A cross-sectional study of the clinical characteristics of hospitalized children with community-acquired pneumonia in eight eastern cities in China

Incidence of community-acquired pneumonia among children under 5 years in Suzhou, China: a hospital-based cohort study

OBJECTIVES

To depict the seasonality and age variations of community-acquired pneumonia (CAP) incidence in the context of the COVID-19 impact.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The observational cohort study was conducted at Soochow University Affiliated Children's Hospital from January 2017 to June 2021 and involved 132 797 children born in 2017 or 2018. They were followed and identified CAP episodes by screening on the Health Information Systems of outpatients and inpatients in the same hospital.

OUTCOME

The CAP episodes were defined when the diagnoses coded as J09-J18 or J20-J22. The incidence of CAP was estimated stratified by age, sex, birth year, health status group, season and month, and the rate ratio was calculated and adjusted by a quasi-Poisson regression model. Stratified analysis of incidence of CAP by birth month was conducted to understand the age and seasonal variation.

RESULTS

The overall incidence of CAP among children aged ≤5 years was 130.08 per 1000 person years. Children aged ≤24 months have a higher CAP incidence than those aged >24 months (176.84 vs 72.04 per 1000 person years, p<0.001). The CAP incidence increased from October, peaked at December and January and the highest CAP incidence was observed in winter (206.7 per 1000 person years, 95% CI 204.12 to 209.28). A substantial decline of CAP incidence was observed during the COVID-19 lockdown from February to August 2020, and began to rise again when the communities reopened.

CONCLUSIONS

The burden of CAP among children is considerable. The incidence of CAP among children ≤5 years varied by age and season and decreased during COVID-19 lockdown.

Severe liver injury affects the outcomes and length of hospital stay in children with community-acquired pneumonia

Background

The present study was undertaken to evaluate the association between liver injury and clinical parameters, outcomes and length of stay (LOS) in hospital in children with community-acquired pneumonia (CAP).

Methods

Clinical data and laboratory indicators of 2,573 children with CAP were analyzed. The association between liver injury and clinical parameters, outcomes and LOS was then analyzed.

Results

Higher liver injury class was associated with higher incidence of severe CAP, comorbidities, hypoxia, requirement for mechanical ventilation, 30-day mortality and intensive care unit admission, and higher indicators of inflammation (C-reactive protein, procalcitonin and white blood cell count), longer LOS, faster respiratory rate and pulse rate, and lower age, serum albumin levels, monocyte and lymphocyte counts. Severe liver injury was identified as an independent factor for 30-day mortality and prolonged LOS in children with CAP. Higher liver injury class was associated with a lower cumulative survival rate (p=0.0004), and log-rank test for trend was used to demonstrate the association of each injury class with 30-day mortality (p=0.0002).

Conclusions

Several parameters were associated with liver injury in children with CAP. Severe liver injury was found to be an independent factor for 30-day mortality and LOS in children with CAP.

Co-infections of SARS-CoV-2 with multiple common respiratory pathogens in infected children: A retrospective study

Since the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, considerable attention has been paid on its epidemiology and clinical characteristics in children patients. However, it is also crucial for clinicians to summarize and investigate the co-infection of SARS-CoV-2 in children.We retrospectively reviewed the clinical manifestations, laboratory findings, and imaging characteristics of COVID-19 patients in co-infection group (CI, n = 27) and single infection group (SI, n = 54). Samples were tested for multiple pathogens.A high incidence (27/81, 33%) of co-infection in children with COVID-19 was revealed. The most frequent co-infected pathogen was mycoplasma pneumoniae (MP, 20/81, 25%), followed by virus (6/81, 7%), and bacteria (4/81, 5%). No significant difference in clinical characteristics, laboratory examinations, or hospital stay was observed between the patients with co-infections and those with monomicrobial, only lower in white blood cell counts (CI: 5.54 ± 0.36 vs SI: 7.38 ± 0.37, P = .002), neutrophil counts (CI: 2.20 ± 0.20 vs SI: 2.92 ± 0.23, P = .024) and lymphocyte counts (CI: 2.72 ± 0.024 vs SI: 3.87 ± 0.28, P = .006). Compared with the patients with monomicrobial, chest imaging of those with co-infections showed consolidation in more cases (CI: 29.6% vs SI: 11.1%, P = .038) and duration of positive in nucleic acid was shorter (CI: 6.69 ± 0.82 vs SI: 9.69 ± 0.74, P = .015).Co-infection was relatively common in children with COVID-19, almost 1/3 had co-infection, most commonly caused by MP. Co-infection did not cause a significant exacerbation in clinical manifestations.

