Management of Community-Acquired Pneumonia in Pediatrics: Adherence to Clinical Guidelines

Childhood Pneumonia in Low- and Middle-Income Countries: A Systematic Review of Prevalence, Risk Factors, and Healthcare-Seeking Behaviors

Childhood pneumonia is a major contributor to illness and death in children under the age of five globally. Despite advancements in medical science, the burden of pediatric community-acquired pneumonia (CAP) remains high, particularly in low- and middle-income countries. This systematic review aims to synthesize existing literature on the prevalence, risk factors, and healthcare-seeking behaviors associated with pediatric CAP to inform the development of targeted community-based interventions. An extensive search of various databases such as Medline, EMBASE, Web of Science, Cochrane, PubMed, PubMed Central, Helinet, SpringerLink, Google Scholar, and Biomed Central was performed, resulting in 65 potentially relevant studies. After a thorough evaluation process, 25 studies were selected for the final analysis. These selected studies offered valuable information on the epidemiology, risk factors, and healthcare-seeking behaviors associated with childhood pneumonia. The review revealed that environmental factors such as indoor air pollution, overcrowding, and exposure to tobacco smoke are significant risk factors for pediatric pneumonia. Additionally, socioeconomic factors, including poverty and a lack of access to clean water and sanitation, contribute to the vulnerability of children to this disease. Poor healthcare-seeking behaviors, driven by limited knowledge and awareness of pneumonia symptoms and treatment, further exacerbate the situation. The review also highlighted the critical role of vaccination, particularly against Haemophilus influenzae type b (Hib) and pneumococcus, in preventing pneumonia. However, gaps in vaccination coverage and challenges in accessing healthcare services remain barriers to effective pneumonia control. In light of these findings, the review recommends the implementation of community-based interventions that address the multifaceted determinants of pediatric pneumonia. These interventions should focus on improving environmental conditions, enhancing access to preventive measures such as vaccination, and promoting better healthcare-seeking behaviors through education and awareness campaigns. It is essential for healthcare providers, policymakers, and community members to collaborate in developing and implementing culturally appropriate and sustainable interventions. This cooperation aims to lessen the impact of pneumonia on children and their families.

Epidemiologic, clinical, and serum markers may improve discrimination between bacterial and viral etiologies of childhood pneumonia

Background

Discrimination of bacterial and viral etiologies of childhood community-acquired pneumonia (CAP) is often challenging. Unnecessary antibiotic administration exposes patients to undue risks and may engender antimicrobial resistance. This study aimed to develop a prediction model using epidemiological, clinical and laboratory data to differentiate between bacterial and viral CAP.

Methods

Data from 155 children with confirmed bacterial or mixed bacterial and viral infection (N = 124) and viral infection (N = 31) were derived from a comprehensive assessment of causative pathogens [Partnerships for Enhanced Engagement in Research-Pneumonia in Pediatrics (PEER-PePPeS)] conducted in Indonesia. Epidemiologic, clinical and biomarker profiles (hematology and inflammatory markers) were compared between groups. The area under the receiver operating characteristic curve (AUROC) for varying biomarker levels was used to characterize performance and determine cut-off values for discrimination of bacterial and mixed CAP versus viral CAP. Diagnostic predictors of bacterial and mixed CAP were assessed by multivariate logistic regression.

Results

Diarrhea was more frequently reported in bacterial and mixed CAP, while viral infections more frequently occurred during Indonesia's rainy season. White blood cell counts (WBC), absolute neutrophil counts (ANC), neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin (PCT) were significantly higher in bacterial and mixed cases. After adjusting for covariates, the following were the most important predictors of bacterial or mixed CAP: rainy season (aOR 0.26; 95% CI 0.08-0.90; p = 0.033), CRP ≥5.70 mg/L (aOR 4.71; 95% CI 1.18-18.74; p = 0.028), and presence of fever (aOR 5.26; 95% CI 1.07-25.91; p = 0.041). The model assessed had a low R-squared (Nagelkerke R² = 0.490) but good calibration (p = 0.610 for Hosmer Lemeshow test). The combination of CRP and fever had moderate predictive value with sensitivity and specificity of 62.28 and 65.52%, respectively.

Conclusion

Combining clinical and laboratory profiles is potentially valuable for discriminating bacterial and mixed from viral pediatric CAP and may guide antibiotic use. Further studies with a larger sample size should be performed to validate this model.

