Prediction of pneumonia in a pediatric emergency department

External validation of two clinical prediction models for pediatric pneumonia

OBJECTIVE

To externally validate two prediction models for pediatric radiographic pneumonia.

METHODS

We prospectively evaluated the performance of two prediction models (Pneumonia Risk Score [PRS] and CARPE DIEM models) from a prospective convenience sample of children 90 days - 18 years of age from a pediatric emergency department undergoing chest radiography for suspected pneumonia between January 1, 2022, to December 31st, 2023. We evaluated model performance using the original intercepts and coefficients and evaluated for performance changes when performing recalibration and re-estimation procedures.

RESULTS

We included 202 patients (median age 3 years, IQR 1-6 years), of whom radiographic pneumonia was found in 92 (41.0%). The PRS model had an area under the receiver operator characteristic curve of 0.72 (95% confidence interval [CI] 0.64-0.79), which was higher than the CARPE DIEM (0.59; 95% CI 0.51-0.67) (P<0.01). Using optimal cutpoints, the PRS model showed higher sensitivity (65.2%, 95% CI 54.6-74.9) and specificity (72.7%, 95% CI 63.4-80.8) compared to the CARPE DIEM model (sensitivity 56.5 [95% CI 45.8-66.8]; specificity 60.9 [95% CI 50.2-69.2]). Recalibration and re-estimation of models improved performance, particularly for the CARPE DIEM model, with gains in sensitivity and specificity, and improved calibration.

CONCLUSION

The PRS model demonstrated better performance than the CARPE DIEM model in predicting radiographic pneumonia. Among children with a high rate of pneumonia, these models did not reach a level of performance sufficient to be used independently of clinical judgement. These findings highlight the need for further validation and improvement of models to enhance their utility.

Predictors of radiographic pneumonia in febrile children with cancer presenting to the emergency department

BACKGROUND

Fever is a common presenting complaint to the pediatric emergency department (PED), especially among oncology patients. While bacteremia has been extensively studied in this population, pneumonia has not. Some studies suggest that chest X-ray (CXR) does not have a role in the investigation of neutropenic fever in the absence of respiratory symptoms, yet non-neutropenic pediatric oncology patients were excluded from these studies.

OBJECTIVE

We aimed to determine the incidence of CXRs ordered for febrile pediatric oncology patients, irrespective of their absolute neutrophil count (ANC), and to evaluate the rates of radiographic pneumonia as well as predictors of the latter in this group.

METHOD

This study was conducted in the PED at the American University of Beirut Medical Center (AUBMC), an Eastern Mediterranean tertiary-care hospital. We conducted a retrospective cohort study of acutely febrile pediatric cancer patients, younger than 18 years, presenting to a tertiary center from 2014 to 2018. We included one randomly selected febrile visit per patient. Fever was defined as a single oral temperature ≥38 °C within 24 h of presentation. We collected data on patient characteristics and outcomes. Our primary outcome was radiographic pneumonia; our secondary outcome was whether a CXR was done or not. We defined radiographic pneumonia as a consolidation, pleural effusion, infiltrate, pneumonia, "infiltrate vs. atelectasis," or possible pneumonia mentioned by the radiologist. SPSS was used for the statistical analysis.

RESULTS

We reviewed a total of 664 medical charts and included data from 342 febrile pediatric patients in our analysis. Of these, 64 (18.7%) had a CXR performed. Overall, 16 (25%) had radiographic pneumonia while 48 (75%) did not. Patients were significantly more likely to have a CXR performed if they presented with upper respiratory tract symptoms, cough (p < 0.001 for both), or abnormal lung auscultation at the bedside (p = 0.004). Patients were also less likely to have a CXR done if they were asymptomatic upon admission to the PED (p < 0.001). However, neither cough nor shortness of breath nor abnormal lung examinations were significant predictors of a positive CXR (p = 0.17, 0.43, and 0.669, respectively). Patients with radiographic pneumonia were found to be significantly younger (4.29 vs. 6 years, p = 0.03), with a longer time since their last chemotherapy (15 vs. 7 days, p = 0.005), and were given intravenous (IV) bolus in the PED (87.5% vs. 56.3%, p = 0.02). Interestingly, patients with higher white blood cell (WBC) counts were more likely to have radiographic pneumonia (4850 vs. 1750, p = 0.01). Having a cough and an abnormal lung examination on presentation increased the odds of having a CXR (adjusted odds ratio [aOR]: 6.6; 95% confidence interval [CI]: 3.4-12.8 and aOR: 4.5; 95% CI: 1.1-18.3, respectively). Returning to the PED for the same complaint within 2 weeks was associated with lower odds of a CXR at the index visit (aOR: 0.3; 95% CI: 0.1-0.6). For every year the child is older, the odds of having radiographic pneumonia decreased by 0.8 (95% CI: 0.6-0.98). However, for every day since the last chemotherapy session, the odds increased by 1.1 (95% CI: 1.01-1.12).

CONCLUSION

In our sample, CXR was not commonly performed in the initial assessment of febrile cancer patients in the PED, unless respiratory symptoms or an abnormal lung examination was noted. However, these were not significant predictors of radiographic pneumonia. Further studies are needed to identify better predictors of pneumonia in this high-risk population.

Preferences for Management of Pediatric Pneumonia: A Clinician Survey of Artificially Generated Patient Cases

BACKGROUND

It is unknown which factors are associated with chest radiograph (CXR) and antibiotic use for suspected community-acquired pneumonia (CAP) in children. We evaluated factors associated with CXR and antibiotic preferences among clinicians for children with suspected CAP using case scenarios generated through artificial intelligence (AI).

