Time to clinical stability among children hospitalized with pneumonia

Time to Clinical Stability in Children With Community-Acquired Pneumonia

BACKGROUND AND OBJECTIVES

Time to clinical stability (TCS) is a commonly used outcome in adults with community-acquired pneumonia (CAP), yet few studies have evaluated TCS in children. Our objective was to determine the association between TCS and disease severity in children with suspected CAP, as well as factors associated with reaching early stability.

METHODS

This is a prospective cohort study of children (aged 3 months to 18 years) hospitalized with suspected CAP. TCS parameters included temperature, heart rate, respiratory rate, and hypoxemia with the use of supplemental oxygen. TCS was defined as time from admission to parameter normalization. The association of TCS with severity and clinical factors associated with earlier TCS were evaluated.

RESULTS

Of 571 children, 187 (32.7%) had at least 1 abnormal parameter at discharge, and none had ≥3 abnormal discharge parameters. A greater proportion of infants (90 [93%]) had all 4 parameters stable at discharge compared with 12- to 18-year-old youths (21 [49%]). The median TCS for each parameter was <24 hours. Younger age, absence of vomiting, diffusely decreased breath sounds, and normal capillary refill were associated with earlier TCS. Children who did not reach stability were not more likely to revisit after discharge.

CONCLUSIONS

A TCS outcome consisting of physiologic variables may be useful for objectively assessing disease recovery and clinical readiness for discharge among children hospitalized with CAP. TCS may decrease length of stay if implemented to guide discharge decisions. Clinicians can consider factors associated with earlier TCS for management decisions.

Predictors of recovery time from severe community-acquired pneumonia among paediatrics patients in selected hospitals in Addis Ababa, Ethiopia: an institution-based retrospective cohort study

OBJECTIVE

Severe community-acquired pneumonia (SCAP) is a significant cause of morbidity worldwide and a major cause of morbidity and mortality in developing countries. Ethiopia ranks 6th out of 15 countries with the highest mortality rate due to pneumonia in children under 5 years of age. The aim of this study was to determine the recovery time from SCAP and factors in paediatric patients in selected hospitals in Addis Ababa.

DESIGN, PARTICIPANTS AND SETTING

A retrospective cohort study was conducted among 407 randomly selected paediatric patients admitted with SCAP in Addis Ababa public hospitals from 1 January 2018 to 31 December 2020.

PRIMARY AND SECONDARY OUTCOMES

Recovery time and recovery rate from SCAP were estimated using Kaplan-Meier and simple frequency statistics, respectively, and the adjusted HR with a 95% CI was used to identify associated factors for recovery.

RESULTS

91.5% (95% CI: 88.3% to 94.1%) of children recovered from SCAP with an overall recovery rate of 11.5 (95% CI: 10.37 to 12.76) per 100 person-day observation, and the median recovery time was 6 days. In the multivariable analysis, older age and the absence of comorbidities were protective factors for early recovery, while stunting and late utilisation of medical care were risk factors.

CONCLUSION

The median recovery time after SCAP was very long compared with the optimal recovery time of 3 days given in the British Thoracic Society guidelines. Older age and absence of comorbidities were found to shorten recovery time, whereas stunting and late initiation of treatment delayed recovery. Therefore, measures that increase the recovery rate and shorten the recovery time, such as primary prevention to eliminate malnutrition and increase the utilisation of medical care in the community, should be strengthened, and health workers should focus on the early detection and treatment of comorbid diseases.

Joint modeling of longitudinal changes of pulse rate and body temperature with time to recovery of pneumonia patients under treatment: a prospective cohort study

BACKGROUND

Pneumonia is the leading infectious cause of mortality worldwide and one of the most common lower respiratory tract infections that is contributing significantly to the burden of antibiotic consumption. The study aims to identify the determinants of the progress of pulse rate, body temperature and time to recovery of pneumonia patients.

METHOD

A prospective cohort study design was used from Felege Hiwot referral hospital on 214 sampled pneumonia patients from March 01, 2022 up to May 31, 2022. The Kaplan-Meier survival estimate and Log-Rank test was used to compare the survival time. Joint model of bivariate longitudinal and time to event model was used to identify factors of longitudinal change of pulse rate and body temperature with time to recovery jointly.