Serum peptidyl-prolyl cis-trans isomerase NIMA-interacting 1 in combination with C-reactive protein and white blood cell as novel predictors for infants with community-acquired pneumonia

The aim of this study was to investigate the predictive value of peptidyl-prolyl cis-trans isomerase NIMA-interacting 1 (Pin1) with C-reactive protein (CRP) and white blood cell (WBC) count for community-acquired pneumonia (CAP) in infants. A total of 84 hospitalized infants with CAP and 69 healthy infants were included in this study. The clinical manifestations and laboratory assay results of infants were recorded. Serum Pin1 level was estimated by enzyme-linked immunosorbent assay. The median serum Pin1 concentration in infants with CAP was significantly higher than that in controls (1.44 vs. 0.21 ng/mL, P < 0.0001). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve (AUC) of the combination Pin1, CRP and WBC (Pin1 + CRP + WBC, 0.943) was higher than Pin1, CRP, WBC alone or the combination of Pin1 and CRP ( P < 0.05). The sensitivity of Pin1 + CRP + WBC (94.0%) was higher than that of Pin1, CRP, WBC alone, or any two combined ( P < 0.05). Pin1 + CRP + WBC also had a high negative predictive value (91.4%). Moreover, serum Pin1 alone had a high specificity (97.0%) and excellent positive predictive value (96.6%) for infants with CAP, which were higher than WBC, Pin1 and WBC in combination, CRP and WBC in combination, and Pin1 + CRP + WBC ( P < 0.05). Therefore, serum Pin 1 was highly expressed in infants with CAP and can singly or in combination with CRP and WBC represent promising novel predictors for infants with CAP.

Prevalence and Associated Factors with Mixed Coinfections among under 5-Year-Old Children with Severe Viral Pneumonia in Vietnam

Community-acquired pneumonia (CAP) is well-recognized as a leading cause of disease burden in children. This study aimed to identify the prevalence of coinfection and associated factors in Vietnamese children ages 1 month to 5 years with viral pneumonia. We performed a cross-sectional study of children who were diagnosed with severe viral pneumonia. Demographic, clinical, and subclinical characteristics were compared between children with viral alone and bacterial coinfection. Multivariate logistic regression was used to determine which factors were associated with risk of coinfection. Of 202 children with severe viral pneumonia, the most common causative agent was respiratory syncytial virus (respiratory syncytial virus [RSV]: 36.1%), followed by influenza virus A (24.3%) and adenovirus (19.8%). Fifty-three children (26.2%) had bacterial superinfection and/or coinfection with other viruses. Haemophilus influenza was the most common bacterium (9.4%), followed by Klebsiella pneumoniae and Pseudomonas aeruginosa (with 4.0%). In infants (toddlers), ages 12 to 24 months with severe viral pneumonia, (odds ratio [OR] = 3.37, 95% confidence interval [CI]: 1.22–9.33), the higher concentrations of procalcitonin (PCT; OR = 1.16; 95% CI: 1.00–1.34), and neutrophils (OR = 1.13; 95% CI: 1.04–1.22) were associated with a higher risk of coinfection. This study underlined the pervasiveness of coinfections among young children with severe viral pneumonia. Provision of effective antiviral treatment, especially for RSV, as well as the advancement of sensitive and rapid diagnostic tools for screening pathogens of pneumonia, is critical to reducing the burden of this disease.

