, 7 with mild pneumonia and 18 with severe pneumonia, the serum concentration of 11 cytokines in three sampling times were dosed. Statistical analysis included parametric and non-parametric tests, Pearson correlation and ROC curve for cut-off definition of cytokines.

RESULTS

At admission, IL-6 serum levels were high in mild or severe pneumonia, and was associated to vomiting (P = 0.019) in both groups; and also to dyspnea (P = 0.012) and white blood cell count (P = 0.045) in patients with severe pneumonia. IL-10 levels were also high in patients with pneumonia and were associated to lymphocytosis (P = 0.025). The ROC curve of the IL-6:IL-10 serum levels ratio discriminated severe pneumonia cases at admission, and persistence of infection in the third day of antibiotic therapy, with positive predictive values of 93% and 89%, respectively.

CONCLUSIONS

The balance between IL-6 and IL-10 serum levels showed to be a more discriminative marker for severity definition and evaluation of recovery in patients with pneumonia.

The Effect of Exclusive Breastfeeding on Hospital Stay and Morbidity due to Various Diseases in Infants under 6 Months of Age: A Prospective Observational Study

Background. Mother's milk is the best for the babies. Protective and preventive role of breast milk was evaluated in this study by assessing the relation of type of feeding and duration of hospital stay or morbidity. Methods. This prospective study was conducted in a tertiary care hospital and 232 infants in the age group of 14 weeks to 6 months formed the sample. There are two groups of infants, that is, one for breastfed and one for top fed infants. Statistical analysis was done and results were calculated up to 95% to 99% level of significance to find effect of feeding pattern on hospital stay due to various diseases and morbidity. Results. Prolonged hospital stay, that is, >7 days, was lesser in breastfed infants and results were statistically significant in case of gastroenteritis (p value < 0.001), bronchopneumonia (p value = 0.0012), bronchiolitis (p value = 0.005), otitis media (p value = 0.003), and skin diseases (p value = 0.047). Lesser morbidity was seen in breastfed infants with gastroenteritis (p value 0.0414), bronchopneumonia (p value 0.03705), bronchiolitis (p value 0.036706), meningitis (p value 0.043), and septicemia (p value 0.04). Conclusions. Breastfed infants have shorter hospital stay and lesser morbidity in regard to various diseases as compared to top fed infants.