METHODS

We performed a survey of general pediatric, pediatric emergency medicine, and emergency medicine attending physicians employed by a private physician contractor. Respondents were given 5 unique, AI-generated case scenarios. We used generalized estimating equations to identify factors associated with CXR and antibiotic use. We evaluated the cluster-weighted correlation between clinician suspicion and clinical prediction model risk estimates for CAP using 2 predictive models.

RESULTS

A total of 172 respondents provided responses to 839 scenarios. Factors associated with CXR acquisition (OR, [95% CI]) included presence of crackles (4.17 [2.19, 7.95]), prior pneumonia (2.38 [1.32, 4.20]), chest pain (1.90 [1.18, 3.05]) and fever (1.82 [1.32, 2.52]). The decision to use antibiotics before knowledge of CXR results included past hospitalization for pneumonia (4.24 [1.88, 9.57]), focal decreased breath sounds (3.86 [1.98, 7.52]), and crackles (3.45 [2.15, 5.53]). After revealing CXR results to clinicians, these results were the sole predictor associated with antibiotic decision-making. Suspicion for CAP correlated with one of 2 prediction models for CAP (Spearman's rho = 0.25). Factors associated with a greater suspicion of pneumonia included prior pneumonia, duration of illness, worsening course of illness, shortness of breath, vomiting, decreased oral intake or urinary output, respiratory distress, head nodding, focal decreased breath sounds, focal rhonchi, fever, and crackles, and lower pulse oximetry.

CONCLUSIONS

Ordering preferences for CXRs demonstrated similarities and differences with evidence-based risk models for CAP. Clinicians relied heavily on CXR findings to guide antibiotic ordering. These findings can be used within decision support systems to promote evidence-based management practices for pediatric CAP.

Community-Acquired Pneumonia in Children

ABSTRACT

Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

OBJECTIVES

We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors.

METHODS

We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors.

RESULTS

Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32).

CONCLUSION

Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections

BACKGROUND

Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP).

OBJECTIVES

We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes.

DESIGN, SETTING AND PARTICIPANTS

This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals.

MAIN OUTCOME AND METHODS

We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes.

RESULTS

We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs.

CONCLUSION

There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Establishment and Validation of a Predictive Model for Radiation-Associated Aspiration Pneumonia in Patients with Radiation-Induced Dysphagia after Nasopharyngeal Carcinoma

Introduction

Radiotherapy for patients with head and neck cancers raises their risk of aspiration pneumonia-related death. We aimed to develop and validate a model to predict radiation-associated aspiration pneumonia (RAP) among patients with dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC).

Materials and Methods

A total of 453 dysphagic patients with NPC were retrospectively recruited from Sun Yat-Sen Memorial Hospital from January 2012 to January 2018. Patients were randomly divided into training cohort (n = 302) and internal validation cohort (n = 151) at a ratio of 2 : 1. The concordance index (C-index) and calibration curve were used to evaluate the accuracy and discriminative ability of this model. Moreover, decision curve analysis was performed to evaluate the net clinical benefit. The results were externally validated in 203 dysphagic patients from the First People's Hospital of Foshan.

Results

Derived from multivariable analysis of the training cohort, four independent factors were introduced to predict RAP, including Kubota water drinking test grades, the maximum radiation dose of lymph node gross tumor volume (Dmax of the GTVnd), neutrophil count, and erythrocyte sedimentation rate (ESR). The nomogram showed favorable calibration and discrimination regarding the training cohort, with a C-index of 0.749 (95% confidence interval (CI), 0.681 to 0.817), which was confirmed by the internal validation cohort (C-index 0.743; 95% CI, 0.669 to 0.818) and the external validation cohort (C-index 0.722; 95% CI, 0.606 to 0.838).

Conclusions

Our study established and validated a simple nomogram for RAP among patients with dysphagia after radiotherapy for NPC.

Factors Associated With Antibiotic Use for Children Hospitalized With Pneumonia

BACKGROUND

Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate. We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP.

METHODS

We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP.

RESULTS

Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63-7.13]), fever (1.66 [1.22-2.27]), and use of supplemental oxygen (1.29 [1.11-1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics.

CONCLUSIONS

Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions.

Clinical characteristics of hospitalized term and preterm infants with community-acquired viral pneumonia

BACKGROUND

Pneumonia is a serious problem that threatens the health of newborns. This study aimed to investigate the clinical characteristics of hospitalized term and preterm infants with community-acquired viral pneumonia.

METHODS

This was a retrospective analysis of cases of community-acquired viral pneumonia in the Neonatal Department. Nasopharyngeal aspirate (NPA) samples were collected for pathogen detection, and clinical data were collected. We analysed pathogenic species and clinical characteristics among these infants.

RESULTS

RSV is the main virus in term infants, and parainfluenza virus (PIV) 3 is the main virus in preterm infants. Patients infected with PIV3 were more susceptible to coinfection with bacteria than those with respiratory syncytial virus (RSV) infection (p < 0.05). Preterm infants infected with PIV3 were more likely to be coinfected with bacteria than term infants (p < 0.05), mainly gram-negative bacteria (especially Klebsiella pneumonia). Term infants with bacterial infection were more prone to fever, cyanosis, moist rales, three concave signs, elevated C-reactive protein (CRP) levels, respiratory failure and the need for higher level of oxygen support and mechanical ventilation than those with simple viral infection (p < 0.05). The incidence of hyponatremia in neonatal community-acquired pneumonia (CAP) was high.