RESULT

As the follow up time of pneumonia patient's increase by one hour the average longitudinal change of pulse rate and body temperature were decreased by 0.4236 bpm and 0.0119 [Formula: see text]. The average longitudinal change of pulse rate and body temperature of patients who lived in rural was 1.4602 bpm and 0.1550 [Formula: see text] times less as compared to urban residence. Patients who had dangerous signs are significantly increased the average longitudinal change of pulse rate and body temperature by 2.042 bpm and 0.6031 [Formula: see text] as compared to patients who had no dangerous signs. A patient from rural residence was 1.1336 times more likely to experience the event of recovery as compared to urban residence. The estimated values of the association parameter for pulse rate and body temperature were -0.4236 bpm and -0.0119 respectively, which means pulse rate and body temperature were negatively related with patients recovery time.

CONCLUSION

Pulse rate and body temperature significantly affect the time to the first recovery of pneumonia patients who are receiving treatment. Age, residence, danger sign, comorbidity, baseline symptom and visiting time were the joint determinant factors for the longitudinal change of pulse rate, body temperature and time to recovery of pneumonia patients. The joint model approach provides precise dynamic predictions, widespread information about the disease transitions, and better knowledge of disease etiology.

Joint modeling of longitudinal measures of pneumonia and time to convalescence among pneumonia patients: a comparison of separate and joint models

BACKGROUND

Globally, pneumonia is the leading cause of children under age five morbidity and mortality with 98% of deaths in developing countries.

OBJECTIVE

This study aimed to identify the determinants of longitudinal measures of pneumonia and time to convalescence or recovery of under five admitted pneumonia patients at Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia.

METHODS

A prospective cohort study was conducted among a randomly selected sample of 101 pneumonia patients using simple random sampling who were on follow up from December 2019 to February 2020. A Linear mixed effect model were used for the longitudinal outcomes and joint model for modeling both longitudinal and time to event outcomes jointly respectively.

RESULTS

The significant values of shared parameters in the survival sub model shows that the use of joint modeling of multivariate longitudinal outcomes with the time to event outcome is the best model compared to separate models. The estimated values of the association parameters: - 0.297(p-value = 0.0021), - 0.121) (p-value = < 0.001) and 0.5452 (p-value = 0.006) indicates association of respiratory rate, pulse rate and oxygen saturation respectively with time to recovery. The significant values show that there is an evidence to say that there is a negative relationship between longitudinal measures of respiratory rate and pulse rate with time to recovery and there is positive relationship between longitudinal measures of oxygen saturation with time to recovery. Variables age, birth order, dangerous signs, severity and visit time were significant factors on the longitudinal measure of pulse rate. The significant factors related to longitudinal measures of oxygen saturation were birth order, severity and visit. From this we can conclude that birth order, severity and visit were significant variables that simultaneously affect the longitudinal measures of respiratory rate, pulse rate and oxygen saturation of patients at 5% level of significance.

CONCLUSION

Results of multivariate joint analysis shows that severity was significant variable that jointly affects the three longitudinal measures and time to recovery of pneumonia patients and we can conclude that patients with severe pneumonia have high values of respiratory rate and pulse rate as well as less amount of oxygen saturation and they need longer time to recover from the disease.

Time to recovery and predictors of severe community-acquired pneumonia among pediatric patients in Debre Markos referral hospital, North West Ethiopia: A retrospective follow-up study

Introduction

Globally, pneumonia is a major cause of morbidity and mortality among children which leads to over 156 million episodes and 14.9 million hospitalizations each year. Besides this fact, the recovery time and predictors of children’s hospitalization related to severe community-acquired pneumonia is not well known. Therefore, the aim of this study was to estimate the median time to recovery and its predictors among severe community-acquired pneumonia patients admitted to the pediatric ward, Debre Markos referral hospital, North West Ethiopia.

Methods

An institution-based retrospective follow-up study was employed among 352 records of children who were admitted starting from January 2016 to December 2018. Patients' charts were retrieved using a structured data extraction tool. Cox proportional hazard model assumption and model fitness was checked. Stratified Cox regression was fitted as a final model. Hazard ratio with its 95% confidence interval was used and P-value < 0.05 was considered as a statistically significant association.

Result

The overall median recovery time was 4 days IQR (3–7). Recovery rate from severe community acquired pneumonia was 16.25 (95% CI: 14.54–18.15) per 100 person day observation. Age (AHR; 0.94 95% CI (0.90–0.98)), being stunted (AHR; 0.62 95% CI (0.43–0.91)), presence of danger sign at admission (AHR; 0.61 95% CI (0.40–0.94)), late presentation to seek care(AHR; 0.64 95% CI (0.47–0.88)) and co-morbidity (AHR; 0.45 95% CI (0.35–0.58)) were significant predictors of recovery time.

