Community-acquired pneumonia in children

The diagnostic efficacy of metagenomic next-generation sequencing (mNGS) in pathogen identification of pediatric pneumonia using bronchoalveolar lavage fluid (BALF): A systematic review and meta-analysis

OBJECTIVE

This meta-analysis evaluates and compares the diagnostic efficacy of metagenomic next-generation sequencing (mNGS) with conventional microbiological tests (CMTs) in diagnosing pediatric pneumonia using bronchoalveolar lavage fluid (BALF).

METHODS

Data were sourced from Embase, PubMed, Web of Science, and the Cochrane Library. The pooled positive detection rate (PDR) of pathogens was estimated using fixed-effects or random-effects models. Subgroup analyses explored factors influencing mNGS diagnostic performance. Data analysis was conducted using Review Manager (RevMan) 5.4 and Stata version 16.0.

RESULTS

The pooled PDR of mNGS was 85.83 %, which is higher than the pooled PDR of 49.97 % for CMTs. A random-effects model indicated that, compared to CMTs, mNGS has a significantly higher PDR in pediatric pneumonia (OR = 3.99, 95 %CI: 2.12-7.50, P < 0.0001, I2 = 81 %). Subgroup analysis indicated that mNGS exhibited greater advantages in the group using the QIAamp kit (OR = 5.55, 95 % CI: 3.03-10.16, P < 0.00001), the group using the Illumina Nextseq platform (OR = 4.87, 95 % CI: 2.97-7.99, P < 0.00001), the DNA-only mNGS group (OR = 4.54, 95 % CI: 2.73-7.54, P < 0.00001), and the non-severe pneumonia group (OR = 4.76, 95 % CI: 3.51-6.46, P < 0.00001). However, when the subgroups were categorized as mixed infections or single-pathogen infections, no statistically significant differences were observed (Mixed: OR = 1.77, 95 % CI: 0.30-10.56, P = 0.53; Single: OR = 3.97, 95 % CI: 0.42-37.87, P = 0.23) CONCLUSION: mNGS demonstrates high diagnostic efficacy in detecting pathogens in BALF from pediatric patients with pneumonia. The diagnostic stability of mNGS is influenced by sample extraction, sequencing platforms, positive interpretation criteria, and disease status. Standardized procedures and technologies can enhance mNGS diagnostic performance.

Antibiotics for Paediatric Community-Acquired Pneumonia: What is the Optimal Course Duration?

Despite significant global reductions in cases of pneumonia during the last 3 decades, pneumonia remains the leading cause of post-neonatal mortality in children aged <5 years. Beyond the immediate disease burden it imposes, pneumonia contributes to long-term morbidity, including lung function deficits and bronchiectasis. Viruses are the most common cause of childhood pneumonia, but bacteria also play a crucial role. However, the optimal duration of antibiotic therapy for bacterial pneumonia remains uncertain in both low- and middle-income countries and in high-income countries. Knowing the optimal duration of antibiotic therapy for pneumonia is crucial for effective antimicrobial stewardship. This is especially important as concerns mount over rising antibiotic resistance in respiratory bacterial pathogens, which increases the risk of treatment failure. Numerous studies have focused on the duration of oral antibiotics and short-term outcomes, such as clinical cure and mortality. In contrast, only one study has examined both intravenous and oral antibiotics and their impact on long-term respiratory outcomes following pneumonia hospitalisation. However, study findings may be influenced by their inclusion criteria when children unlikely to have bacterial pneumonia are included. Efforts to differentiate between bacterial and non-bacterial pneumonia continue, but a validated, accurate, and simple point-of-care diagnostic test remains elusive. Without certainty that a child has bacterial pneumonia, determining the optimal duration of antibiotic treatment is challenging. This review examines the evidence for the recommended duration of antibiotics for treating uncomplicated pneumonia in otherwise healthy children and concludes that the question of duration is unresolved.

Subtractive genomics and drug repurposing strategies for targeting Streptococcus pneumoniae: insights from molecular docking and dynamics simulations

Introduction

Streptococcus pneumoniae is a Gram-positive bacterium responsible for severe infections such as meningitis and pneumonia. The increasing prevalence of antibiotic resistance necessitates the identification of new therapeutic targets. This study aimed to discover potential drug targets against S. pneumoniae using an in silico subtractive genomics approach.

Methods

The S. pneumoniae genome was compared to the human genome to identify non-homologous sequences using CD-HIT and BLASTp. Essential genes were identified using the Database of Essential Genes (DEG), with consideration for human gut microflora. Protein-protein interaction analyses were conducted to identify key hub genes, and gene ontology (GO) studies were performed to explore associated pathways. Due to the lack of crystal structure data, a potential target was modeled in silico and subjected to structure-based virtual screening.

Results

Approximately 2,000 of the 2,027 proteins from the S. pneumoniae genome were identified as non-homologous to humans. The DEG identified 48 essential genes, which was reduced to 21 after considering human gut microflora. Key hub genes included gpi, fba, rpoD, and trpS, associated with 20 pathways. Virtual screening of 2,509 FDA-approved compounds identified Bromfenac as a leading candidate, exhibiting a binding energy of -26.335 ± 29.105 kJ/mol.

Discussion

Bromfenac, particularly when conjugated with AuAgCu2O nanoparticles, has demonstrated antibacterial and anti-inflammatory properties against Staphylococcus aureus. This suggests that Bromfenac could be repurposed as a potential therapeutic agent against S. pneumoniae, pending further experimental validation. The approach highlights the potential for drug repurposing by targeting proteins essential in pathogens but absent in the host.

Clinical characteristics of pathogens in children with community-acquired pneumonia were analyzed via targeted next-generation sequencing detection

Background

The primary purpose of this study was to detect the pathogen species using targeted next-generation sequencing (tNGS) to investigate the characteristics of community-acquired pneumonia (CAP)-related pathogens in children in Xiantao city, Hubei province, China.

Methods

A total of 1,527 children with CAP were prospectively recruited from our hospital between May 2022 and February 2023. Information on age and sex was collected from the medical records. Pathogen detection was performed using standard detection methods and tNGS.

Results

The positive coincidence rate of standard detection methods and tNGS were 61.95% (946/1,527) and 97.05% (1,482/1,527), respectively. Among the 1,482 children with CAP, the numbers of bacteria, virus, chlamydia, and mycoplasma infection were 1,188, 975, 321, and 1, respectively. Co-existing species showed high prevalence in CAP, and the prevalence of children infected with only one pathogen was 20.31%. The numbers of children infected with two and three pathogens were the highest, accounting for 29.22% and 25.17%, respectively. Among the 44 pathogens detected using tNGS, 17 species of bacteria, 25 species of viruses, one species of chlamydia, and one species of mycoplasma were documented. Among all infectious pathogens, the top five were Haemophilus influenzae, Acinetobacter baumannii, Streptococcus pneumoniae, human herpes virus type 5 (HHV-5), and Mycoplasma pneumoniae. The results showed that pathogenic infections in children with CAP were related to age but not to gender.

Conclusion

The infection pathogens in children with CAP were complex and the incidence of co-existence was observed to be high. The pathogens involved in CAP were closely related to the age of the child. In addition, tNGS was shown to better identify pathogens than the standard detection method, which is crucial for improving the accuracy of early CAP diagnosis and initiating appropriate treatment in a timely manner, ultimately enhancing treatment outcomes.