CONCLUSIONS

RSV and PIV3 were the leading causes of neonatal viral CAP. PIV3 infection is the main cause of viral CAP in preterm infants, and these individuals are more likely to be coinfected with bacteria than term infants, mainly gram-negative bacteria. Term infants with CAP coinfected with bacteria were more likely to have greater disease severity than those with single viral infections.

Validation of Prediction Models for Pneumonia Among Children in the Emergency Department

BACKGROUND

Several prediction models have been reported to identify patients with radiographic pneumonia, but none have been validated or broadly implemented into practice. We evaluated 5 prediction models for radiographic pneumonia in children.

METHODS

We evaluated 5 previously published prediction models for radiographic pneumonia (Neuman, Oostenbrink, Lynch, Mahabee-Gittens, and Lipsett) using data from a single-center prospective study of patients 3 months to 18 years with signs of lower respiratory tract infection. Our outcome was radiographic pneumonia. We compared each model's area under the receiver operating characteristic curve (AUROC) and evaluated their diagnostic accuracy at statistically-derived cutpoints.

RESULTS

Radiographic pneumonia was identified in 253 (22.2%) of 1142 patients. When using model coefficients derived from the study dataset, AUROC ranged from 0.58 (95% confidence interval, 0.52-0.64) to 0.79 (95% confidence interval, 0.75-0.82). When using coefficients derived from original study models, 2 studies demonstrated an AUROC >0.70 (Neuman and Lipsett); this increased to 3 after deriving regression coefficients from the study cohort (Neuman, Lipsett, and Oostenbrink). Two models required historical and clinical data (Neuman and Lipsett), and the third additionally required C-reactive protein (Oostenbrink). At a statistically derived cutpoint of predicted risk from each model, sensitivity ranged from 51.2% to 70.4%, specificity 49.9% to 87.5%, positive predictive value 16.1% to 54.4%, and negative predictive value 83.9% to 90.7%.

CONCLUSIONS

Prediction models for radiographic pneumonia had varying performance. The 3 models with higher performance may facilitate clinical management by predicting the risk of radiographic pneumonia among children with lower respiratory tract infection.

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia

OBJECTIVES

To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.

STUDY DESIGN

We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.

RESULTS

A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period.

CONCLUSIONS

Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases.

A Prediction Model for Pediatric Radiographic Pneumonia

BACKGROUND

Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use.

METHODS

We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk.

RESULTS

Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77-0.84). Of 229 children with a predicted risk of <4%, 13 (5.7%) had radiographic CAP (sensitivity of 94.9% at a 4% risk threshold). Conversely, of 229 children with a predicted risk of >39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold).

CONCLUSIONS

A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.

Development of the Novel Pneumonia Risk Score to Predict Radiographic Pneumonia in Children

BACKGROUND

The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia.

METHODS

We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia.

RESULTS

Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73).

CONCLUSIONS

In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.

Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children

OBJECTIVES

The objective of this study was to determine emergency department (ED) physician adherence with the 2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) guidelines for outpatient management of children with mild-to-moderate community-acquired pneumonia (CAP).

METHODS

A cross-sectional survey of physicians on the American Academy of Pediatrics Section on Emergency Medicine Survey listserv was conducted. We evaluated ED physicians' reported adherence with the PIDS/IDSA guidelines through presentation of 4 clinical vignettes representing mild-to-moderate CAP of presumed viral (preschool-aged child), bacterial (preschool and school-aged child), and atypical bacterial (school-aged child) etiology.

RESULTS

Of 120 respondents with analyzable data (31.4% response rate), use of chest radiograph (CXR) was nonadherent to the guidelines in greater than 50% of respondents for each of the 4 vignettes. Pediatric emergency medicine fellowship training was independently associated with increased CXR use in all vignettes, except for school-aged children with bacterial CAP. Guideline-recommended amoxicillin was selected to treat bacterial CAP by 91.7% of the respondents for preschool-aged children and by 75.8% for school-aged children. Macrolide monotherapy for atypical CAP was appropriately selected by 88.2% and was associated with obtaining a CXR (adjusted odds ratio, 3.9 [95% confidence interval, 1.4-11.1]). Guideline-adherent antibiotic use for all vignettes was independently associated with congruence between respondent's presumed diagnosis and the vignette's intended etiologic diagnosis.

CONCLUSIONS

Reported ED CXR use in the management of outpatient CAP was often nonadherent to the PIDS/IDSA guidelines. Most respondents were adherent to the guidelines in their use of antibiotics. Strategies to increase diagnostic test accuracy are needed to improve adherence and reduce variation in care.

Urinary Proadrenomedullin and Disease Severity in Children With Suspected Community-acquired Pneumonia

BACKGROUND

Plasma proadrenomedullin (proADM) is a promising biomarker to predict disease severity in community-acquired pneumonia (CAP). Urinary biomarkers offer advantages over blood, including ease of collection. We evaluated the association between urinary proADM and disease severity in pediatric CAP.

METHODS

We performed a prospective cohort study of children 3 months to 18 years with CAP. Urinary proADM/creatinine (Cr) was calculated. Disease severity was defined as: mild (discharged home), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with supplemental oxygen and complicated pneumonia) and severe (eg, vasopressors and invasive ventilation). Outcomes were examined using logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP.

RESULTS

Of the 427 children included, higher proADM/Cr was associated with increased odds of severe disease compared with nonsevere disease [suspected CAP, odds ratio (OR) 1.02 (95% confidence interval (CI) 1.003, 1.04); radiographic CAP, OR 1.03 (95% CI 1.01, 1.06)] when adjusted for other covariates. ProADM/Cr had an area under the receiver operating characteristic curve of 0.56 (threshold 0.9 pmol/mg) to differentiate severe from nonsevere disease in suspected CAP and 0.65 in radiographic CAP (threshold 0.82 pmol/mg). Healthy controls had less proADM in their urine (median, 0.61 pmol/mg) compared with suspected (0.87 pmol/mg, P = 0.018) and radiographic (0.73 pmol/mg, P = 0.016) CAP.