Regional Perspective of Antimicrobial Stewardship Programs in Latin American Pediatric Emergency Departments

Antibiotic stewardship (AS) programs have become a priority for health authorities to reduce the number of infections by super-resistant microorganisms. The need for these initiatives to minimize the inadequate use of antimicrobials is essential, and the election of the antibiotic in the emergency department usually impacts the choice of treatment if the patients need hospital admission, becoming an opportunity for antibiotic stewardship. In the pediatric population, broad-spectrum antibiotics are more likely to be overprescribed without any evidence-based management, and most of the publications have focused on the prescription of antibiotics in ambulatory settings. Antibiotic stewardship efforts in pediatric emergency departments in Latin American settings are limited. The lack of literature on AS programs in the pediatric emergency departments in Latin America (LA) limits the information available. The aim of this review was to give a regional perspective on how pediatric emergency departments in LA are working towards antimicrobial stewardship.

Evaluation of a Pediatric Community-Acquired Pneumonia Antimicrobial Stewardship Intervention at an Academic Medical Center

(1) Background: Pneumonia is the leading diagnosis associated with antibiotic use in hospitalized children. The Infectious Diseases Society of America published pediatric community-acquired pneumonia (CAP) guidelines in 2011, but adherence to recommendations varies across institutions. The purpose of this study was to evaluate the impact of an antimicrobial stewardship intervention on antibiotic prescribing in pediatric patients admitted to an academic medical center. (2) Methods: This single-center pre/post-intervention evaluation included children admitted for CAP during three time periods (pre-intervention and post-intervention groups 1 and 2). The primary outcomes were changes in inpatient antibiotic selection and duration following the interventions. Secondary outcomes included discharge antibiotic regimens, length of stay, and 30-day readmission rates. (3) Results: A total of 540 patients were included in this study. Most patients were under five years of age (69%). Antibiotic selection significantly improved, with prescriptions for ceftriaxone decreasing (p < 0.001) and ampicillin increasing (p < 0.001) following the interventions. Antibiotic duration decreased from a median of ten days in the pre-intervention group and post-intervention group 1 to eight days in post-intervention group 2. (4) Conclusions: Our antibiotic stewardship intervention directed at pediatric CAP treatment resulted in improved antibiotic prescriptions and provides data that can be used to further educate providers at our institution.

Adherence to guidelines on the use of amoxicillin for treatment of ambulatory pneumonia in children younger than 5 years, Colombia, 2017-2019

Objectives

To determine the level of adherence to clinical guidelines in prescribing amoxicillin to children younger than 5 years with pneumonia in outpatient settings in Colombia from 2017 to 2019, and assess the factors associated with adherence.

Methods

This was a cross-sectional study of secondary data from the Colombian Integrated Social Protection Information System database. Adherence was defined as prescription of oral amoxicillin for bacterial and unspecified pneumonia and non-prescription for viral pneumonia. Variables examined included: age (< 1 year, 1-4 years) of child; sex; cause of pneumonia (bacterial, viral, unspecified); region (Andean, Amazonian, Pacific, Caribbean, Insular, Orinoquian); and payment mechanism (without prior authorization, capitation, direct payment, pay per case, pay for event).

Results

Of 215 925 cases of community-acquired pneumonia reported during 2017-2019, 64.8% were from the Andean region, 73.9% were bacterial pneumonia and 1.8% were viral pneumonia. Adherence to guidelines was observed in 5.8% of cases: this was highest for children diagnosed with viral (86.0%) compared with bacterial (2.0%) pneumonia. For children diagnosed with bacterial pneumonia, 9.4% were prescribed any antibiotic. A greater proportion of children covered by capitated payments (22.3%) were given treatment consistent with the guidelines compared with payment for event (1.3%).

Conclusion

In this first study from Colombia, adherence to guidelines for outpatient treatment of children with bacterial pneumonia was low and was better for viral pneumonia. Further qualitative studies are needed to explore the reasons for this lack of adherence and why bacterial pneumonia was the most commonly reported etiology.

