Association of Radiology Findings with Etiology of Community Acquired Pneumonia among Children

Clinical Manifestations and Outcomes of SARS-CoV-2 Infection in Children and Adolescents

Compared to adults, children are more likely to experience asymptomatic infections or mild-to-moderate symptoms of SARS-CoV-2 infection that resemble other viral infections. However, a substantial proportion of children experience severe disease; more than 2000 US children have died of COVID-19, significantly exceeding the death toll from influenza. Risk factors for severe disease include age less than 6 months and 12 to 17 years, as well as the presence of underlying conditions, especially 2 or more conditions. Multisystem inflammatory syndrome in children is a life-threatening post-infectious complication seen in children. Children experience post-acute sequelae of SARS-CoV-2 but at lower rates than adults.

Clinical Features and Management Strategies in Children With Mycoplasma Pneumoniae

OBJECTIVE

Mycoplasma pneumoniae (Mp) is the most detected bacterial pathogen in children with community-acquired pneumonia (CAP). Our primary objective was to compare the clinical presentation, clinical management, and outcomes of children with and without Mp CAP across 6 children's hospitals.

METHODS

Eligible children were 2 months old or above and diagnosed with CAP in a prospective multicenter cohort study between October 1, 2015 and June 31, 2018. Children were excluded if they had complex chronic conditions. Children were tested for Mp via polymerase chain reaction assays. Clinical outcomes included hospitalization, and among hospitalized children length of stay, pediatric intensive care unit (PICU) admission, and rehospitalization within 8 weeks of discharge. Negative binomial and logistic regression were performed to determine the association of Mp with clinical outcomes.

RESULTS

Of the 415 children included, 38 (7.4%) had Mp detected. Children with Mp were older [median interquartile range age 8.8 (3.1, 13.0) vs. 4.6 (interquartile range: 2, 8.2) y], more likely to receive azithromycin (68.4% vs. 22.2%) and more likely to receive antibiotics in the prior 2 weeks (63.2% vs. 35.7%) versus those with non-Mp CAP. Children with Mp CAP were 33% less likely to stay in the hospital for an additional day (95% CI: 0.48-0.94).

CONCLUSION

Children with Mp CAP are more likely to have a longer duration of symptoms, but there are no statistical differences in symptom prevalence, laboratory values, or radiographic findings. There was no statistical difference in clinical outcomes for children with Mp CAP suggesting that clinical presentation and outcomes are similar between Mp and non-Mp CAP. Polymerase chain reaction testing for Mp CAP may be the only way to discriminate between non-Mp and Mp CAP.

Guideline-Concordant Antibiotic Use in Children With Community-Acquired Pneumonia

BACKGROUND

Despite national guidelines on appropriate antibiotic therapy, there is wide variation in antibiotic decision-making for children with community-acquired pneumonia. This study sought to determine prevalence and factors associated with guideline-concordant antibiotic use in children presenting with pneumonia to the emergency department (ED).

METHODS

We enrolled children aged younger than 18 years presenting to the ED at 2 US children's hospitals between September 2017 and May 2019 with clinical and radiographic pneumonia. The primary outcome was guideline-concordant antibiotic use as defined by the 2011 Infectious Diseases Society of America pediatric pneumonia guideline and local expert consensus. Outcomes included proportion of antibiotic use and proportion of guideline-concordant treatment. We used multivariable logistic regression models to determine associations of comorbidities and functional limitations, clinical findings, and radiographic characteristics with overall antibiotic use and guideline-concordant treatment.

RESULTS

Among 772 included children, 573 received antibiotics (74.2%), and 441 (57.1%) received guideline-concordant antibiotic treatment. Antibiotic initiation was less likely in those with interstitial findings on chest radiograph (adjusted odds ratio [aOR], 0.14; 95% CI, 0.07-0.25) and negative results or nonperformance of viral testing (aOR, 0.39; 95% CI, 0.24-0.65). Guideline-concordant treatment was more likely in those with chest indrawing (aOR, 2.22; 95% CI, 1.34-3.66) and less likely in those with clinically significant effusion (aOR, 0.21; 95% CI, 0.06-0.76).

CONCLUSIONS

Among children presenting to the ED with pneumonia, more than 40% received treatment inconsistent with guideline recommendations. These observations underscore opportunities to improve appropriate antibiotic use in this population.

Transcriptomic Biomarkers Associated With Microbiological Etiology and Disease Severity in Childhood Pneumonia

BACKGROUND

Challenges remain in discerning microbiologic etiology and disease severity in childhood pneumonia. Defining host transcriptomic profiles during illness may facilitate improved diagnostic and prognostic approaches.

METHODS

Using whole blood RNA sequencing from 222 hospitalized children with radiographic pneumonia and 45 age-matched controls, we identified differentially expressed (DE) genes that best identified children according to detected microbial pathogens (viral only vs bacterial only and typical vs atypical bacterial [with or without [±] viral co-detection]) and an ordinal measure of phenotypic severity (moderate, severe, very severe).

RESULTS

Overall, 135 (61%) children had viral-only detections, 15 (7%) had typical bacterial detections (± viral co-detections), and 26 (12%) had atypical bacterial detections (± viral co-detections). Eleven DE genes distinguished between viral-only and bacterial-only detections. Sixteen DE genes distinguished between atypical and typical bacterial detections (± viral co-detections). Nineteen DE genes distinguished between levels of pneumonia severity, including 4 genes also identified in the viral-only versus bacterial-only model (IGHGP, PI3, CD177, RAP1GAP1) and 4 genes from the typical versus atypical bacterial model (PRSS23, IFI27, OLFM4, ABO).