CONCLUSIONS

Urinary proADM/Cr ratio measured at the time of emergency department visit was statistically associated with the development of severe outcomes in children with CAP, with stronger discriminatory performance in radiographic disease.

Proadrenomedullin Predicts Severe Disease in Children With Suspected Community-acquired Pneumonia

BACKGROUND

Proadrenomedullin (proADM), a vasodilatory peptide with antimicrobial and anti-inflammatory properties, predicts severe outcomes in adults with community-acquired pneumonia (CAP) to a greater degree than C-reactive protein and procalcitonin. We evaluated the ability of proADM to predict disease severity across a range of clinical outcomes in children with suspected CAP.

METHODS

We performed a prospective cohort study of children 3 months to 18 years with CAP in the emergency department. Disease severity was defined as mild (discharged home), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with supplemental oxygen, broadening of antibiotics, complicated pneumonia), and severe (eg, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined using proportional odds logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP.

RESULTS

Among 369 children, median proADM increased with disease severity (mild: median [IQR], 0.53 [0.43-0.73]; mild-moderate: 0.56 [0.45-0.71]; moderate-severe: 0.61 [0.47-0.77]; severe: 0.70 [0.55-1.04] nmol/L) (P = .002). ProADM was significantly associated with increased odds of developing severe outcomes (suspected CAP: OR, 1.68; 95% CI, 1.2-2.36; radiographic CAP: OR, 2.11; 95% CI, 1.36-3.38) adjusted for age, fever duration, antibiotic use, and pathogen. ProADM had an AUC of 0.64 (95% CI, .56-.72) in those with suspected CAP and an AUC of 0.77 (95% CI, .68-.87) in radiographic CAP.

CONCLUSIONS

ProADM was associated with severe disease and discriminated moderately well children who developed severe disease from those who did not, particularly in radiographic CAP.

An analysis of clinical predictive values for radiographic pneumonia in children

Introduction

Healthcare providers in resource-limited settings rely on the presence of tachypnoea and chest indrawing to establish a diagnosis of pneumonia in children. We aimed to determine the test characteristics of commonly assessed signs and symptoms for the radiographic diagnosis of pneumonia in children 0–59 months of age.

Methods

We conducted an analysis using patient-level pooled data from 41 shared datasets of paediatric pneumonia. We included hospital-based studies in which >80% of children had chest radiography performed. Primary endpoint pneumonia (presence of dense opacity occupying a portion or entire lobe of the lung or presence of pleural effusion on chest radiograph) was used as the reference criterion radiographic standard. We assessed the sensitivity, specificity, and likelihood ratios for clinical findings, and combinations of findings, for the diagnosis of primary endpoint pneumonia among children 0–59 months of age.

Results

Ten studies met inclusion criteria comprising 15 029 children; 24.9% (n=3743) had radiographic pneumonia. The presence of age-based tachypnoea demonstrated a sensitivity of 0.92 and a specificity of 0.22 while lower chest indrawing revealed a sensitivity of 0.74 and specificity of 0.15 for the diagnosis of radiographic pneumonia. The sensitivity and specificity for oxygen saturation <90% was 0.40 and 0.67, respectively, and was 0.17 and 0.88 for oxygen saturation <85%. Specificity was improved when individual clinical factors such as tachypnoea, fever and hypoxaemia were combined, however, the sensitivity was lower.

Conclusions

No single sign or symptom was strongly associated with radiographic primary end point pneumonia in children. Performance characteristics were improved by combining individual signs and symptoms.

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

AIM

Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs.

METHODS

This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015.

RESULTS

Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078).

CONCLUSION

Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.

Identification of pediatric respiratory diseases using a fine-grained diagnosis system

Respiratory diseases, including asthma, bronchitis, pneumonia, and upper respiratory tract infection (RTI), are among the most common diseases in clinics. The similarities among the symptoms of these diseases precludes prompt diagnosis upon the patients' arrival. In pediatrics, the patients' limited ability in expressing their situation makes precise diagnosis even harder. This becomes worse in primary hospitals, where the lack of medical imaging devices and the doctors' limited experience further increase the difficulty of distinguishing among similar diseases. In this paper, a pediatric fine-grained diagnosis-assistant system is proposed to provide prompt and precise diagnosis using solely clinical notes upon admission, which would assist clinicians without changing the diagnostic process. The proposed system consists of two stages: a test result structuralization stage and a disease identification stage. The first stage structuralizes test results by extracting relevant numerical values from clinical notes, and the disease identification stage provides a diagnosis based on text-form clinical notes and the structured data obtained from the first stage. A novel deep learning algorithm was developed for the disease identification stage, where techniques including adaptive feature infusion and multi-modal attentive fusion were introduced to fuse structured and text data together. Clinical notes from over 12000 patients with respiratory diseases were used to train a deep learning model, and clinical notes from a non-overlapping set of about 1800 patients were used to evaluate the performance of the trained model. The average precisions (AP) for pneumonia, RTI, bronchitis and asthma are 0.878, 0.857, 0.714, and 0.825, respectively, achieving a mean AP (mAP) of 0.819. These results demonstrate that our proposed fine-grained diagnosis-assistant system provides precise identification of the diseases.