Defining effective durations of antibiotic therapy for community-acquired pneumonia and urinary tract infections in hospitalized children

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) and urinary tract infections (UTI) are two common childhood infections often leading to hospital admission. National guidelines for CAP and UTI in children recommend durations of antibiotic therapy of 10 days and 7-14 days, respectively. Due to concerns of rising antimicrobial resistance and an increased awareness of harms associated with prolonged courses of antibiotics, there is a renewed emphasis on reevaluating commonly prescribed durations of antibiotic therapy across bacterial infections. We describe recent clinical trials and observational studies evaluating durations of therapy for CAP and UTI in adults and children and translate the findings to our suggested approach for selecting durations of antibiotic therapy in hospitalized children.

RECENT FINDINGS

There is a growing body of evidence, primarily in adults, that shorter durations of therapy than are commonly prescribed are just as effective as longer durations for CAP and UTIs.

SUMMARY

Combining clinical trial data from adults with available data in children, we believe it is reasonable to consider 5 days of therapy for CAP, 3-5 days of therapy for cystitis, and 7 days of therapy for pyelonephritis for most hospitalized children with uncomplicated infections.

Epidemiology of community-acquired pneumonia among hospitalised children in Indonesia: a multicentre, prospective study

OBJECTIVE

To identify aetiologies of childhood community-acquired pneumonia (CAP) based on a comprehensive diagnostic approach.

DESIGN

'Partnerships for Enhanced Engagement in Research-Pneumonia in Paediatrics (PEER-PePPeS)' study was an observational prospective cohort study conducted from July 2017 to September 2019.

SETTING

Government referral teaching hospitals and satellite sites in three cities in Indonesia: Semarang, Yogyakarta and Tangerang.

PARTICIPANTS

Hospitalised children aged 2-59 months who met the criteria for pneumonia were eligible. Children were excluded if they had been hospitalised for >24 hours; had malignancy or history of malignancy; a history of long-term (>2 months) steroid therapy, or conditions that might interfere with compliance with study procedures.

MAIN OUTCOMES MEASURES

Causative bacterial, viral or mixed pathogen(s) for pneumonia were determined using microbiological, molecular and serological tests from routinely collected specimens (blood, sputum and nasopharyngeal swabs). We applied a previously published algorithm (PEER-PePPeS rules) to determine the causative pathogen(s).

RESULTS

188 subjects were enrolled. Based on our algorithm, 48 (25.5%) had a bacterial infection, 31 (16.5%) had a viral infection, 76 (40.4%) had mixed bacterial and viral infections, and 33 (17.6%) were unable to be classified. The five most common causative pathogens identified were Haemophilus influenzae non-type B (N=73, 38.8%), respiratory syncytial virus (RSV) (N=51, 27.1%), Klebsiella pneumoniae (N=43, 22.9%), Streptococcus pneumoniae (N=29, 15.4%) and Influenza virus (N=25, 13.3%). RSV and influenza virus diagnoses were highly associated with Indonesia's rainy season (November-March). The PCR assays on induced sputum (IS) specimens captured most of the pathogens identified in this study.

CONCLUSIONS

Our study found that H. influenzae non-type B and RSV were the most frequently identified pathogens causing hospitalised CAP among Indonesian children aged 2-59 months old. Our study also highlights the importance of PCR for diagnosis and by extension, appropriate use of antimicrobials.

TRAIL REGISTRATION NUMBER

NCT03366454.

The remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia

INTRODUCTION

Despite availability of several official guidelines, not all the problems related to the most effective and safe use of antibiotics in children with community-acquired pneumonia (CAP) have been solved. Presently, too many children receive unneeded antibiotics or, when antibiotics are mandatory, the choice of the drug is not appropriate.

AREAS COVERED

In this paper, the authors discuss the remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia and provide their expert perspectives.

EXPERT OPINION

Further improvement in pediatric CAP management could be derived from physician education on antibiotic use and a larger use, particularly in office practice, of point of care testing or new technologies (i.e. artificial intelligence) to define etiology of a lower respiratory infection. However, recommendations regarding the duration of antibiotic therapy vary largely because of the absence of reliable data on the optimal CAP treatment according to the bacterial etiology of the disease, its severity, and child characteristics. Available evidence seems to confirm that a short course of antibiotics, approximately 5 days, can be effective and lead to results not substantially different from those obtained with prolonged-course antibiotic therapy, at least in patients with mild to moderate disease.

