Management Of Community-acquired Pneumonia In Children Research Articles

Clinical and bacteriological profile of community acquired pneumonia in hospitalized children

Community-acquired pneumonia (CAP) is the leading cause of mortality and morbidity with important clinical impact across the World. India accounts for 23 per cent of global pneumonia burden with case fatality rates between 14 and 30 per cent. Pneumonia is basically classified into typical and atypical pneumonia. Emerging evidence indicates that dual typical and atypical bacterial infections function synergistically in many cases and together likely enhance the severity of CAP. However, the optimal management of CAP in children is still not well defined and the diagnosis is challenging when based solely on clinical observations since the common symptoms of CAP, especially at an early stage, are similar to those of ordinary respiratory tract infections. So RT-PCR is a rapid and precise molecular technique is used for rapid detection of bacteria causing community acquired pneumonia. A total of 268 samples were tested for the respective bacterial pathogens, among the tested the most common pathogen was Haemophilus influenzae (18.3%, 49/268) followed by S. pneumoniae (14.6%,39/268), M. catarhallis (9.3%,25/268),M. pneumoniae (9%, 24/268), B. parapertusis (3.4%,9/268), B. pertusis (1.5%, 4/268), C. pneumoniae (1.5%, 4/268), C. burnetti (1.1%, 3/268)and L. pneumophila (0.74%, 2/268). H. influenza and S. pneumoniae were the most commonly detected organisms among the community acquired pneumonia patients.

Cytokine profile in community-acquired pneumonia in children

Community-acquired pneumonia (CAP) is one of the most common acute infectious diseases. To date, the incidence of CAP among children was decreased significantly worldwide, mainly due to increasing use of effective preventive measures. Nevertheless, CAP remains a common cause of childhood morbidity and mortality. Pneumonia may develop at any age, but most often it occurs in young children, who are more likely to have a more severe course of pneumonia. Currently, early diagnosis and prognosis of the disease severity in children is an urgent issue. It was found that, in most cases, a panel of conventional biomarkers, including the number of leukocytes, procalcitonin, CRP is not sufficient for the diagnosis of pediatric CAP. There is a demand for new biological markers which, along with clinical evaluation, may significantly improve diagnostics and management of CAP in children, thus reducing the risk of adverse outcomes associated with this disease. Such markers could be found among the cytokines, which are active participants in the CAP pathogenesis. The aim of this study was to determine the level of several cytokines in blood serum of children with CAP and to assess changes in the cytokine profile depending on the patient’s age and severity of the disease. The study included 117 children aged 1 to 18 years with a diagnosis of CAP confirmed by X-ray examination. The comparison group included 28 healthy children who did not have CAP or other signs of acute respiratory viral infection at the time of examination, being free of any chronic pathology requiring outpatient observation. A number of cytokines were determined quantitatively in blood serum, i.e., IL-1β, IFNγ, IL-2, IL-4, IL-6, IL-10, TNFα, IFNλ2 (IL-28A), IFNλ3 (IL-28B), IL-8, MCP-1, IL-17AF, GM-CSF using test systems based on the “sandwich” method of solid-phase ELISA using peroxidase labeling. As a result, it was found that the content of IL-6, IL-17AF, IL-1β, IFNγ, MCP-1, IFNλ2 (IL-28A), IFNλ3 (IL-28B), GM-CSF was significantly higher in the group of children with severe community-acquired pneumonia. The levels of certain cytokines, e.g., IL-6, IFNλ2 (IL-28A), IFNλ3 (IL-28B), GM-CSF varied depending on the age of patients, thus, probably, reflecting the degree of immune system activation in the children of different age groups.

Does procalcitonin have clinical utility in the management of paediatric community-acquired pneumonia? A PRO/CON debate.

Although the overwhelming majority of community-acquired pneumonia (CAP) in children is caused by viral infections, treatment of CAP is among the most common indications for antibiotic use in children. This is largely driven by the imprecision of clinical diagnostic tools to differentiate viral from bacterial pneumonia and highlights the need for improved approaches to optimizing management of CAP in children. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate that discusses the clinical utility of procalcitonin in children with CAP.

Pediatricians' Compliance to the Clinical Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children in Pakistan.