Ultrasonography Compared to Computed Tomography in Pediatric Complicated Pneumonia: Beyond Radiation

Introduction Some children with community-acquired pneumonia (CAP) experience progression to complicated community-acquired pneumonia (CCAP). It is characterized by local pulmonary or systemic complications such as para-pneumonic effusion, empyema, necrotizing pneumonia, and lung abscess. Imaging has an essential contribution to both the diagnosis and treatment of CCAP. While chest radiography and lung ultrasound (LUS) are commonly used for initial evaluation, chest computed tomography (CT), although valuable, raises concerns due to ionizing radiation exposure. Against the backdrop of increasing awareness regarding radiation risks in pediatric patients and the growing availability of bedside LUS, we conducted this study. Objective The aim of this study was to assess the agreement between LUS and contrast-enhanced chest CT in identifying specific findings in patients of complicated pneumonia, such as pleural effusion, pleural thickening, parenchymal consolidation, cavities, atelectasis, and hydropneumothorax. Methods We retrospectively compared CT and LUS images from 50 patients under 18 years of age admitted with clinical and radiological diagnosis of complicated pneumonia between January 2022 and June 2023, who underwent both imaging modalities within a seven-day interval. Images were assessed for pleural effusion, septations, pleural thickening, parenchymal consolidation, cavities, hydropneumothorax, and atelectasis. Results Pleural effusion without septations was found in 25 (50%) patients on chest CT, whereas it was noted in 20 (40%) patients on LUS. Pleural effusion with septations was found in 21 (42%) patients on chest CT, whereas it was noted in 27 (54%) patients on LUS. Pleural thickening was found in 19 (38%) patients on chest CT, whereas it was noted in 9 (18%) patients on LUS. Lung parenchymal consolidation was found in 30 (60%) patients on chest CT, whereas it was noted in 16 (32%) patients on LUS. Atelectasis was found in 25 (50%) patients on chest CT, whereas it was noted in 26 (52%) patients on LUS. Parenchymal cavities were found in six (12%) patients on chest CT, whereas it was noted in two (4%) patients on LUS. Hydropneumothorax was found in six (12%) patients on chest CT, whereas it was noted in one (2%) patients on LUS. Conclusions LUS can be used as an initial investigation in complicated pneumonia, while chest CT is reserved for cases with suspicion of specific complications of pneumonia.

Treatment of mild to moderate community-acquired pneumonia in previously healthy children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-FIMMG-SIMG)

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside the hospital or other healthcare settings, typically affecting previously healthy individuals. This intersociety consensus aims to provide evidence-based recommendations for the antibiotic treatment of mild to moderate CAP in previously healthy children in Italy.A systematic review was conducted to identify the most recent and relevant evidence. Embase, Scopus, PubMed, and Cochrane databases were systematically screened, with a date restriction from 2012 to April 2024, but without language limitations. The review included studies conducted in high-income countries on antibiotic therapy in children over 3 months of age diagnosed with mild-moderate CAP. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods. The final recommendations were obtained through a Delphi consensus of an expert panel.Amoxicillin is the first-line treatment if the child is at least immunized against Haemophilus influenzae type b (low/very low quality of evidence, strong recommendations), while amoxicillin-clavulanate or second- or third-generation cephalosporins should be prescribed for those unimmunized or with incomplete immunization coverage for both H. influenzae type b and Streptococcus pneumoniae (low/very low quality of evidence, strong recommendations). Macrolides should be considered in addition to amoxicillin in children over 5 years old, if symptoms persist and the clinical condition remains good after 48 h of therapy (low/very low quality of evidence, strong recommendations). The dosage of amoxicillin is 90 mg/kg/day divided in three doses, although two doses could be considered to improve compliance (moderate quality of evidence, weak recommendations). A five-day duration of therapy is recommended, with clinical monitoring and re-assessment approximately 72 h after the start of antibiotic treatment to evaluate symptom resolution (moderate quality of evidence, strong recommendations).To improve the management of CAP in pediatric patients, we have developed this consensus based on a thorough review of the best available evidence and extensive discussions with an expert panel. However, further efforts are needed. Future research should focus on enhancing diagnostic accuracy, optimizing antibiotic utilization, comparing the efficacy of different antibiotic regimens, and determining the optimal dosage and duration of treatment in different setting.

Palm Multidiagnostic of Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae Using One-Tube CRISPR/Cas12a

The recent high incidence of Mycoplasma pneumoniae (Mp) infections has raised widespread public health concerns. Therefore, rapid and accurate diagnosis of respiratory pathogenic microbial infections is of paramount importance to provide clinicians with accurate diagnostic insights and guide clinical medication. In response to this urgent need, we developed a one-tube Palm CRISPR/Cas12a Diagnostic (PaCD) method. This method facilitates the rapid detection of Mp infections, as well as three other prevalent respiratory pathogens, Chlamydia pneumoniae (Cp), Haemophilus influenzae (Hi), and Streptococcus pneumoniae (SP). In addition, 3D printing was employed to fabricate a compact detection device that includes a temperature control module set at 39°C and a blue light irradiation module, significantly enhancing the feasibility of point-of-care testing. The PaCD diagnostic process takes only 30 min with a detection limit of 50 copies/test, making it suitable for analysis of sputum and throat swab samples. PaCD demonstrated 100% concordance (72/72) with next-generation sequencing and exhibited high concordance with computed tomography test results. These findings demonstrate the clinical feasibility of PaCD for the rapid and accurate diagnosis of infections caused by four prevalent respiratory pathogens, offering theoretical insights into the versatile application of point-of-care tests for the detection of other respiratory pathogens in various clinical scenarios.

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.

Neutrophil to lymphocyte ratio in pediatric patients with asthmatic exacerbation and community-acquired pneumonia

BACKGROUND

Compared with a lower neutrophil to lymphocyte ratio(NLR), a higher one denotes severe asthma exacerbation in hospitalized asthmatic children. In addition, NLR is significantly higher in pediatric patients with community-acquired pneumonia (CAP) than those without. Nevertheless, its role in pediatric patients with concomitant asthmatic exacerbation and CAP remains unknown.

METHODS

In this retrospective study including 1032 pediatric patients aged 5 to 14 years old, the diagnostic and prognostic value of NLR in children with concomitant asthmatic exacerbation and non-severe CAP were investigated.

RESULTS

The sensitivity and specificity of NLR for a diagnosis of CAP in patients with asthmatic exacerbation were 56.9% and 90.1%, respectively. The cutoff value of NLR for a diagnosis of CAP in patients with asthmatic exacerbation was 4.15 (P < 0.001). The cumulative asthmatic exacerbation during 3-month followup of patients with high NLR were 23 (21.3%) and 58 (42.0%) in the asthma and asthmatic CAP groups, respectively (P < 0.001). The patients with high NLR who had unimproved CAP were 15 (8.3%) and 23 (12.2%) in the CAP and asthmatic CAP groups, respectively (P = 0.006). Multivariate analyses showed that along with the increase of NLR by 1.0 point, the HR for the occurrence of asthmatic exacerbation and unimproved CAP were 2.91 [1.83-3.96] (P = 0.001) and 3.38 [1.66-5.10] (P < 0.001), respectively.

CONCLUSIONS

NLR had high and moderate diagnostic value for the exclusion and indication of CAP, respectively, in pediatric patients with asthmatic exacerbation. It also had prognostic value for the outcomes of pediatric patients with concomitant asthmatic exacerbation and CAP.