Characterizing T cell subsets in the nasal mucosa of children with acute respiratory symptoms

BACKGROUND

In infants admitted to an ICU with respiratory failure, there is an association between the ratio of CD8⁺ to CD4⁺ T cells within the upper respiratory tract and disease severity. Whether this ratio is associated with respiratory disease severity within children presenting to a pediatric emergency department is not known.

METHODS

We studied a convenience sample of 63 children presenting to a pediatric emergency department with respiratory symptoms. T cell subsets in the nasal mucosa were analyzed by flow cytometry. We compared CD4⁺ and CD8⁺ T cells subsets in these samples and analyzed the proportion of these subsets that expressed markers associated with tissue residency.

RESULTS

We were able to identify major subsets of CD8 and CD4 T cells within the nasal mucosa using flocked swabs. We found no difference in the ratio CD8⁺ to CD4⁺ T cells in children with upper or lower respiratory illness. A positive association between tissue-resident memory T cell frequency and patient age was identified.

CONCLUSIONS

In our patient populations, the CD8⁺:CD4⁺ ratio was not associated with disease severity. The majority of T cells collected on nasal swabs are antigen experienced, and there is an association between the frequency of tissue-resident T cells and age.

IMPACT

Immune cell populations from the nasal mucosa can be captured using flocked nasal swabs and analyzed by flow cytometry. Nasal CD8⁺:CD4⁺ ratio does not predict respiratory illness severity in children presenting to the emergency department. The frequency of CD8⁺ and CD4⁺ resident memory T cells within the nasal mucosa increases with age.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Clinical predictors of radiological pneumonia: A cross-sectional study from a tertiary hospital in Nepal

Background

Despite readily availability of vaccines against both Hemophilus influenzae and Pneumococcus, pneumonia remains the most common cause of morbidity and mortality in children under the age of five years in Nepal. With growing antibiotic resistance and a general move towards more rational antibiotic use, early identification of clinical signs for the prediction of radiological pneumonia would help practitioners to start the treatment of patients. The main aim of this study was to reassess the clinical predictors of pneumonia in Nepal.

Methods

This cross-sectional study was conducted between June 2015 and November 2015 at Tribhuvan University Teaching Hospital, a tertiary hospital in Kathmandu, Nepal. Children aged 3–60 months with a clinical diagnosis of pneumonia by a physician were enrolled in the study. Radiological pneumonia was identified and categorized as per World Health Organization guidelines by an experienced radiologist blinded to patient characteristics. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia.

Results

Out of 1021 children with fever, 160 cases were clinically diagnosed as pneumonia and were enrolled for this study. Among the enrolled patients, 61% had radiological pneumonia. Tachypnea had the highest sensitivity of 99%, while bronchial breathing had the highest specificity of 100%. During univariate analysis, grunting, wheezing, nasal discharge, decreased breath sounds, noisy breathing and hypoxemia were associated with radiological pneumonia. Only hypoxemia remained an independent predictor when adjusted for all the factors.

Conclusion

Tachypnea was the most sensitive sign, whereas bronchial breathing was most specific sign for radiological pneumonia.

Biomarkers and Disease Severity in Children With Community-Acquired Pneumonia

BACKGROUND

Host biomarkers predict disease severity in adults with community-acquired pneumonia (CAP). We evaluated the association of the white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP), and procalcitonin with the development of severe outcomes in children with CAP.

METHODS

We performed a prospective cohort study of children 3 months to 18 years of age with CAP in the emergency department. The primary outcome was disease severity: mild (discharged from the hospital), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with receipt of intravenous fluids, supplemental oxygen, complicated pneumonia), and severe (eg, intensive care, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined within the cohort with suspected CAP and in a subset with radiographic CAP.

RESULTS

Of 477 children, there were no statistical differences in the median WBC count, ANC, CRP, or procalcitonin across severity categories. No biomarker had adequate discriminatory ability between severe and nonsevere disease (area under the curve [AUC]: 0.53-0.6 for suspected CAP and 0.59-0.64 for radiographic CAP). In analyses adjusted for age, antibiotic use, fever duration, and viral pathogen detection, CRP was associated with moderate-severe disease (odds ratio 1.12; 95% confidence interval, 1.0-1.25). CRP and procalcitonin revealed good discrimination of children with empyema requiring chest drainage (AUC: 0.83) and sepsis with vasoactive infusions (CRP AUC: 0.74; procalcitonin AUC: 0.78), although prevalence of these outcomes was low.

CONCLUSIONS

WBC count, ANC, CRP, and procalcitonin are generally not useful to discriminate nonsevere from severe disease in children with CAP, although CRP and procalcitonin may have some utility in predicting the most severe outcomes.

Repeat assessment of examination signs among children in Malawi with fast-breathing pneumonia

Background

As part of a randomised controlled trial of treatment with placebo versus 3 days of amoxicillin for nonsevere fast-breathing pneumonia among Malawian children aged 2–59 months, a subset of children was hospitalised for observation. We sought to characterise the progression of fast-breathing pneumonia among children undergoing repeat assessments to better understand which children do and do not deteriorate.

Methods

Vital signs and physical examination findings, including respiratory rate, arterial oxygen saturation measured by pulse oximetry (S_pO2), chest indrawing and temperature were assessed every 3 h for the duration of hospitalisation. Children were assessed for treatment failure during study visits on days 1, 2, 3 and 4.

Results

Hospital monitoring data from 436 children were included. While no children had S_pO2 90–93% at baseline, 7.4% (16 of 215) of children receiving amoxicillin and 9.5% (21 of 221) receiving placebo developed S_pO2 90–93% during monitoring. Similarly, no children had chest indrawing at enrolment, but 6.6% (14 of 215) in the amoxicillin group and 7.2% (16 of 221) in the placebo group went on to develop chest indrawing during hospitalisation.