Community-acquired pneumonia (CAP) is among the most commonly prevailing acute infections in children that may require hospitalization. Inconsistencies among suggested care and actual management practices are usually observed, which raises the need to assess local clinical practices. The current study was conducted to evaluate pediatricians’ compliance with the standard clinical practice guidelines and their antibiotic-prescribing behavior for the management of CAP in children. Methods: A descriptive cross-sectional study was conducted using a self-administered questionnaire; which was provided to pediatricians by the researchers. Statistical analysis was performed with SPSS 25 Statistics; χ2 tests (or Fisher-exact tests) with the p-value set at < 0.05 as the threshold for statistical significance. Results: The overall response rate was 59.2%. Male respondents were (n = 101; 42.6%), and the respondents (n = 163; 68.7%) were under 30 years of age. Amoxicillin (n = 122; 51.5%) was considered as the most commonly used first-line treatment for non-severe pneumonia, whereas a smaller proportion (n = 81; 34.2%) of respondents selected amoxicillin–clavulanate. Likewise, amoxicillin (n = 100; 42.2%) was the most popular choice for non-severe pneumonia in hospitalized children; however, if children had used antibiotics earlier to admission, respondents showed an inclination to prescribe a macrolide (n = 95; 40.0%) or second-generation cephalosporin (n = 90; 37.9%). More than 90% responded that children <6 months old with suspected bacterial CAP will probably receive better therapeutic care by hospitalization. Restricting exposure to the antibiotic as much as possible (n = 71; 29.9%), improving antibiotic prescribing (n = 59; 24.8%), and using the appropriate dose of antimicrobials (n = 29; 12.2%) were considered the major factors by the respondents to reduce antimicrobials resistance. Conclusions: The selection of antibiotics and diagnostic approach was as per the recommendations, but indication, duration of treatment, and hospitalization still can be further improved.

Epidemiological and clinical analysis of community-acquired Mycoplasma pneumonia in children from a Spanish population, 2010–2015

Introduction and objectivesMycoplasma pneumoniae (MP) is one of the most common etiological agents of community-acquired pneumonia (CAP) in children. We aimed to describe the clinical and epidemiological characteristics, treatment and outcome of children diagnosed with community-acquired MP pneumonia (CAMP) in a tertiary hospital in Valencia, Spain. Material and methodsMedical records of children <14 years with CAMP were retrospectively reviewed from January 2010 to December 2015. Patients with radiological evidence of pneumonia and microbiological confirmation of MP (PCR from nasopharyngeal swab and/or serum specific IgM) were considered CAMP. ResultsOne hundred and sixty two children were diagnosed with CAMP; median age 6 years (IQR: 4–9). The positive MP test rate among children with CAP progressively increased with age as did the empirical use of macrolides. There were two peaks of cases in 2011 and in 2015, being July, August, November and December the seasons with the higher number of cases. The most frequent radiological pattern was segmental infiltrate (62.3%) and 22 (13.6%) children had pleural effusion. It was noteworthy the mild symptomatology and low levels of inflammatory parameters that children with CAMP had. A macrolide was empirically initiated in 68.5% of cases. Hospital admission rate was inversely proportional to patient's age. ConclusionsAccording to this study, older, less symptomatic patients and with lower inflammatory parameters had the greatest rate of MP infection among children with CAP and thus they could benefit of empiric macrolide therapy. Therefore, knowing the epidemiology of a geographical area may be important for the management of CAP in children.

Epidemiological and clinical analysis of community-acquired Mycoplasma pneumonia in children from a Spanish population, 2010-2015

ResumenIntroducción y objetivosMycoplasma pneumoniae (MP) es uno de los agentes etiológicos más comunes de las neumonías adquiridas en la comunidad (NAC) en niños. Objetivo: describir las características clínicas y epidemiológicas, tratamiento y evolución de los pacientes con NAC por MP (NACM) en un hospital terciario de Valencia, España.Material y métodosSe revisaron retrospectivamente las historias clínicas de los niños < 14 años con NACM entre enero de 2010 y diciembre de 2015. Los pacientes con evidencia radiológica de neumonía y confirmación microbiológica de MP (PCR de exudado nasofaríngeo y/o anticuerpos IgM específicos frente a MP) se consideraron NACM.ResultadosUn total de 162 pacientes se diagnosticaron de NACM; mediana de edad de 6 años (rango intercuartílico: 4-9 años). La proporción de pruebas positivas para MP en pacientes con NAC, así como el uso empírico de macrólidos, aumentó progresivamente con la edad. Hubo un pico de casos en 2011 y en 2015, con un máximo de casos en julio, agosto, noviembre y diciembre. El patrón radiológico más frecuente fue el infiltrado segmentario (62,3%), mientras que 22 (13,6%) presentaron derrame pleural. Los niños con NACM desarrollaron una clínica leve, con poca elevación de parámetros inflamatorios. Se inició tratamiento empírico con un macrólido en el 68,5% de los casos. La necesidad de ingreso hospitalario fue inversamente proporcional a la edad del paciente.ConclusionesSegún este estudio, los niños con NAC de mayor edad tuvieron la mayor proporción de infección por MP, siendo poco sintomáticos y con escasa elevación de parámetros inflamatorios, pudiéndose beneficiar del tratamiento empírico con macrólidos. Por consiguiente, conocer la epidemiología de un área geográfica podría ser importante para el abordaje de las NAC en niños.