Community-Acquired Pneumonia in Children

ABSTRACT

Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.

Prevalence of Ventilator-Associated Pneumonia in Children Admitted to Pediatric ‎Intensive Care Units in the Middle East: A Systematic Review

Ventilator-associated pneumonia (VAP) is a common healthcare-associated disease in intensive care units, leading to significant morbidity and mortality. This systematic review aims to investigate the prevalence, risk factors, and prevention strategies for VAP in the Middle East. PubMed, SCOPUS, Web of Science, Science Direct, and Google Scholar were systematically searched to include the relevant literature. Rayyan QCRI was used throughout this systematic approach. Ten studies, involving a total of 6295 patients diagnosed with VAP, were included in this review. Among these patients, 336 (5.3%) developed VAP. The prevalence of VAP in children and neonates in the Middle East was relatively low. Risk factors associated with VAP development included prematurity, low birth weight, prolonged mechanical ventilation, enteral feeding, intrusive devices such as umbilical catheters, and cardiac operations. All reviewed studies emphasized the importance of infection control measures in reducing the risk of VAP.

A pediatric case series of invasive pneumococcal disease caused by S.Pneumonia serotype-19A despite full dose vaccination

Streptococcus pneumoniae is the leading cause of community-acquired pneumonia and bacterial meningitis in children. Although pneumococcal conjugate vaccines (PCVs) are commonly available, invasive pneumococcal disease (IPD) still remains a life-threatening complication. Serotype 19A has high invasive potential and is capable of causing extensive and destructive lung disease. This strain has greater invasive potential, may have a growth advantage over other pneumococcal serotypes in normally sterile sites, and is often resistant to multiple antibiotics. Although being a component of PCV13 vaccine, serotype 19A may still be seen in fully vaccinated children and can cause invasive disease. Herein, we present four cases of IPD caused by S. pneumoniae serotype 19A who received the full regimen of PCV13 vaccination.

Risk prediction model for long-term atelectasis in children with pneumonia

BACKGROUND

This study aimed to develop a risk prediction model for long-term atelectasis in children with pneumonia.

METHODS

A retrospective study of 532 children with atelectasis was performed at the Children's Hospital of Chongqing Medical University from February 2017 to March 2020. The predictive variables were screened by LASSO regression analysis and the nomogram was drawn by R software. The area under the Receiver Operating Characteristic (ROC) curve, calibration chart and decision curve were used to evaluate the predictive accuracy and clinical utility. 1000 Bootstrap resampling was used for internal verification.

RESULTS

Multivariate logistic regression analysis showed that clinical course before bronchoscopy, length of stay, bronchial mucus plug formation, age were independent risk factors for long-term atelectasis in children. The area under the ROC curve of nomogram was 0.857(95% CI = 0.8136 ~ 0.9006) in training set and 0.849(95% CI = 0.7848-0.9132) in the testing set. The calibration curve demonstrated that the nomogram was well-fitted, and decision curve analysis (DCA) showed that the nomogram had good clinical utility.

CONCLUSIONS

The model based on the risk factors of long-term atelectasis in children with pneumonia has good predictive accuracy and consistency, which can provide a certain reference value for clinical prevention and treatment of long-term atelectasis in children.

Early peripheral blood lymphocyte subsets and cytokines in predicting the severity of influenza B virus pneumonia in children

Background

Children with influenza B virus infection have a higher susceptibility and higher severity of illness. The activation and disorder of immune function play an important role in the severity of influenza virus infection. This study aims to investigate whether early lymphocyte count and cytokines can provide predictive value for the progression in children with influenza B virus pneumonia.

Methods

A retrospective cohort study was conducted to analyze the clinical data of children with influenza B virus pneumonia from December 1, 2021, to March 31, 2022, in the National Children's Regional Medical Center (Shengjing Hospital of China Medical University). According to the severity of the disease, the children were divided into a mild group and a severe group, and the clinical characteristics, routine laboratory examination, lymphocyte subsets, and cytokines were compared.

Results

A total of 93 children with influenza B virus pneumonia were enrolled, including 70 cases in the mild group and 23 cases in the severe group. Univariate analysis showed that drowsiness, dyspnea, white blood cell (WBC), lymphocytes, monocytes, procalcitonin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), fibrinogen (FIB), Immunoglobulin M (IgM), lung consolidation, total T cell count, CD4⁺ T cell count, CD8⁺ T cell count, NK cell count, NK cell % and B cell % had statistical differences between the mild and severe groups (P<0.05). In multivariate logistic regression analysis, reduced ALT (OR = 1.016), FIB (OR = 0.233), CD8⁺ T cell count (OR = 0.993) and NK cell count (OR = 0.987) were independently associated with the development of severe influenza B virus pneumonia.

Conclusions

The levels of T lymphocytes and NK cells were related to the progression of influenza B virus pneumonia in children, and the reduction of CD8⁺ T cell count and NK cell count can be used as independent risk factors for predicting the severity of influenza B virus pneumonia.

In Silico Subtractive Proteomics and Molecular Docking Approaches for the Identification of Novel Inhibitors against Streptococcus pneumoniae Strain D39

Streptococcus pneumoniae is a notorious Gram-positive pathogen present asymptomatically in the nasophayrnx of humans. According to the World Health Organization (W.H.O), pneumococcus causes approximately one million deaths yearly. Antibiotic resistance in S. pneumoniae is raising considerable concern around the world. There is an immediate need to address the major issues that have arisen as a result of persistent infections caused by S. pneumoniae. In the present study, subtractive proteomics was used in which the entire proteome of the pathogen consisting of 1947 proteins is effectively decreased to a finite number of possible targets. Various kinds of bioinformatics tools and software were applied for the discovery of novel inhibitors. The CD-HIT analysis revealed 1887 non-redundant sequences from the entire proteome. These non-redundant proteins were submitted to the BLASTp against the human proteome and 1423 proteins were screened as non-homologous. Further, databases of essential genes (DEGG) and J browser identified almost 171 essential proteins. Moreover, non-homologous, essential proteins were subjected in KEGG Pathway Database which shortlisted six unique proteins. In addition, the subcellular localization of these unique proteins was checked and cytoplasmic proteins were chosen for the druggability analysis, which resulted in three proteins, namely DNA binding response regulator (SPD_1085), UDP-N-acetylmuramate-L-alanine Ligase (SPD_1349) and RNA polymerase sigma factor (SPD_0958), which can act as a promising potent drug candidate to limit the toxicity caused by S. pneumoniae. The 3D structures of these proteins were predicted by Swiss Model, utilizing the homology modeling approach. Later, molecular docking by PyRx software 0.8 version was used to screen a library of phytochemicals retrieved from PubChem and ZINC databases and already approved drugs from DrugBank database against novel druggable targets to check their binding affinity with receptor proteins. The top two molecules from each receptor protein were selected based on the binding affinity, RMSD value, and the highest conformation. Finally, the absorption, distribution, metabolism, excretion, and toxicity (ADMET) analyses were carried out by utilizing the SWISS ADME and Protox tools. This research supported the discovery of cost-effective drugs against S. pneumoniae. However, more in vivo/in vitro research should be conducted on these targets to investigate their pharmacological efficacy and their function as efficient inhibitors.