Risk Factors for Severe Community-aquired Pneumonia Among Children Hospitalized With CAP Younger Than 5 Years of Age

BACKGROUND

Community-acquired pneumonia (CAP) causes great morbidity and mortality as well as enormous economic burden worldwide. This study intended to describe the clinical characteristics of CAP and explore the risk factors of severe CAP among children in downtown Suzhou, China.

METHODS

This was a retrospective study of childhood hospitalizations in Soochow University Affiliated Children's Hospital from January 1, 2010, to December 31, 2014. Children who were residents of downtown Suzhou, 29 days to < 5 years of age, with discharge diagnosis codes J09 to J18 and J20 to J22 were included. Medical charts and chest radiograph reports were reviewed for included children to collect clinical information. CAP with intensive care unit (ICU) admission and poor clinical outcome were categorized as severe CAP.

RESULTS

A total of 28,043 children were identified with CAP; 17,501 (62.4%) of these children were male, and 20,747 (74.0%) children were less than 2 years of age. The common clinical symptoms at admission were cough (94.8%), fever (52.9%), wheezing (37.7%) and respiratory distress (9.5%). In total, 21,898 (78.1%) children had radiologic evidence of pneumonia, and 1,403 (5.0%) children developed at least 1 complication. Multivariate regression analysis showed that younger age, congenital heart disease and abnormal white blood cells, and C-reactive protein results were independent risk factors for both ICU admission and poor clinical outcome (odds ratio [OR] > 1 for all). Respiratory distress symptoms at admission (OR = 12.10) greatly increased the risk for ICU admission, while ICU admission (OR = 8.87) and complications (OR = 2.55) increased the risk of poor outcome. However, cough was a protective factor for ICU admission, so were wheezing, antibiotic and antiviral therapies for clinical failure.

CONCLUSION

Pediatric CAP hospitalizations of those of younger age, with congenital heart diseases, respiratory distress symptoms/tachypnea, abnormal white blood cells and C-reactive protein results as well as complications were at higher risk for progressing to severe CAP.

Hospitalization Rate and Population-based Incidence of Hospitalization for Community-acquired Pneumonia Among Children in Suzhou, China

BACKGROUND

Data on hospitalization burden of community-acquired pneumonia (CAP) in children are very limited in China. This study aimed to estimate the hospitalization rate (HR) and population-based incidence of hospitalization of CAP for children <15 years of age in Suzhou, China.

METHODS

This was a retrospective study of children hospitalized in Soochow University Affiliated Children's Hospital from January 2010 to December 2014. Children who were residents of downtown Suzhou, 29 days to <15 years of age, with discharge diagnosis codes (International Classification of Diseases, 10th revision) including J09-J18 and J20-J22 were included. All-cause clinical community-acquired pneumonia (CCAP) and radiographically confirmed pneumonia (RCAP) were identified based on individual medical chart review. The HR and population-based cumulative incidence of hospitalization (HI) were calculated.

RESULTS

Among 184,734 children <15 years of age admitted to Soochow University Affiliated Children's Hospital during the study period, 31,302 children were identified as having CCAP and 24,218 (77.4%) children confirmed as having RCAP. CCAP hospitalization occurred year round and peaked during winter and early spring. The overall HRs for CCAP and RCAP were 189.0 [95% confidence interval (CI): 187.1-190.9] and 146.2 (95% CI: 144-148) per 1000 hospitalizations, respectively, and the HIs per 100,000 children annually were CCAP, 3235.8 (95% CI: 3207.3-3264.2) and RCAP, 2503.5 (95% CI: 2478.3-2528.6). For children <5 years of age, the HR for CCAP was 248.4 (95% CI: 245.9-250.9) and RCAP was 194.0 (95% CI: 191.4-196.3) per 1000 hospitalizations; the HI for CCAP was 6956.2 (95% CI: 6892.8-7019.6) and 5431.9 (95% CI: 5375.4-5488.4) per 100,000 children for RCAP. The highest HR and HI were observed in children 29 days to <6 months of age: HR for CCAP was 407.4 (95% CI: 400.9-413.9) per 1000 hospitalizations and HI for CCAP was 11,203.7 (95% CI: 11,026.8-11,380.6) per 100,000 children annually.

