Clinical case review: A method to improve identification of true clinical and radiographic pneumonia in children meeting the World Health Organization definition for pneumonia

Taneli Puumalainen,Socorro Lupisan,Petri Ruutu,Erma Abucejo-Ladesma,Eric Af Simoes,Hanna Nohynek,Beatriz Quiambao,Marilla G Lucero,Tarja Heiskanen-Kosma,Ian Riley

doi:10.1186/1471-2334-8-95

Abstract

BackgroundThe World Health Organization's (WHO) case definition for childhood pneumonia, composed of simple clinical signs of cough, difficult breathing and fast breathing, is widely used in resource poor settings to guide management of acute respiratory infections. The definition is also commonly used as an entry criteria or endpoint in different intervention and disease burden studies.MethodsA group of paediatricians conducted a retrospective review of clinical and laboratory data including C-reactive protein concentration and chest radiograph findings among Filipino children hospitalised in the Bohol Regional Hospital who were enrolled in a pneumococcal vaccine efficacy study and had an episode of respiratory disease fulfilling the WHO case definition for clinical pneumonia. Our aim was to evaluate which disease entities the WHO definition actually captures and what is the probable aetiology of respiratory infections among these episodes diagnosed in this population.ResultsAmong the 12,194 children enrolled to the vaccine study we recorded 1,195 disease episodes leading to hospitalisation which fulfilled the WHO criteria for pneumonia. In total, 34% of these episodes showed radiographic evidence of pneumonia and 11% were classified as definitive or probable bacterial pneumonia. Over 95% of episodes of WHO-defined severe pneumonia (with chest indrawing) had an acute lower respiratory infection as final diagnosis whereas 34% of those with non-severe clinical pneumonia had gastroenteritis or other non-respiratory infection as main cause of hospitalisation.ConclusionThe WHO definition for severe pneumonia shows high specificity for acute lower respiratory infection and provides a tool to compare the total burden of lower respiratory infections in different settings.Trial registrationISRCTN62323832

Highlights

The World Health Organization's (WHO) case definition for childhood pneumonia, composed of simple clinical signs of cough, difficult breathing and fast breathing, is widely used in resource poor settings to guide management of acute respiratory infections
Our study demonstrates that in this population of Filipino children the WHO definition of clinical pneumonia captures a broad spectrum of respiratory infections varying from mild upper respiratory infections to severe bacterial pneumonia
The case fatality rate of 0.5% observed in the severe pneumonia group was similar to that in a recent multi-centre study evaluating antimicrobial treatment alternatives for WHO-defined severe pneumonia [16], but lower than the 2.1% and 12% mortality described in Bohol, the Philippines during 1990's and in Lombok, Indonesia among children hospitalised for acute lower respiratory infection, respectively [17,18]

Summary

Introduction

The World Health Organization's (WHO) case definition for childhood pneumonia, composed of simple clinical signs of cough, difficult breathing and fast breathing, is widely used in resource poor settings to guide management of acute respiratory infections. While it is estimated that these criteria detect over 80 percent of children that require antibiotic treatment for probable bacterial pneumonia or hospital care for severe disease, 20 to 30 percent of children fulfilling the criteria receive unnecessary antimicrobials for non-severe viral respiratory infection [3]. This is especially true for children with expiratory wheezing due to asthma, bronchiolitis or other viral respiratory infections who are often misclassified as pneumonia requiring antimicrobial treatment and referred for inpatient care [4]

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