Predicting the causative pathogen among children with pneumonia using a causal Bayesian network

BACKGROUND

Pneumonia remains a leading cause of hospitalization and death among young children worldwide, and the diagnostic challenge of differentiating bacterial from non-bacterial pneumonia is the main driver of antibiotic use for treating pneumonia in children. Causal Bayesian networks (BNs) serve as powerful tools for this problem as they provide clear maps of probabilistic relationships between variables and produce results in an explainable way by incorporating both domain expert knowledge and numerical data.

METHODS

We used domain expert knowledge and data in combination and iteratively, to construct, parameterise and validate a causal BN to predict causative pathogens for childhood pneumonia. Expert knowledge elicitation occurred through a series of group workshops, surveys and one-on-one meetings involving 6-8 experts from diverse domain areas. The model performance was evaluated based on both quantitative metrics and qualitative expert validation. Sensitivity analyses were conducted to investigate how the target output is influenced by varying key assumptions of a particularly high degree of uncertainty around data or domain expert knowledge.

RESULTS

Designed to apply to a cohort of children with X-ray confirmed pneumonia who presented to a tertiary paediatric hospital in Australia, the resulting BN offers explainable and quantitative predictions on a range of variables of interest, including the diagnosis of bacterial pneumonia, detection of respiratory pathogens in the nasopharynx, and the clinical phenotype of a pneumonia episode. Satisfactory numeric performance has been achieved including an area under the receiver operating characteristic curve of 0.8 in predicting clinically-confirmed bacterial pneumonia with sensitivity 88% and specificity 66% given certain input scenarios (i.e., information that is available and entered into the model) and trade-off preferences (i.e., relative weightings of the consequences of false positive versus false negative predictions). We specifically highlight that a desirable model output threshold for practical use is very dependent upon different input scenarios and trade-off preferences. Three commonly encountered scenarios were presented to demonstrate the potential usefulness of the BN outputs in various clinical pictures.

CONCLUSIONS

To our knowledge, this is the first causal model developed to help determine the causative pathogen for paediatric pneumonia. We have shown how the method works and how it would help decision making on the use of antibiotics, providing insight into how computational model predictions may be translated to actionable decisions in practice. We discussed key next steps including external validation, adaptation and implementation. Our model framework and the methodological approach can be adapted beyond our context to broad respiratory infections and geographical and healthcare settings.

Modern approaches at the management of children with community-acquired pneumonia

Experts of The Union of Pediatricians of Russia have developed current clinical guidelines for management of children with community-acquired pneumonia, which were approved by the Scientific and Practice Council of Ministry of Public Health of the Russian Federation in January 2022. Particular attention is paid to the etiological structure, modern classification, diagnostic tests and flagship approaches to antibacterial therapy of community-acquired pneumonia in children based on the principles of evidentiary medicine. 

Molecular epidemiology of respiratory syncytial virus in children with acute respiratory illnesses in Africa: A systematic review and meta-analysis

Background

Globally, the respiratory syncytial virus (RSV) is the most common etiologic agent of acute respiratory illnesses in children. However, its burden has not been well addressed in developing countries. We aimed to estimate the molecular epidemiology of RSV in children less than 18 years of age with acute respiratory infections in Africa by conducting a systematic review and meta-analysis.

Methods

We systematically searched PubMed, Scopus, CINAHL, and Global Index Medicus databases to identify studies published from January 1, 2002, to April 27, 2022, following the PRISMA 2020 guideline. We assessed the study quality using the Joanna Brigg's Institute (JBI) critical appraisal checklists. We conducted a qualitative synthesis by describing the characteristics of included studies and performed the quantitative synthesis with random effects model using STATA-14. We checked for heterogeneity with Q statistics, quantified by I², and determined the prediction interval. We performed subgroup analyses to explain the sources of heterogeneity and assessed publication biases by funnel plots augmented with Egger's test.

Results

Eighty-eight studies with 105 139 participants were included in the review. The overall pooled prevalence of RSV in children <18 years of age was 23% (95% confidence interval (CI) = 20, 25%). Considerable heterogeneity was present across the included studies. The adjusted prediction interval was found to be 19%-27%. Heterogeneities were explained by subgroups analyses. The highest prevalence of RSV was found among inpatients, 28% (95% CI = 25, 31%) compared with inpatients/outpatients and outpatients, with statistically significant differences (P < 0.01). The RSV estimate was also highest among those with acute lower respiratory tract illnesses (ALRTIs), 28% (95% CI = 25, 31%) compared with acute upper respiratory tract illnesses (AURTIs) and both acute upper/lower respiratory manifestations, with statistically different prevalence (P < 0.01). RSV infection estimates in each sub-region of Africa were statistically different (P < 0.01). There were no statistically significant differences in RSV infections by designs, specimen types, and specimen conditions, despite them contributing to heterogeneity.

Conclusions

We found a high prevalence of RSV in pediatric populations with acute respiratory tract illnesses in Africa, highlighting that the prevention and control of RSV infections in children deserve more attention.

Registration

PROSPERO CRD42022327054.

The molecular characteristics, diagnosis, and treatment of macrolide-resistant Mycoplasma pneumoniae in children

The purpose of this study is to review the molecular characteristics, the diagnosis, and treatment of the widespread infection of macrolide-resistant Mycoplasma pneumoniae (M. pneumoniae; MRMP) in children, thus providing a better knowledge of this infection and presenting the associated problems. Single point mutations in the V region of the 23S rRNA gene of M. pneumoniae genome are associated with macrolide resistance. P1-1, MLVA4-5-7-2, and ST3 are usually the predominated genetic types in the M. pneumoniae epidemics. The short-term two times serological IgM (or together with IgG) test in the acute stage can be used for confirmation. Combined serological testing and PCR might be a more prudent method to reduce macrolide consumption and antibiotic selective pressure in a clinical setting. Molecular methods for the detection of single-nucleotide mutations in the V region of the 23S rRNA gene can be used for the diagnosis of MRMP. The routine use of macrolide for the treatment of macrolide-sensitive Mycoplasma pneumoniae (MSMP) infections can get good effect, but the effects are limited for severe MRMP infections. Additional corticosteroids may be required for the treatment of severe MRMP infections in children in China during the era of MRMP.

The dilemma of improving rational antibiotic use in pediatric community-acquired pneumonia

Pneumonia is the number one cause of disease and deaths in children under five years old, outside the neonatal period, with the greatest number of cases reported from resource-limited settings. The etiology is variable, with not much information on the local etiology drug resistance profile in many countries. Recent studies suggest an increasing contribution from respiratory viruses, also in children with severe pneumonia, with an increased relative contribution in settings that have good vaccine coverage against common bacterial pathogens. Respiratory virus circulation was greatly reduced during highly restrictive measures to contain the spread of COVID-19 but rebounded once COVID-19 restrictions were relaxed. We conducted a comprehensive literature review of the disease burden, pathogens, case management and current available prevention of community acquired childhood pneumonia, with a focus on rational antibiotic use, since the treatment of respiratory infections is the leading cause of antibiotic use in children. Consistent application of revised World Health Organisation (WHO) guidance that children presenting with coryzal symptoms or wheeze can be managed without antibiotics in the absence of fever, will help to reduce unnecessary antibiotic use, as will increased availability and use of bedside inflammatory marker tests, such as C-reactive protein (CRP) in children with respiratory symptoms and fever.

Epidemiology and mortality predictors for severe childhood community-acquired pneumonia in ICUs: A retrospective observational study

Background

To identify the epidemiology and mortality predictors of severe childhood community-acquired pneumonia (CAP) and evaluate the influence of medications on clinical outcomes in the real world.