CONCLUSIONS

There is a considerable burden of CAP among children <15 years of age in Suzhou, particularly among children 29 days to <6 months of age and during winter and early spring. These data provide valuable information to monitor CAP trends over time in children of Suzhou, China.

Etiologic spectrum and occurrence of coinfections in children hospitalized with community-acquired pneumonia

Background

Co-infections are common in childhood community acquired pneumonia (CAP). However, their etiological pattern and clinical impact remains inconclusive.

Methods

Eight hundred forty-six consecutive children with CAP were evaluated prospectively for the presence of viral and bacterial pathogens. Nasopharyngeal aspirates were examined by direct immunofluorescence assay or polymerase chain reaction (PCR) for viruses. PCR of nasopharyngeal aspirates and enzyme-linked immunosorbent assays were performed to detect M. pneumoniae. Bacteria was detected in blood, bronchoalveolar lavage specimen, or pleural fluid by culture.

Results

Causative pathogen was identified in 70.1% (593 of 846) of the patients. The most commonly detected pathogens were respiratory syncytial virus (RSV) (22.9%), human rhinovirus (HRV) (22.1%), M. pneumoniae (15.8%). Coinfection was identified in 34.6% (293 of 846) of the patients. The majority of these (209 [71.3%] of 293) were mixed viral-bacterial infections. Age < 6 months (odds ratio: 2.1; 95% confidence interval: 1.2–3.3) and admission of PICU (odds ratio: 12.5; 95% confidence interval: 1.6–97.4) were associated with mix infection. Patients with mix infection had a higher rate of PICU admission.

Conclusions

The high mix infection burden in childhood CAP underscores a need for the enhancement of sensitive, inexpensive, and rapid diagnostics to accurately identify pneumonia pathogens.

Etiology of community-acquired pneumonia in 1500 hospitalized children

Childhood community‐acquired pneumonia (CAP) is a common illness; however, comprehensive studies of hospitalizations for CAP among children in China based on prospective and multicenter data collection are limited. The aim of this investigation was to determine the respiratory pathogens responsible for CAP in hospitalized children. From January to December 2015, oropharyngeal swabs and blood serum were collected from hospitalized children with CAP symptoms ranging in age from 6 months to 14 years at 10 hospitals across China. We used immunofluorescence to detect antibodies for eight respiratory viruses and passive agglutination to detect specific IgM against Mycoplasma pneumoniae (M. pneumoniae). Of 1500 children presenting with CAP, 691 (46.1%) tested positive for at least one pathogen (virus or M. pneumoniae). M. pneumoniae (32.4%) was detected most frequently, followed by respiratory syncytial virus (11.5%), adenovirus (5.0%), influenza A virus (4.1 %), influenza B virus (3.4%), parainfluenza virus types 2 and 3 type (3.1 %), parainfluenza virus type 1 (2.9%), and human metapneumovirus (0.3%). Co‐infections were identified in 128 (18.5%) of the 691 cases. These data provide a better understanding of viral etiology and M. pneumoniae in CAP in children between 6 months and 14 years in China. More study of the etiologic investigations that would further aid the management of pneumonia is required. With effective immunization for RSV, ADV, and M. pneumoniae infections, more than one‐half of the pneumonia cases in this study could have been prevented.

The etiology of community-acquired pneumonia among children under 5 years of age in mainland China, 2001-2015: A systematic review

BACKGROUND

The aim of this systematic review was to examine the etiology of community-acquired pneumonia (CAP) among Chinese children younger than 5 y and provide evidence for further cost-effectiveness analyses for vaccine development, diagnostic strategies and empirical treatments.