Aetiology of acute respiratory infection in preschool children requiring hospitalisation in Europe-results from the PED-MERMAIDS multicentre case-control study

Background

Both pathogenic bacteria and viruses are frequently detected in the nasopharynx (NP) of children in the absence of acute respiratory infection (ARI) symptoms. The aim of this study was to estimate the aetiological fractions for ARI hospitalisation in children for respiratory syncytial virus (RSV) and influenza virus and to determine whether detection of specific respiratory pathogens on NP samples was associated with ARI hospitalisation.

Methods

349 children up to 5 years of age hospitalised for ARI (following a symptom-based case definition) and 306 hospital controls were prospectively enrolled in 16 centres across seven European Union countries between 2016 and 2019. Admission day NP swabs were analysed by multiplex PCR for 25 targets.

Results

RSV was the leading single cause of ARI hospitalisations, with an overall population attributable fraction (PAF) of 33.4% and high seasonality as well as preponderance in younger children. Detection of RSV on NP swabs was strongly associated with ARI hospitalisation (OR adjusted for age and season: 20.6, 95% CI: 9.4 to 45.3). Detection of three other viral pathogens showed strong associations with ARI hospitalisation: influenza viruses had an adjusted OR of 6.1 (95% CI: 2.5 to 14.9), parainfluenza viruses (PIVs) an adjusted OR of 4.6 (95% CI: 1.8 to 11.3) and metapneumoviruses an adjusted OR of 4.5 (95% CI: 1.3 to 16.1). Influenza viruses had a PAF of 7.9%, PIVs of 6.5% and metapneumoviruses of 3.0%. In contrast, most other pathogens were found in similar proportions in cases and controls, including Streptococcus pneumoniae, which was weakly associated with case status, and endemic coronaviruses.

Conclusion

RSV is the predominant cause of ARI hospitalisations in young children in Europe and its detection, as well as detection of influenza virus, PIV or metapneumovirus, on NP swabs can establish aetiology with high probability. PAFs for RSV and influenza virus are highly seasonal and age dependent.

Approach to Identifying Causative Pathogens of Community-Acquired Pneumonia in Children Using Culture, Molecular, and Serology Tests

Determining the causative pathogen(s) of community-acquired pneumonia (CAP) in children remains a challenge despite advances in diagnostic methods. Currently available guidelines generally recommend empiric antimicrobial therapy when the specific etiology is unknown. However, shifts in epidemiology, emergence of new pathogens, and increasing antimicrobial resistance underscore the importance of identifying causative pathogen(s). Although viral CAP among children is increasingly recognized, distinguishing viral from bacterial etiologies remains difficult. Obtaining high quality samples from infected lung tissue is typically the limiting factor. Additionally, interpretation of results from routinely collected specimens (blood, sputum, and nasopharyngeal swabs) is complicated by bacterial colonization and prolonged shedding of incidental respiratory viruses. Using current literature on assessment of CAP causes in children, we developed an approach for identifying the most likely causative pathogen(s) using blood and sputum culture, polymerase chain reaction (PCR), and paired serology. Our proposed rules do not rely on carriage prevalence data from controls. We herein share our perspective in order to help clinicians and researchers classify and manage childhood pneumonia.

Impact of reducing the duration of antibiotic treatment on the long-term prognosis of community acquired pneumonia

Background

The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) is not well established. The aim of this study was to assess the impact of reducing the duration of antibiotic treatment on long-term prognosis in patients hospitalized with CAP.

Methods

This was a multicenter study assessing complications developed during 1 year of patients previously hospitalized with CAP who had been included in a randomized clinical trial concerning the duration of antibiotic treatment. Mortality at 90 days, at 180 days and at 1 year was analyzed, as well as new admissions and cardiovascular complications. A subanalysis was carried out in one of the hospitals by measuring C-reactive protein (CRP), procalcitonin (PCT) and proadrenomedullin (proADM) at admission, at day 5 and at day 30.

Results

A total of 312 patients were included, 150 in the control group and 162 in the intervention group. Ninety day, 180 day and 1-year mortality in the per-protocol analysis were 8 (2.57%), 10 (3.22%) and 14 (4.50%), respectively. There were no significant differences between both groups in terms of 1-year mortality (p = 0.94), new admissions (p = 0.84) or cardiovascular events (p = 0.33). No differences were observed between biomarker level differences from day 5 to day 30 (CRP p = 0.29; PCT p = 0.44; proADM p = 0.52).

Conclusions

Reducing antibiotic treatment in hospitalized patients with CAP based on clinical stability criteria is safe, without leading to a greater number of long-term complications.