Methods

We conducted a multicenter retrospective observational study among children aged ≤5 years with severe CAP, separately comparing the detailed information between those who experienced in-hospital death and those who survived in three different age groups. A multivariate logistic regression model was used to determine mortality predictors.

Results

A total of 945 children were recruited: 341 young children aged 2-59 months, 47 infants aged 29 days to 2 months, and 557 neonates aged less than 28 days. A total of 88 deaths occurred (9.3%). There was low adherence to antimicrobial guidelines in the group aged 2-59 months, and carbapenems widely served as initial empirical regimens. However, analysis of all three age groups showed that the efficacy of antibacterial drugs with initial empirical selection grades higher than those recommended by the guidelines was not better than that of antibacterial drugs with grades recommended by the guidelines. In multivariate analyses, very severe pneumonia (odds ratio (OR): 3.48; 95% confidence interval (CI): 1.36-8.93), lower birth weight (OR: 4.64; 95% CI: 1.78-12.20), severe underweight (OR: 6.06; 95% CI: 2.34-15.63), mechanical ventilation (OR: 2.58; 95% CI: 1.00-6.62; OR: 15.63; 95% CI 3.25-76.92), a higher number of comorbidities (OR: 8.40; 95% CI: 1.89-37.04), comorbidities including anemia (OR: 5.24; 95% CI: 2.33-11.76) and gastrointestinal hemorrhage (OR: 3.79; 95% CI: 1.36-10.53), and the use of sedative-hypnotics (OR: 2.60; 95% CI: 1.14-5.95) were independent risk factors for death; infants treated with probiotics had a lower mortality rate (OR: 0.14; 95% CI: 0.06-0.33).

Conclusions

Severe CAP remains a primary cause of death in children under 5 years of age. Clinical characteristics, comorbidities and medications are evidently associated with death. Importantly, we should pay particular attention to the identification of mortality predictors and establish prophylactic measures to reduce mortality.

Novel care pathway to optimise antimicrobial prescribing for uncomplicated community-acquired pneumonia: study protocol for a prospective before-after cohort study in the emergency department of a tertiary care Canadian children's hospital

INTRODUCTION

Evidence-based recommendations for paediatric community-acquired pneumonia (CAP) diagnosis and management are needed. Uncomplicated CAP is often caused by respiratory viruses, especially in younger children; these episodes self-resolve without antibiotic treatment. Unfortunately, there are no clinical criteria that reliably discriminate between viral and bacterial disease, and so the majority of children diagnosed with CAP are given antibiotics-even though these will often not help and may cause harm. We have developed a novel care pathway that incorporates point-of-care biomarkers, radiographic patterns, microbiological testing and targeted follow-up. The primary study objective is to determine if the care pathway will be associated with less antimicrobial prescribing.

METHODS AND ANALYSIS

A prospective, before-after, study. Previously well children aged≥6 months presenting to a paediatric emergency department (ED) that have at least one respiratory symptom/sign, receive chest radiography, and are diagnosed with CAP by the ED physician will be eligible. Those with medical comorbidities, recently diagnosed pulmonary infection, or ongoing fever after≥4 days of antimicrobial therapy will be excluded. In the control (before) phase, eligible participants will be managed as per the standard of care. In the intervention (after) phase, eligible participants will be managed as per the novel care pathway. The primary outcome will be the proportion of participants in each phase who receive antimicrobial treatment for CAP. The secondary outcomes include: clinical cure; re-presentation to the ED; hospitalisation; time to resolution of symptoms; drug adverse events; caregiver satisfaction; child absenteeism from daycare/school; and caregiver absenteeism from work.

ETHICS AND DISSEMINATION

All study documentation has been approved by the Hamilton Integrated Research Ethics Board and informed consent will be obtained from all participants. Data from this study will be presented at major conferences and published in peer-reviewed publications to facilitate collaborations with networks of clinicians experienced in the dissemination of clinical guidelines.

TRIAL REGISTRATION NUMBER

NCT05114161.

Application of Metagenomic Next-Generation Sequencing (mNGS) Using Bronchoalveolar Lavage Fluid (BALF) in Diagnosing Pneumonia of Children

Pneumonia is the leading cause of death in children; the pathogens are often difficult to diagnose. In this study, the performance of metagenomic next-generation sequencing (mNGS) using bronchoalveolar lavage fluid (BALF) samples from 112 children with confirmed pneumonia has been evaluated. mNGS performed a significantly higher positive detection rate (91.07%, 95% confidence interval [CI] 83.80% to 95.40%) and coincidence rate against the final diagnosis (72.32%, 95% CI 62.93% to 80.15%) than that of conventional methods (70.54%, 95% CI 61.06% to 78.58% and 56.25%, 95% CI 46.57% to 65.50%, respectively) (P < 0.01 and P < 0.05, respectively). Bacteria, viruses, and their mixed infections were common in children with pneumonia. Streptococcus pneumoniae was the most common bacterial pathogen in children with pneumonia, while Haemophilus parainfluenzae and Haemophilus influenzae seemed more likely to cause nonsevere pneumonia in children. In contrast, human cytomegalovirus (CMV) infection and the simultaneous bacterial infections could cause severe pneumonia, especially in children with underlying diseases. After adjustments of antibiotics based on mNGS and conventional methods, the conditions improved in 109 (97.32%) children. mNGS of BALF samples has shown great advantages in diagnosing the pathogenic etiology of pneumonia in children, especially when considering the limited volumes of BALF and the previous use of empirical antibiotics, contributing to the timely adjustment of antibiotic treatments, which can potentially improve the prognosis and decrease the mortality. IMPORTANCE Our study indicates high efficiency of mNGS using BALF for the detection of causative pathogens that cause pneumonia in children. mNGS can be a potential diagnostic tool to supplement conventional methods for children's pneumonia.

Bacterial etiology of pneumonia in children up to 2 months of age: a systematic review

Background: Following the widespread introduction of childhood pneumococcal conjugate vaccines (PCVs), a significant impact on pneumonia mortality in children under five years of age has been reported. It is still unknown whether PCVs are expected to reduce pneumonia burden in younger children, particularly ≤2 months of age, as current evidence on the role of S. pneumoniae in pneumonia etiology in this age group is scarce. We aimed to summarize the evidence of bacterial etiology of pneumonia in children ≤2 months of age. Methods: We conducted a systematic review considering studies evaluating a variety of syndromes associated with pneumonia, and reporting on laboratory confirmed etiologies, considering any diagnostic method and a variety of clinical specimens.  We searched Medline/PubMed, Embase, WoS, Central and Index Medicus Global published in any language till April 30th, 2021. We included studies addressing the outcomes of interest in children ≤2 months of age and reporting on clinical trials, observational studies, and case series with at least 10 events. Screening of citations and data extraction were conducted in duplicate by independent reviewers, according to the study protocol registered on PROSPERO. Descriptive analyses of the various etiologic agents by syndrome are reported. Results: We identified 3,744 citations, of which 22 publications reporting on 13 studies were included. Study methods varied significantly. Nonetheless, gram positive organisms, in particular S. pneumoniae, were identified as important etiologic agents of pneumonia in children ≤2 months of age. Viral etiologies, in particular Respiratory Syncytial Virus, Rhinovirus, and Influenza were also identified. Conclusions: This review provides the most comprehensive analysis to date of the etiologies of pneumonia in children ≤2 months of age, suggesting that PCV impact is expected to occur in this age group. These results also have major implications for diagnosis and treatment of pneumonia in this age group.