METHODS

The literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were obtained by searching PubMed, Embase, Web-of Science, and the Chinese databases Wanfang Data and China National Knowledge Infrastructure. All CAP etiological studies on children under 5 y of age from China published in Chinese and English between the years of 2001 and 2015 were included. A total of 48 studies were included in the final review, comprising 100 151 hospitalized children with CAP episodes. Heterogeneity and the percentage of variation between studies was analyzed based on Q statistic and I² indices, respectively. Random effect models were used to calculate the weighted average rate in all analyses.

RESULTS

The most frequently detected bacterial agents were Klebsiella pneumoniae (5.4%), Streptococcus pneumoniae (5.2%), Escherichia coli (5.2%), Staphylococcus aureus (3.9%), Haemophilus influenza (3.6%) and Haemophilus parainfluenzae (3.3%). The most frequently detected viruses were human rhinovirus (20.3%, in just 2 studies), respiratory syncytial virus (RSV, 17.3%), human bocavirus (9.9%), parainfluenza virus (5.8%), human metapneumovirus (3.9%) and influenza (3.5%). Mycoplasma pneumoniae and Chlamydophila pneumoniae were identified in 9.5% and 2.9%, respectively, of children under 5 y of age with CAP.

CONCLUSION

This article provides the most comprehensive analysis to date of the factors contributing to CAP in children under 5 y of age. S. pneumoniae, H. influenzae and influenza were the most common vaccine-preventable diseases in children. Corresponding, vaccines should be introduced into Chinese immunization programs, and further economic evaluations should be conducted. RSV is common in Chinese children and preventative measures could have a substantial impact on public health. These data also have major implications for diagnostic strategies and empirical treatments.

Serotype Distribution, Antimicrobial Susceptibility, and Molecular Epidemiology of Streptococcus pneumoniae Isolated from Children in Shanghai, China

OBJECTIVE

Streptococcus pneumoniae is a common pathogenic cause of pediatric infections. This study investigated the serotype distribution, antimicrobial susceptibility, and molecular epidemiology of pneumococci before the introduction of conjugate vaccines in Shanghai, China.

METHODS

A total of 284 clinical pneumococcal isolates (270, 5, 4,3, and 2 of which were isolated from sputum, bronchoalveolar lavage fluid, blood, cerebral spinal fluid, and ear secretions, respectively) from children less than 14 years of age who had not been vaccinated with a conjugate vaccine, were collected between January and December in 2013. All isolates were serotyped by multiplex polymerase chain reaction or quellung reactions and antimicrobial susceptibility testing was performed using the broth microdilution method. The molecular epidemiology of S.pneumoniae was analyzed by multilocus sequence typing (MLST).

RESULTS

Among the 284 pneumococcal isolates, 19F (33.5%), 19A (14.1%), 23F (12.0%), and 6A (8.8%) were the most common serotypes and the coverage rates of the 7-, 10-, and 13-valent pneumococcal conjugate vaccines (PCV7, PCV10, and PCV13) were 58.6%, 59.4% and 85.1%, respectively. Antimicrobial susceptibility showed that the prevalence rates of S.pneumoniae resistance to penicillin were 11.3% (32/284). Approximately 88.0% (250/284) of the isolates exhibited multi-drug resistance. MLST analysis revealed a high level of diversity, with 65 sequence types (STs) among 267 isolates. Specifically, the four predominant STs were ST271 (24.3%, 65/267), ST320 (11.2%, 30/267), ST81 (9.7%, 26/267), and ST3173 (5.2%, 14/267), which were mainly associated with serotypes 19F, 19A, 23F, and 6A, respectively.

CONCLUSIONS

The prevalent serotypes among clinical isolates from children were 19F, 19A, 23F, and 6A and these isolates showed high resistance rates to β-lactams and macrolides. The Taiwan19F-14 clone played a predominant role in the dissemination of pneumococcal isolates in Shanghai, China. Therefore, continued and regional surveillance on pneumococcal isolates may be necessary.