The Influence of National Guidelines on the Management of Community-Acquired Pneumonia in Children. Do Pediatricians Follow the Recommendations?

This is a retrospective study whose main objective was to analyze the influence of the Polish Guidelines for the Management of Respiratory Tract Infections of 2010 (PGMRTI) on in-hospital treatment of children with community-acquired pneumonia (CAP). Files from four Warsaw hospitals were reviewed to identify children with uncomplicated CAP, treated before (2008-2009) (pre-PGMRTI) and after (2011-2012) (post-PGMRTI) publication of the guidelines. Predefined data on the management were compared. A cohort of 2,359 children (1,081 pre-PGMRTI and 1,278 post-PGMRTI) was included. We found that co-amoxiclav was the most common first-line therapy in children >3months of age (34.6% and 40.4% pre- and post-PGMRTI, respectively), followed by cefuroxime (31.8% and 20.9% pre- and post-PGMRTI, respectively; p<0.0001) and macrolides (17.4% and 24.5% pre- and post-PGMRTI, respectively; p<0.0001). Amoxicillin was rarely used (5.4% and 4.9%, pre- and post-PGMRTI, respectively). The study revealed an overuse of inhaled bronchodilators, corticosteroids, and mucoactive drugs. Blood diagnostic tests were applied to a significant percentage of patients: blood cultures (41.2% and 44.5% pre-and post-PGMRTI, respectively) and serology for atypical pathogens (27.9% and 44.9% pre-and post-PGMRTI, respectively; p<0.0001). The number of follow-up chest X-rays increased (30.5% and 53.8% pre- and post-PGMRTI, respectively; p<0.0001). In conclusion, the study demonstrates an unsatisfactory influence of the guidelines on in-hospital management of CAP in children. Despite an explicit recommendation for the use of amoxicillin, it was still underused. Other methods of education and guideline dissemination are needed to optimize the prescribing of antibiotics.

Management of community-acquired pneumonia in infants and children: Clinical practice guidelines endorsed by the Saudi Pediatric Infectious Diseases Society.

The World Health Organization (WHO) has reported that pneumonia continues to be a significant cause of mortality in the pediatric age group for children under five years of age, where it accounts for nearly one-fifth of childhood deaths worldwide [1]. In this report, we provide the most up to date guidelines for the management of community-acquired pneumonia (CAP) in infants and children aged over 90 days. The current recommendations given by the Pediatric Infectious Diseases Society and Infectious Diseases Society of America 2011 Practice guidelines, WHO, and other international guidelines are considered as well as regional variations in susceptibility patterns and resources [[1], [2], [3], [4], [5], [6]]. Some published and unpublished antibiograms from several tertiary care organizations in the regions comprising Saudi Arabia, United Arab Emirates, Kuwait, and Oman have shown significant improvements in the susceptibility pattern of Streptococcus pneumoniae to penicillin for the last three years, so the current recommendations have been customized accordingly [2,3]. These guidelines cover the diagnosis and therapeutic options for the management of CAP in children. The definition of children-specific guidelines for the management of CAP can reduce morbidity and mortality. We present a clinical statement from the Saudi Pediatric Infectious Diseases Society (SPIDS) concerning the management of CAP in children.

Serum Endocan Levels in Children with Community-Acquired Pneumonia

In this study, it was aimed to compare the levels of serum endocan with commonly used markers, and also to define the suitability for determination of disease severity in patients with community-acquired pneumonia (CAP). The study included 60 patients and 28 healthy subjects. Pneumonia severity was determined according to British Thoracic Society guidelines for the management of CAP in children. Serum levels of endocan and C-reactive protein (CRP) and white blood cell (WBC), and neutrophil count were measured. Serum endocan levels were increased in patients with CAP. CRP levels, WBC count, neutrophil count and neutrophil lymphocyte ratio were also higher in the CAP group than healthy control group. Endocan was correlated with CRP and WBC count and disease severity. For the identification of CAP, the area under the receiver operating characteristic (ROC) curve of CRP was acceptable for CRP, but not for endocan (0.812 and 0.649, respectively). ROC analysis for endocan to differentiate between severe CAP (n ...