Conclusion

The median recovery time from severe community-acquired pneumonia was long so that measures to reduce recovery time should be strengthened.

Discharge Before Return to Respiratory Baseline in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are commonly hospitalized with acute respiratory infections (ARI). These children frequently require respiratory support at baseline and are often discharged before return to respiratory baseline.

OBJECTIVE

To determine if discharge before return to respiratory baseline is associated with reutilization among children with NI hospitalized with ARI.

METHODS

This single-center retrospective cohort study included children with NI aged 1 to 18 years hospitalized with ARI who required increased respiratory support between January 2010 and September 2015. The primary exposure was discharge before return to respiratory baseline. The primary outcome was 30-day hospital reutilization. A generalized estimating equation was used to examine the association between exposure and outcome while accounting for within-patient clustering and patient-level clinical complexity and illness severity.

RESULTS

In the 632 hospitalizations experienced by 366 children, children were discharged before return to respiratory baseline in 30.4% of hospitalizations. Compared with those hospitalizations in which children were discharged at baseline, hospitalizations with a discharge before return to respiratory baseline were more likely to be for privately insured, technology-dependent children with respiratory comorbidities. Compared with discharges at respiratory baseline, discharges with increased respiratory support had no difference in 30-day reutilization (32.8% vs 31.8%; P = .81; adjusted OR 0.80, 95% CI 0.51-1.26).

CONCLUSIONS

Among children with NI hospitalized with ARI, discharge before return to respiratory baseline was common, but it was not associated with hospital reutilization. Return to respiratory baseline may not be a necessary component of discharge criteria in this population.

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

Radiologic Diagnosis and Hospitalization among Children with Severe Community Acquired Pneumonia: A Prospective Cohort Study

Objectives

This study was designed to assess the role of chest radiography for the diagnosis of pneumonia and assess the association of clinical characteristics with radiologic findings and predictors of hospitalization among children with severe community acquired pneumonia.

Methods

A prospective study was conducted on 122 children between ages of 3 month and 14 years admitted to pediatric emergency unit with diagnosis of severe pneumonia from September 1^st to November 30^th, 2017. Eligible children were subjected to chest radiography which was read by two senior radiologists independently (R1 and R2). Disagreements between R1 and R2 were resolved by a third senior radiologist (R3). Level of agreement between radiologists was assessed using Cohen's kappa coefficient. Clinical and laboratory parameters which could explain the variability in the duration of hospital stay were assessed using a linear regression mode. Independent predictors were assessed using multiple linear regression.

Results

The median age of the cohort was 10.0 months (interquartile range (IQR): 6.75-24.0); 76 (62.3%) were male. Nearly half, 63 (51.6%) did not have radiologic evidence of pneumonia. There was low level of agreement between R1 and R2 in reporting consolidation (kappa=0.435, p-value≤0.001), haziness (kappa=0.375, p-value≤0.001), and infiltration (kappa=0.267, p-value=0.008). Children with higher recorded temperature were more likely to have radiologic abnormalities suggesting pneumonia (p-value=0.033). The median duration of hospitalization was 3 days (IQR: 1-4 days); 118 (96.7%) were discharged with improvement. Height-for-age z-score (Coef.=0.203, R²=0.041, p-value=0.027); and hemoglobin level (Coef.=-0.249, R²=0.062, p-value=0.006) explained 4.1% and 6.2% of the variability in the duration of hospital stay, respectively.

Conclusion

Radiologic evidence of pneumonia was absent in half of the children with severe pneumonia. There was low agreement between senior radiologists in reporting chest radiographic findings, potentially necessitating harmonization activities to uniformly implement the WHO guidelines in reading chest radiographs.

Factors Associated With Pneumonia Severity in Children: A Systematic Review

Community-acquired pneumonia in children is associated with significant morbidity and mortality; however, data are limited in predicting which children will have negative outcomes, including clinical deterioration, severe disease, or development of complications. The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) pediatric pneumonia guideline includes criteria that were modified from adult criteria and define pneumonia severity to assist with resource allocation and site-of-care decision-making. However, the PIDS/IDSA criteria have not been formally developed or validated in children. Definitions for mild, moderate, and severe pneumonia also vary across the literature, further complicating the development of standardized severity criteria. This systematic review summarizes (1) the current state of the evidence for defining and predicting pneumonia severity in children as well as (2) emerging evidence focused on risk stratification of children with pneumonia.