Conclusion

Repeat monitoring of children with fast-breathing pneumonia identified vital and physical examination signs not present at baseline, including S_pO2 90–93% and chest indrawing. This information may support providers and policymakers in developing guidance for care of children with nonsevere pneumonia.

This study characterised the progression of fast-breathing pneumonia among children in Malawi. Repeat monitoring of children identified vital and physical exam signs not present at baseline, including oxygen saturation of 90–93% and chest indrawing.http://bit.ly/2vUlckS

Decision rule to predict pneumonia in children presented with acute febrile respiratory illness

BACKGROUND

It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph.

METHOD

This was a multicenter prospective study in 3 emergency departments. Children younger than 6 years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios.

RESULTS

Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever <3 days (0 points), 3-4 days (2 points), 5-6 days (4 points), ≥7 days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpO₂ ≤96% or tachypnea (3 points). The Area under ROC curve of the PAFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. A PAFRI score of ≥0 gives a sensitivity of 91.7% and negative predictive value of 97.7%.

CONCLUSION

PAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation.

WHAT'S KNOWN ON THIS SUBJECT

It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients.

WHAT THIS STUDY ADDS

The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.

Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low-value care

AIM

Low-value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X-ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices.

METHODS

We extracted data from the electronic medical record for all children aged 1-12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis.

RESULTS

A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes.

CONCLUSION

Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.

Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group

Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.

Predictors of Bacteremia in Children Hospitalized With Community-Acquired Pneumonia

BACKGROUND AND OBJECTIVES

The yield of blood cultures in children hospitalized with community-acquired pneumonia (CAP) is low. Characteristics of children at increased risk of bacteremia remain largely unknown.

METHODS

We conducted a secondary analysis of a retrospective cohort study of children aged 3 months to 18 years hospitalized with CAP in 6 children's hospitals from 2007 to 2011. We excluded children with complex chronic conditions and children without blood cultures performed at admission. Clinical, laboratory, microbiologic, and radiologic data were assessed to identify predictors of bacteremia.

RESULTS

Among 7509 children hospitalized with CAP, 2568 (34.2%) had blood cultures performed on the first day of hospitalization. The median age was 3 years. Sixty-five children with blood cultures performed had bacteremia (2.5%), and 11 children (0.4%) had bacteremia with a penicillin-nonsusceptible pathogen. The prevalence of bacteremia was increased in children with a white blood cell count >20 × 10³ cells per µL (5.4%; 95% confidence interval 3.5%-8.1%) and in children with definite radiographic pneumonia (3.3%; 95% confidence interval 2.4%-4.4%); however, the prevalence of penicillin-nonsusceptible bacteremia was below 1% even in the presence of individual predictors. Among children hospitalized outside of the ICU, the prevalence of contaminated blood cultures exceeded the prevalence of penicillin-nonsusceptible bacteremia.

CONCLUSIONS

Although the prevalence of bacteremia is marginally higher among children with leukocytosis or radiographic pneumonia, the rates remain low, and penicillin-nonsusceptible bacteremia is rare even in the presence of these predictors. Blood cultures should not be obtained in children hospitalized with CAP in a non-ICU setting.

Performance of prediction rules and guidelines in detecting serious bacterial infections among Tanzanian febrile children

Background

Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SBI from well-resourced countries at outpatient level may help to improve current guidelines; however, their diagnostic performance has not been evaluated in resource-limited countries, where clinical conditions, access to care, and diagnostic capacity differ. The aim of this study was to estimate the diagnostic accuracy of existing prediction rules and clinical guidelines in identifying children with SBI in a cohort of febrile children attending outpatient health facilities in Tanzania.

Methods

Structured literature review to identify available prediction rules and guidelines aimed at detecting SBI and retrospective, external validation on a dataset containing 1005 febrile Tanzanian children with acute infections. The reference standard, SBI, was established based on rigorous clinical and microbiological criteria.

Results

Four prediction rules and five guidelines, including IMCI, could be validated. All examined rules and guidelines had insufficient diagnostic accuracy for ruling-in or ruling-out SBI with positive and negative likelihood ratios ranging from 1.04–1.87 to 0.47–0.92, respectively. IMCI had a sensitivity of 36.7% (95% CI 29.4–44.6%) at a specificity of 70.3% (67.1–73.4%). Rules that use a combination of clinical and laboratory testing had better performance compared to rules and guidelines using only clinical and or laboratory elements.

Conclusions

Currently applied guidelines for managing children with febrile illness have insufficient diagnostic accuracy in detecting children with SBI. Revised clinical algorithms including simple point-of-care tests with improved accuracy for detecting SBI targeting in tropical resource-poor settings are needed. They should undergo careful external validation against clinical outcome before implementation, given the inherent limitations of gold standards for SBI.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4371-y) contains supplementary material, which is available to authorized users.

Temperature-Adjusted Respiratory Rate for the Prediction of Childhood Pneumonia

OBJECTIVES

As both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia.

METHODS

In this retrospective cross-sectional analysis of 91,429 children < 5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds.

RESULTS

The mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75-0.78) versus AUC = 0.73 (95% CI, 0.72-0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57-0.59) to 0.72 (95% CI, 0.70-0.73).

CONCLUSIONS

The effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia.

Can clinical prediction models assess antibiotic need in childhood pneumonia? A validation study in paediatric emergency care

Objectives

Pneumonia is the most common bacterial infection in children at the emergency department (ED). Clinical prediction models for childhood pneumonia have been developed (using chest x-ray as their reference standard), but without implementation in clinical practice. Given current insights in the diagnostic limitations of chest x-ray, this study aims to validate these prediction models for a clinical diagnosis of pneumonia, and to explore their potential to guide decisions on antibiotic treatment at the ED.