Assessment of surveillance predictors for suspected respiratory syncytial virus, influenza and Streptococcus pneumoniae infections in children aged <5 years in Madagascar

•

A sensitive surveillance case definition can be defined based on specific symptoms.

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Intercostal recession and dyspnoea may be used to identify children with respiratory syncytial virus (RSV) infection.

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Fever was not necessarily a good predictor of paediatric RSV infection.

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Headache may be used to identify influenza infection in children.

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Sweats and productive cough may define infection due to Streptococcus pneumoniae in children.

Background

The lack of rapid, sensitive and affordable diagnostic tests that can distinguish a wide variety of respiratory pathogens at the point of care is an obstacle to the rapid implementation of control measures following events and epidemics. In addition, the absence of a standardized case definition to differentiate putative aetiologies is a challenge to assessing the burden of disease. This study aimed to identify the clinical spectrum of respiratory pathogens commonly associated with respiratory tract infections in the context of disease surveillance.

Methods

Data obtained from prospective hospital-based severe acute respiratory infection surveillance among children aged <5 years from November 2010 to July 2013 were used in this study.

Results

Intercostal recession and dyspnoea were predictive of respiratory syncytial virus (RSV) infection, whereas headache and chills were more often observed during influenza A infection. Male patients were at a higher risk for RSV infection than female patients. Productive cough, chills, sweating and weight loss were significantly associated with Streptococcus pneumoniae infection. The presence of fever did not necessarily indicate RSV infection.

Conclusions

Combined with other examinations, this study shows the value of including the syndromic approach in the panel of diagnostic criteria for rapid identification of the risk of infectious diseases in areas where laboratory diagnostics are challenging. Given the current situation with coronavirus disease 2019, this approach may help decision makers to implement appropriate control measures.

An immunoinformatics-based designed multi-epitope candidate vaccine (mpme-VAC/STV-1) against Mycoplasma pneumoniae

Pneumonia is a serious global health problem that accounts for over one million deaths annually. Among the main microorganisms causing pneumonia, Mycoplasma pneumoniae is one of the most common ones for which a vaccine is immediately required. In this context, a multi-epitope vaccine against this pathogen could be the best option that can induce effective immune response avoiding any serious adverse reactions. In this study, using an immunoinformatics approach we have designed a multi-epitope vaccine (mpme-VAC/STV-1) against M. pneumoniae. Our designed mpme-VAC/STV-1 is constructed using CTL (cytotoxic T lymphocyte), HTL (Helper T lymphocyte), and B-cell epitopes. These epitopes are selected from the core proteins of 88 M. pneumoniae genomes that were previously identified through reverse vaccinology approaches. The epitopes were filtered according to their immunogenicity, population coverage, and several other criteria. Sixteen CTL/B- and thirteen HTL/B- epitopes that belong to 5 core proteins were combined together through peptide linkers to develop the mpme-VAC/STV-1. The heat-labile enterotoxin from E. coli was used as an adjuvant. The designed mpme-VAC/STV-1 is predicted to be stable, non-toxic, non-allergenic, non-host homologous, and with required antigenic and immunogenic properties. Docking and molecular dynamic simulation of mpme-VAC/STV-1 shows that it can stimulate TLR2 pathway mediated immunogenic reactions. In silico cloning of mpme-VAC/STV-1 in an expression vector also shows positive results. Finally, the mpme-VAC/STV-1 also shows promising efficacy in immune simulation tests. Therefore, our constructed mpme-VAC/STV-1 could be a safe and effective multi-epitope vaccine for immunization against pneumonia. However, it requires further experimental and clinical validations.

Mycoplasma pneumoniae infection prediction model for hospitalized community-acquired pneumonia children

OBJECTIVES

We sought to develop a nomogram to predict Mycoplasma pneumoniae (Mp) infection among hospitalized children with community-acquired pneumonia (CAP) and compare it with another model developed from age and duration of fever.

METHODS

Data on 5904 CAP children who were enrolled at Shanghai Children's Medical Center were retrospectively collected and divided into a training set (n = 4133) and a validation set (n = 1771). The model's performance was determined by concordance index (C-index), calibration curves, Brier scores, and decision curve analyses (DCAs). Akaike information criterion (AIC) and Bayesian information criterion (BIC) were used for model comparisons.

RESULTS

Incorporating five factors (age, duration of fever, erythrocyte sedimentation rate, leukocyte count, and neutrophil proportion), the nomogram achieved good C-index values of 0.74 (95% confidence interval [CI]: 0.72-0.76) and 0.75 (95% CI: 0.73-0.78) and good Brier scores of 0.14 (95% CI: 0.13-0.15) and 0.17 (95% CI: 0.15-0.18) in predicting Mp infection in the training and validation cohorts, respectively, and had moderate fitted calibration plots. The DCAs showed good clinical usefulness of the nomogram. Patients were effectively divided into low, medium, and high risk groups by two cut-off score points of the nomogram, 210 and 300. With the lower AIC (3673.5) and BIC (3774.7) value, the model of five predictors is the better model.

CONCLUSIONS

By using five predictor variables, a simple nomogram of good predictive accuracy for Mp infection and moderate agreements between the actual outcome and the predicted probability was constructed. It could serve as a tool to aid physicians in clinical decision-making processes.

Evaluation of the in vitro activity of ceftaroline, ceftazidime/avibactam and comparator antimicrobial agents against clinical isolates from paediatric patients in Kuwait: ATLAS data 2012-19

OBJECTIVES

To report antimicrobial resistance data for Gram-positive and Gram-negative pathogens isolated from paediatric patients in three hospitals in Kuwait during 2012-19.

METHODS

In vitro activity of antimicrobials against isolates from documented infections was determined using CLSI broth microdilution method and breakpoints at a central laboratory. Enterobacterales and Pseudomonas aeruginosa isolates were screened for β-lactamases using multiplex PCR assays. Phenotypic determination of resistance in Haemophilus influenzae and Gram-positive isolates was performed using standard methodologies.

RESULTS

Among 515 Enterobacterales isolates, 29.3% were ESBL-positive; susceptibility was highest to amikacin, ceftazidime/avibactam and meropenem (≥97.4%), regardless of ESBL status. CTX-M-15 was identified in 87.1% of ESBL-positive Escherichia coli and 84.2% of ESBL-positive Klebsiella pneumoniae isolates. Of 111 P. aeruginosa isolates, 9.9% were MDR and 12.6% meropenem-resistant (MEM-R). Amikacin and ceftazidime/avibactam had the highest susceptibility rates in the overall group (≥92.8%), with reduced rates among MDR and MEM-R isolates. All 269 MRSA and 180 MSSA isolates were susceptible to daptomycin, linezolid, teicoplanin, tigecycline and vancomycin. All MSSA and 99.3% of MRSA were ceftaroline susceptible. All 168 pneumococcal isolates were susceptible to ceftaroline, linezolid, tigecycline and vancomycin. H. influenzae and Streptococcus pyogenes ceftaroline susceptibility rates were ≥93.3% and ≥95.6%.