CONCLUSIONS

We identified transcriptomic biomarkers associated with microbial detections and phenotypic severity in children hospitalized with pneumonia. These DE genes are promising candidates for validation and translation into diagnostic and prognostic tools.

Twenty-four Month Outcomes of Extended- Versus Standard-course Antibiotic Therapy in Children Hospitalized With Pneumonia in High-risk Settings: A Randomized Controlled Trial

BACKGROUND

Pediatric community-acquired pneumonia (CAP) can lead to long-term respiratory sequelae, including bronchiectasis. We determined if an extended (13-14 days) versus standard (5-6 days) antibiotic course improves long-term outcomes in children hospitalized with CAP from populations at high risk of chronic respiratory disease.

METHODS

We undertook a multicenter, double-blind, superiority, randomized controlled trial involving 7 Australian, New Zealand, and Malaysian hospitals. Children aged 3 months to ≤5 years hospitalized with radiographic-confirmed CAP who received 1-3 days of intravenous antibiotics, then 3 days of oral amoxicillin-clavulanate, were randomized to either extended-course (8-day oral amoxicillin-clavulanate) or standard-course (8-day oral placebo) arms. Children were reviewed at 12 and 24 months. The primary outcome was children with the composite endpoint of chronic respiratory symptoms/signs (chronic cough at 12 and 24 months; ≥1 subsequent hospitalized acute lower respiratory infection by 24 months; or persistent and/or new chest radiographic signs at 12-months) at 24-months postdischarge, analyzed by intention-to-treat, where children with incomplete follow-up were assumed to have chronic respiratory symptoms/signs ("worst-case" scenario).

RESULTS

A total of 324 children were randomized [extended-course (n = 163), standard-course (n = 161)]. For our primary outcome, chronic respiratory symptoms/signs occurred in 97/163 (60%) and 94/161 (58%) children in the extended-courses and standard-courses, respectively [relative risk (RR) = 1.02, 95% confidence interval (CI): 0.85-1.22]. Among children where all sub-composite outcomes were known, chronic respiratory symptoms/signs between groups, RR = 1.10, 95% CI: 0.69-1.76 [extended-course = 27/93 (29%) and standard-course = 24/91 (26%)]. Additional sensitivity analyses also revealed no between-group differences.

CONCLUSION

Among children from high-risk populations hospitalized with CAP, 13-14 days of antibiotics (versus 5-6 days), did not improve long-term respiratory outcomes.

Prevalence of and Risks for Bacterial Infections in Hospitalized Children With Bronchiolitis

BACKGROUND AND OBJECTIVES

Viral bronchiolitis is a common pediatric illness. Treatment is supportive; however, some children have concurrent serious bacterial infections (cSBIs) requiring antibiotics. Identifying children with cSBI is challenging and may lead to unnecessary treatment. Improved understanding of the prevalence of and risk factors for cSBI are needed to guide treatment. We sought to determine the prevalence of cSBI and identify factors associated with cSBI in children hospitalized with bronchiolitis.

METHODS

We performed a retrospective cohort study of children <2 years old hospitalized with bronchiolitis at a free-standing children's hospital from 2012 to 2019 identified by International Classification of Diseases codes. cSBI was defined as bacteremia, urinary tract infection, meningitis, or pneumonia. Risk factors for cSBI were identified using logistic regression.

RESULTS

We identified 7871 admissions for bronchiolitis. At least 1 cSBI occurred in 4.2% of these admissions; with 3.5% meeting our bacterial pneumonia definition, 0.4% bacteremia, 0.3% urinary tract infection, and 0.02% meningitis. cSBI were more likely to occur in children with invasive mechanical ventilation (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.78-3.63), a C-reactive protein ≥4 mg/dL (OR 2.20, 95% CI 1.47-3.32), a concurrent complex chronic condition (OR 1.67, 95% CI 1.22-2.25) or admission to the PICU (OR 1.46, 95% CI 1.02-2.07).

CONCLUSIONS

cSBI is uncommon among children hospitalized with bronchiolitis, with pneumonia being the most common cSBI. Invasive mechanical ventilation, elevated C-reactive protein, presence of complex chronic conditions, and PICU admission were associated with an increased risk of cSBI.

Community-acquired bacterial pneumonia in children: an update on antibiotic duration and immunization strategies

PURPOSE OF REVIEW

This review is structured to update clinicians on the epidemiology, antibiotic treatment, and prevention of pediatric bacterial pneumonia. The review provides information regarding the current research on antibiotic management for bacterial pneumonia and the newest immunization recommendations to prevent pneumococcal pneumonia and other respiratory infections.

RECENT FINDINGS

The recommended length of antibiotic therapy for bacterial pneumonia has been discrepant between low-income and high-income countries. Recently, randomized controlled trials conducted in high-income countries provided evidence to support a short antibiotic course (3-5 days) for uncomplicated bacterial pneumonia in otherwise healthy children. The negative impact of inaccurate penicillin allergy labels in children with pneumonia has emphasized the importance of prompt allergy de-labeling. Newer pneumococcal vaccines are recommended for children and are expected to have a significant impact on bacterial pneumonia rates.

SUMMARY

Pediatric bacterial pneumonia is an important contributor to childhood morbidity and mortality. A short antibiotic course seems to be sufficient for the outpatient management of uncomplicated bacterial pneumonia; however, more studies are required in the inpatient setting. Future studies will inform the impact of recently introduced pneumococcal and respiratory syncytial virus vaccines on the epidemiology of bacterial pneumonia.