Methods

We systematically identified clinical prediction models for childhood pneumonia and assessed their quality. We evaluated the validity of these models in two populations, using a clinical reference standard (1. definite/probable bacterial, 2. bacterial syndrome, 3. unknown bacterial/viral, 4. viral syndrome, 5. definite/probable viral), measuring performance by the ordinal c-statistic (ORC). Validation populations included prospectively collected data of children aged 1 month to 5 years attending the ED of Rotterdam (2012–2013) or Coventry (2005–2006) with fever and cough or dyspnoea.

Results

We identified eight prediction models and could evaluate the validity of seven, with original good performance. In the Dutch population 22/248 (9%) had a bacterial infection, in Coventry 53/301 (17%), antibiotic prescription was 21% and 35% respectively. Three models predicted a higher risk in children with bacterial infections than in those with viral disease (ORC ≥0.55) and could identify children at low risk of bacterial infection.

Conclusions

Three clinical prediction models for childhood pneumonia could discriminate fairly well between a clinical reference standard of bacterial versus viral infection. However, they all require the measurement of biomarkers, raising questions on the exact target population when implementing these models in clinical practice. Moreover, choosing optimal thresholds to guide antibiotic prescription is challenging and requires careful consideration of potential harms and benefits.

Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort

OBJECTIVE

To improve the prediction of pediatric pneumonia by developing a series of models based on clinically distinct subgroups. We hypothesized that these subgroup models would provide superior estimates of pneumonia risk compared with a single pediatric model.

STUDY DESIGN

We conducted a secondary analysis of a prospective cohort being evaluated for radiographic pneumonia in an urban pediatric emergency department (ED). Using multivariate modeling, we created 4 models across subgroups stratified by age and presence of wheezing to predict the risk of pneumonia.

RESULTS

A total of 2351 patients were included in the study. In this series, the prevalence of pneumonia was 8.5%, and 21.6% were hospitalized. The highest prevalence of pneumonia was in children aged >2 years without wheezing (13.3%). Children aged <2 years with wheezing had the lowest prevalence of pneumonia (4.0%). The most accurate model was for children aged <2 years with wheezing (area under the curve [AUC], 0.80), and the poorest performing model was for those aged <2 years without wheezing (AUC, 0.64). The AUC of a combination of the 4 subgroup models was 0.76 (95% CI, 0.72-0.80). The precision of the models' estimates (expected vs observed) was ± 3.7%.

CONCLUSIONS

Using 4 complementary prediction models for pediatric pneumonia, an accurate risk of pneumonia can be calculated. These models can provide the basis for clinical decision making support to guide the use of chest radiographs and promote antibiotic stewardship.

Association of vitamin D receptor gene FokI polymorphism and susceptibility to CAP in Egyptian children: a multicenter study

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of child deaths around the world. Recently, the vitamin D receptor (VDR) gene has emerged as a susceptibility gene for CAP.

OBJECTIVES

To evaluate the association of the VDR gene Fok I polymorphism with susceptibility to CAP in Egyptian children.

METHODS

This was a multicenter case-control study of 300 patients diagnosed with CAP, and 300 well-matched healthy control children. The VDR Fok I (rs2228570) polymorphism was genotyped by PCR-restriction fragment length polymorphism (RFLP), meanwhile serum 25-hydroxy vitamin D (25D) level was assessed using ELISA method.

RESULTS

The frequencies of the VDR FF genotype and F allele were more common in patients with CAP than in our control group (OR = 3.6; (95% CI: 1.9-6.7) for the FF genotype; P = 0.001) and (OR: 1.8; (95% CI: 1.4-2.3) for the F allele; P = 0.01). Patients carrying the VDR FF genotype had lower serum (25D) level (mean; 14.8 ± 3.6 ng/ml) than Ff genotype (20.6 ± 4.5 ng/ml) and the ff genotype (24.5 ± 3.7 ng/ml); P < 0.01.

CONCLUSION

The VDR gene Fok I (rs2228570) polymorphism confers susceptibility to CAP in Egyptian children.

Building a Prediction Model for Radiographically Confirmed Pneumonia in Peruvian Children: From Symptoms to Imaging

Background

Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru.

Methods

Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo₂), and addition of lung ultrasound.

Results

Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo₂ than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve [AUC] = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo₂ did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo₂ ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%).

Conclusions

The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.

Negative Chest Radiography and Risk of Pneumonia

: media-1vid110.1542/5804413949001PEDS-VA_2018-0236Video Abstract BACKGROUND AND OBJECTIVES: The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia.

METHODS

Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit.

RESULTS

There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4-5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%-99.6%).

CONCLUSIONS

A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy.

Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis

PURPOSE

Pneumonia is the third leading cause of death in children under 5 years of age worldwide. In pediatrics, both the accuracy and safety of diagnostic tools are important. Lung ultrasound (LUS) could be a safe diagnostic tool for this reason. We searched in the literature for diagnostic studies about LUS to predict pneumonia in pediatric patients using systematic review and meta-analysis.

METHODS

The Medline, CINAHL, Cochrane Library, Embase, SPORTDiscus, ScienceDirect, and Web of Science databases from inception to September 2017 were searched. All studies that evaluated the diagnostic accuracy of LUS in determining the presence of pneumonia in patients under 18 years of age were included.