CONCLUSIONS

Most isolates of Enterobacterales (including resistant phenotypes) and P. aeruginosa from Kuwait during 2012-19 were susceptible to ceftazidime/avibactam. Ceftaroline was active against most Gram-positive isolates, including resistant phenotypes, and ESBL-negative Enterobacterales. These results indicate that novel antibiotics such as ceftazidime/avibactam and ceftaroline represent valuable treatment options for paediatric infections, including those caused by MDR organisms.

Pediatric Lower Respiratory Tract Infections: Imaging Guidelines and Recommendations

Lower respiratory tract infection (LRTI) remains a major cause of morbidity and mortality in children. Various organisms cause LRTI, including viruses, bacteria, fungi, and parasites, among others. Infections caused by 2 or more organisms also occur, sometimes enhancing the severity of the infection. Medical imaging helps confirm a diagnosis but also plays a role in the evaluation of acute and chronic sequelae. Medical imaging tests help evaluate underlying pathology in pediatric patients with recurrent or long-standing symptoms as well as the immunocompromised.

Effects of minocycline on macrolide-unresponsive Mycoplasma pneumoniae pneumonia in children: a single-center retrospective study

BACKGROUND

Macrolide-resistant Mycoplasma pneumoniae (Mp) has become widespread in the world. We sought to determine the independently associated risk factors for refractory Mp pneumonia among macrolide-unresponsive Mp pneumonia children treated with minocycline and to investigate the effects of minocycline against macrolide-unresponsive Mp pneumonia.

METHODS

In our center, we retrospectively analyzed the data of hospitalized macrolide-unresponsive Mp pneumonia patients aged ≤18 years old who changed macrolide therapies to minocycline treatments between March 2013 and September 2018. Patient characteristics and defervescence after minocycline treatment were compared between refractory Mp pneumonia and non-refractory Mp pneumonia groups. Multivariable logistic regression analysis was performed among these macrolide-unresponsive Mp pneumonia patients.

RESULTS

Among 150 included macrolide-unresponsive Mp pneumonia children treated with minocycline; 30 cases (20.0%) were refractory Mp pneumonia. Duration of macrolide treatment before administration of minocycline (odds ratio =2.87, 95% CI: 1.79-4.61, P<0.001) and serum procalcitonin levels (odds ratio =13.50, 95% CI: 1.22-149.57, P=0.034) were independently associated with refractory Mp pneumonia. Defervescence after minocycline treatment was significantly longer among the refractory Mp pneumonia group than in the non-refractory Mp pneumonia group (median 2 vs. 1 day, P<0.001). Only one case (0.7%) suspected of a side effect of minocycline therapy was observed.

CONCLUSIONS

Two risk factors independently associated with refractory Mp pneumonia were determined. Early use of minocycline might safely prevent macrolide-unresponsive Mp pneumonia from progressing to refractory Mp pneumonia.

Viral and Atypical Bacterial Detection in Young Nepalese Children Hospitalized with Severe Pneumonia

Respiratory viruses cause a substantial proportion of respiratory tract infections in children but are underrecognized as a cause of severe pneumonia hospitalization in low-income settings. We employed 22 real-time PCR assays and retrospectively reanalyzed 610 nasopharyngeal aspirate specimens from children aged 2 to 35 months with severe pneumonia (WHO definition) admitted to Kanti Childrens' Hospital in Kathmandu, Nepal, from January 2006 through June 2008. Previously, ≥1 of 7 viruses had been detected by multiplex reverse transcription-PCR in 30% (188/627) of cases. Reanalyzing the stored specimens, we detected ≥1 pathogens, including 18 respiratory viruses and 3 atypical bacteria, in 98.7% (602/610) of cases. Rhinovirus (RV) and respiratory syncytial virus (RSV) were the most common, detected in 318 (52.1%) and 299 (49%) cases, respectively, followed by adenovirus (AdV) (10.6%), human metapneumovirus (hMPV) (9.7%), parainfluenza virus type 3 (8.4%), and enterovirus (7.7%). The remaining pathogens were each detected in less than 5%. Mycoplasma pneumoniae was most common among the atypical bacteria (3.7%). Codetections were observed in 53.3% of cases. Single-virus detection was more common for hMPV (46%) and RSV (41%) than for RV (22%) and AdV (6%). The mean cycle threshold value for detection of each pathogen tended to be lower in single-pathogen detections than in codetections. This finding was significant for RSV, RV, and AdV. RSV outbreaks occurred at the end of the monsoon or during winter. An expanded diagnostic PCR panel substantially increased the detection of respiratory viruses in young Nepalese children hospitalized with severe pneumonia. IMPORTANCE Respiratory viruses are an important cause of respiratory tract infections in children but are underrecognized as a cause of pneumonia hospitalization in low-income settings. Previously, we detected at least one of seven respiratory viruses by PCR in 30% of young Nepalese children hospitalized with severe pneumonia over a period of 36 months. Using updated PCR assays detecting 21 different viruses and atypical bacteria, we reanalyzed 610 stored upper-respiratory specimens from these children. Respiratory viruses were detected in nearly all children hospitalized for pneumonia. RSV and rhinovirus were the predominant pathogens detected. Detection of two or more pathogens was observed in more than 50% of the pneumonia cases. Single-virus detection was more common for human metapneumovirus and RSV than for rhinovirus and adenovirus. The concentration of virus was higher (low cycle threshold [CT] value) for single detected pathogens, hinting at a high viral load as a marker of clinical significance.

The Metabolome of Carbapenem-Resistant Klebsiella pneumoniae Infection in Plasma

AIM

Carbapenem-resistant Klebsiella pneumoniae- (CR-Kp-) mediated infections represent a challenge for clinical practitioners due to their expanding prevalence in hospital environments and antibiotic resistance. However, few studies have shown metabolic changes of carbapenem-resistant Klebsiella pneumoniae and CR-Kp-negative patients, and relevant studies are urgently needed.

METHODS

In this study, we comprehensively profile the metabolites of 20 CR-Kp-positive and 18 CR-Kp-negative patients in plasma by using 2D gas chromatography-time-of-flight mass spectrometry (GC×GC-TOFMS).

RESULTS

We identified 58 metabolites that were carbapenem-resistant Klebsiella pneumoniae-associated. N-Acetyl glucosamine, butanedioic acid, and myoinositol play a significant character in CR-Kp infection.

CONCLUSIONS

Our study provides valuable data to serve as potential targets for developing therapies against CR-Kp infection.

Genotype and mutation patterns of macrolide resistance genes of Mycoplasma pneumoniae from children with pneumonia in Qingdao, China, in 2019

OBJECTIVES

This study assessed the incidence and resistance of Mycoplasma pneumoniae (MP) in children in Qingdao, China, in 2019.

METHODS

We detected MP infection in 78 pharyngeal swabs from children with pneumonia by qPCR. The RepMP4 element in the P1 adhesin gene, domain V of the 23S rRNA gene, and the L4/L22 ribosomal proteins were amplified by nested PCR. Evolutionary analysis was conducted based on the P1 gene sequence. Resistance mutations in domain V of the 23S rRNA gene and L4/L22 ribosomal proteins were analysed.

RESULTS

The incidence of MP infection in children with pneumonia was 59.0% (46/78). The mean duration of MP infection was longer than that of non-MP infection. According to P1 gene sequencing of 21 samples, 12 (57.1%) were type 1 and 9 (42.9%) were type 2. Drug resistance mutations A2063G in domain V of 23S rRNA gene and T508C in L22 were identified from all sequenced MP. However, mutations at positions 2064 and 2617 were not found in this study. C162A mutation appeared in most type 2 samples. A430G mutation appeared in one type 1 sample and in several type 2 samples. T279C mutation in L22 was mostly found in type 2 samples.