Vaikų bendruomenėje įgytos pneumonijos diagnostika ir gydymas

Straipsnyje pateikiamos naujausios vaikų bendruomenėje įgytos pneumonijos diagnostikos ir gydymo rekomendacijos, paruoštos pagal SAM projektą "Asmens sveikatos priežiūros kokybės gerinimas reglamentuojant rizikingiausius pacientų saugai diagnostikos ir gydymo protokolus" Nr. VP1-4.3-VRM-02-V-05-015.

The Impact of Adherence to Pediatric Community-Acquired Pneumonia Guidelines on Clinical Outcomes.

Community-acquired pneumonia (CAP) accounts for over 150,000 hospitalizations annually in the United States,1 and is one of the most common inpatient diagnoses.2 In children, treatment for CAP is typically presumptive based on epidemiologic data specifying the most common etiologies for each age group. Guidelines from the Infectious Diseases Society of America on management of CAP in children recommend initial empiric therapy of ampicillin or penicillin G for a child who is hospitalized. In addition, the guidelines strongly recommend collection of blood cultures (BCs) in any children requiring hospitalization for presumed moderate to severe bacterial CAP.3 The primary objective of our study was to evaluate how closely we adhere to guidelines on empiric therapy choices for management of pediatric CAP, including how often BCs were obtained and subsequently influenced management. Our secondary objective was to assess whether this management correlated with clinical outcomes.

Viral Infections in Children with Community-Acquired Pneumonia

Viral pathogens are commonly isolated from children with community-acquired pneumonia (CAP). Viruses like respiratory syncytial virus, human rhinovirus, human metapneumovirus, parainfluenza viruses, and influenza may act as sole pathogens or may predispose to bacterial pneumonia by a variety of mechanisms. New, emerging, or reemerging viral pathogens occasionally cause outbreaks of severe respiratory tract infection in children. The 2009–2010 H1N1 influenza virus pandemic resulted in increased rates of influenza-related hospitalizations and deaths in children. Rapid viral diagnostic tests based on antigen detection or nucleic acid amplification are increasingly available for clinical use and confirm the importance of viral infection in children hospitalized with CAP. Recently published guidelines for the management of CAP in children note that positive viral test results can modify clinical decision making in children with suspected pneumonia by allowing antibacterial therapy to be withheld in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.

Reply to Tamma &amp; Cosgrove and Esposito

TO THE EDITOR—We are grateful for the comments of Drs Tamma and Cosgrove [1] on the issue of duration of therapy, particularly as it impacts antibiotic exposure in the child and the community. Greater antibiotic exposure is associated with greater antimicrobial resistance and also adds to costs and toxicities of therapy. This particular issue prompted considerable discussion within the writing group. However, with no scientific evidence in children from randomized controlled trials or even high-quality observational studies conducted in North American centers, the extrapolated data from community-acquired pneumonia (CAP) in adults, well-reviewed by Tamma and Cosgrove, was not felt to be of sufficient relevance to make these recommendations for children. Although children may have fewer comorbid conditions than adults, our guidelines do review the many other differences, including the relative immune incompetence in preschool-aged children compared with adults, as well as the role of viral coinfections. Differences in outcomes for children compared with adults with urinary tract infections highlight the challenges of extrapolating adult treatment protocols to children [2]. However, we certainly agree with the critical importance of this issue and included it as one of our research priorities, as provided in our Table 10: “Develop clinical trial designs that can provide information on the lowest effective antimicrobial dose for the shortest duration of therapy to decrease the development of antimicrobial resistance and the risk of antimicrobial toxicity.” Although the guidelines are unable to address the duration of antibiotic therapy based on adequate evidence, they do emphasize the importance of viral infection as a cause of pneumonia in the preschool-aged child and state that “antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.” We believe that if this recommendation is followed, it will significantly decrease the use of inappropriate antimicrobials in children and is well aligned with the goals expressed by Drs Tamma and Cosgrove. We also thank Dr Esposito for her letter citing 8 concerns regarding the Executive Summary of the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America clinical practice guidelines on the management of CAP in children >3 months [3, 4]. In her review of the Executive Summary, she may have overlooked the reference (p 618) to the full-text electronic article for the guidelines that provides a detailed description of the methods, background, and, most important, the Evidence Summaries that support each recommendation. The comments and questions she raises are all addressed within the full text that is available online (doi: 10.1093/cid/cir531).