RESULTS

1042 articles were found by systematic search. 76 articles were assessed for eligibility. Seventeen studies were included in the systematic review. We included 2612 pooled cases. The age of the pooled sample population ranged from 0 to about 21 years old. Summary sensitivity, specificity, and AUC were 0.94 (IQR: 0.89-0.97), 0.93 (IQR: 0.86-0.98), and 0.98 (IQR: 0.94-0.99), respectively. No agreement on reference standard was detected: nine studies used chest X-rays, while four studies considered the clinical diagnosis. Only one study used computed tomography.

CONCLUSIONS

LUS seems to be a promise tool for diagnosing pneumonia in children. However, the high heterogeneity found across the individual studies, and the absence of a reliable reference standard, make the finding questionable. More methodologically rigorous studies are needed.

A Multisite Intervention for Pediatric Community-acquired Pneumonia in Community Settings

OBJECTIVES

The majority of children with community-acquired pneumonia (CAP) are primarily evaluated in community hospital emergency departments (EDs); however, studies on the management of pediatric CAP have largely targeted care provided in freestanding children's hospital EDs or inpatient settings. The objectives of this study were to examine whether implementation of a CAP pathway within three community hospital EDs and inpatient units improved process measures related to appropriate laboratory testing and antibiotic prescribing and to compare performance on these measures between the community hospitals and a freestanding children's hospital.

METHODS

Through a multidisciplinary approach (including general emergency medicine [EM] providers, pediatric fellowship-trained EM providers, and pediatric hospitalists), a CAP pathway was designed and implemented at three community hospitals in January and February 2016. Diagnostic and therapeutic process measures were collected using administrative data and medical record abstraction 1 year pre- and postintervention. Chi-square statistics and statistical process control P-charts were used to examine adherence to these process measures.

RESULTS

Across the community hospitals, 544 patients preintervention and 321 patients postintervention met inclusion criteria, with 290 children's hospital patients meeting criteria in the postintervention period. Adherence to process measures increased postintervention for appropriate laboratory testing, narrow-spectrum antibiotic stewardship and macrolide stewardship by 10.8% (95% confidence interval [CI] = 4.7% to 16.9%), 8.3% (95% CI = 21.5% to 15.2%), and 3.1% (95% CI = -4.3% to 10.4%), respectively. Statistical process control P-charts demonstrated special cause variation immediately after implementation of the intervention in regards to appropriate laboratory testing.

CONCLUSION

Implementation of a CAP pathway through a multisite community hospital intervention improved adherence to evidence-based recommendations for laboratory testing and antibiotic stewardship. Similar interventions may improve the quality of care for children with CAP on a population level, as community hospitals are where these patients are seen most frequently.

Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis

Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.

Reliability of Examination Findings in Suspected Community-Acquired Pneumonia

BACKGROUND

The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP.

METHODS

This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS

No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate.

CONCLUSIONS

In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.

Clinical features and inflammatory markers in pediatric pneumonia: a prospective study

In this prospective, observational study on previously healthy children <18 years, we aimed to study the diagnostic ability of clinical features and inflammatory markers to (i) predict pathologic chest radiography in suspected pneumonia and (ii) differentiate etiology in radiological proven pneumonia. In 394 cases of suspected pneumonia, 265 (67%) had radiographs consistent with pneumonia; 34/265 had proof of bacterial etiology. Of the cases, 86.5% had received pneumococcal conjugate vaccine. In suspected pneumonia, positive chest radiography was significantly associated with increasing C-reactive protein (CRP) values, higher age, and SpO₂ ≤92% in multivariate logistic regression, OR 1.06 (95% CI 1.03 to 1.09), OR 1.09 (95% CI 1.00 to1.18), and OR 2.71 (95% CI 1.42 to 5.18), respectively. In proven pneumonia, bacterial pneumonia was significantly differentiated from viral/atypical pneumonia by increasing CRP values and SpO₂ >92% in multivariate logistic regression, OR 1.09 (95% CI 1.05 to 1.14) and OR 0.23 (95% CI 0.06 to 0.82), respectively. Combining high CRP values (>80 mg/L) and elevated white blood cell (WBC) count provided specificity >85%, positive likelihood ratios >3, but sensitivity <46% for both radiographic proven and bacterial pneumonia.

CONCLUSION

With relatively high specificity and likelihood ratio CRP, WBC count and hypoxemia may be beneficial in ruling in a positive chest radiograph in suspected pneumonia and bacterial etiology in proven pneumonia, but with low sensitivity, the clinical utility is limited. What is Known: • Pneumonia is recommended to be a clinical diagnosis, and neither clinical features nor inflammatory markers can reliably distinguish etiology. • The etiology of pneumonia has changed after routine pneumococcal conjugate vaccine. What is New: • High CRP and WBC counts were associated with infiltrates in children with suspected pneumonia and with bacterial infection in proven pneumonia. • In the post-pneumococcal vaccination era, viral etiology is expected, and in cases of pneumonia with low CRP and WBC counts, a watch-and-wait strategy for antibiotic treatment may be applied.

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses

OBJECTIVE

To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses.

MATERIALS AND METHODS

We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification.

RESULTS

Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage.

CONCLUSION

Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

Analysis of the parameters of respiration patterns extracted from thermal image sequences

Remote estimation of vital signs is an important and active area of research. The goal of this work was to analyze the feasibility of estimating respiration parameters from video sequences of faces recorded using a mobile thermal camera. Different estimators were analyzed and experimentally verified. It was demonstrated that the respiration rate, periodicity of respiration, and presence and length of apnea periods could be reliably estimated from signals recorded using a portable thermal camera. The size of the camera and efficiency of the methods allow the implementation of this method in smart glasses.