CONCLUSION

The incidence of MP infection was 59.0% in children with pneumonia in Qingdao in 2019. Type 1 MP infection was slightly more common than type 2, indicating that the genotype of MP is gradually shifting from type 1 to type 2. Macrolide resistance mutation A2063G could be detected in all sequenced MP.

A Proof of Concept of the Role of TDM-Based Clinical Pharmacological Advices in Optimizing Antimicrobial Therapy on Real-Time in Different Paediatric Settings

Introduction: Antimicrobial treatment is quite common among hospitalized children. The dynamic age-associated physiological variations coupled with the pathophysiological alterations caused by underlying illness and potential drug-drug interactions makes the implementation of appropriate antimicrobial dosing extremely challenging among paediatrics. Therapeutic drug monitoring (TDM) may represent a valuable tool for assisting clinicians in optimizing antimicrobial exposure. Clinical pharmacological advice (CPA) is an approach based on the correct interpretation of the TDM result by the MD Clinical Pharmacologist in relation to specific underlying conditions, namely the antimicrobial susceptibility of the clinical isolate, the site of infection, the pathophysiological characteristics of the patient and/or the drug-drug interactions of cotreatments. The aim of this study was to assess the role of TDM-based CPAs in providing useful recommendations for the real-time personalization of antimicrobial dosing regimens in various paediatric settings. Materials and methods: Paediatric patients who were admitted to different settings of the IRCCS Azienda Ospedaliero-Universitaria of Bologna, Italy (paediatric intensive care unit [ICU], paediatric onco-haematology, neonatology, and emergency paediatric ward), between January 2021 and June 2021 and who received TDM-based CPAs on real-time for personalization of antimicrobial therapy were retrospectively assessed. Demographic and clinical features, CPAs delivered in relation to different settings and antimicrobials, and type of dosing adjustments were extracted. Two indicators of performance were identified. The number of dosing adjustments provided over the total number of delivered CPAs. The turnaround time (TAT) of CPAs according to a predefined scale (optimal, <12 h; quasi-optimal, between 12-24 h; acceptable, between 24-48 h; suboptimal, >48 h). Results: Overall, 247 CPAs were delivered to 53 paediatric patients (mean 4.7 ± 3.7 CPAs/patient). Most were delivered to onco-haematological patients (39.6%) and to ICU patients (35.8%), and concerned mainly isavuconazole (19.0%) and voriconazole (17.8%). Overall, CPAs suggested dosing adjustments in 37.7% of cases (24.3% increases and 13.4% decreases). Median TAT was 7.5 h (IQR 6.1-8.8 h). Overall, CPAs TAT was optimal in 91.5% of cases, and suboptimal in only 0.8% of cases. Discussion: Our study provides a proof of concept of the helpful role that TDM-based real-time CPAs may have in optimizing antimicrobial exposure in different challenging paediatric scenarios.

Evaluation of Human Respiratory Syncytial Virus and Human Parainfluenza Virus Type 3 among Hospitalized Children in Northwest of Iran

Background

Acute respiratory tract infections (ARTIs) are the leading cause of illnesses in children. Human respiratory syncytial virus (HRSV) and human parainfluenza viruses (HPIVs) are among the most common etiologic agents associated with viral respiratory tract infections in children worldwide. Nevertheless, limited information is available on the spread of infections of these two viruses in northwest Iran.

Objective

The purpose of the current study is to evaluate the frequency of RSV and HPIV-3 and clinical features among Iranian children with confirmed respiratory infections between April 2019 and March 2020.

Methods

100 nasopharyngeal swabs were collected from hospitalized patients (under 5 years old) with ARTI from Tabriz Children's Hospital. Detection of respiratory viruses was performed using the nested RT-PCR method.

Results

Respiratory syncytial virus and HPIV-3 were recognized in 18% (18/100) and 2% (2/100) of children, respectively. Ten (55.6%) of the RSV-positive samples were male, while 8 (44.4%) were female. HPIV-3 was found only among 2 male patients (100%). Most patients (61.1%) with RSV infection were less than 12 months old. Additionally, samples that were positive for HPIV-3 were less than 12 months old. RSV infections had occurred mainly during the winter season.

Conclusions

This study confirms that RSV can be one of the important respiratory pathogens in children in northwestern Iran. However, according to this study, HPIV-3 has a lower prevalence among children in this area than RSV. Therefore, implementing a routine diagnosis for respiratory pathogens can improve the management of respiratory infections in children.

Epidemiology of Respiratory Pathogens Among Children Hospitalized for Pneumonia in Xiamen: A Retrospective Study

OBJECTIVES

To investigate the etiology of common respiratory pathogens in children < 2 years of age hospitalized with pneumonia in Xiamen from 2014 to 2017.

METHODS

The medical records of 5581 children with pneumonia were retrospectively reviewed. Direct immunofluorescent test was used for respiratory virus testing. Bacteria were detected by conventional culture method. The results of pathogen detection at admission were analyzed as well as the clinical outcomes of children.

RESULTS

The burden of hospitalized children with pneumonia was highest among infants < 6 months old (58.2%). Respiratory syncytial virus (RSV) was the most common respiratory virus (26.0%) followed by parainfluenza (4.8%) and adenovirus (3.2%). Haemophilus influenzae was the most common bacteria detected (16.6%) followed by Moraxella catarrhalis (13.4%), Staphylococcus aureus (13.0%), Streptococcus pneumoniae (12.3%), Escherichia coli (5.1%) and Klebsiella pneumoniae (4.8%). Notably, RSV and K. pneumoniae were detected more frequently in severe pneumonia (35.0% and 10.9%) versus mild pneumonia (25.6% and 4.6%), with higher rates of ICU admissions, longer hospital stays and higher hospital costs compared to those infected with other respiratory pathogens.

CONCLUSIONS

Among children < 2 years of age hospitalized with pneumonia in Xiamen, RSV was the most common respiratory virus, while H. influenzae and S. pneumoniae remained the predominant bacterial pathogens detected. Considering the low implementation rate of vaccines against pneumococcal and Hib pneumonia in China, there is an urgent need to increase both vaccination rates to reduce pneumococcal and Hib disease burden.

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial

IMPORTANCE

Community-acquired pneumonia (CAP) is a common occurrence in childhood; consequently, evidence-based recommendations for its treatment are required.

OBJECTIVE

To determine whether 5 days of high-dose amoxicillin for CAP was associated with noninferior rates of clinical cure compared with 10 days of high-dose amoxicillin.

DESIGN, SETTING, AND PARTICIPANTS

The SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) study was a 2-center, parallel-group, noninferiority randomized clinical trial consisting of a single-center pilot study from December 1, 2012, to March 31, 2014, and the follow-up main study from August 1, 2016, to December 31, 2019 at the emergency departments of McMaster Children's Hospital and the Children's Hospital of Eastern Ontario. Research staff, participants, and outcome assessors were blinded to treatment allocation. Eligible children were aged 6 months to 10 years and had fever within 48 hours, respiratory symptoms, chest radiography findings consistent with pneumonia as per the emergency department physician, and a primary diagnosis of pneumonia. Children were excluded if they required hospitalization, had comorbidities that would predispose them to severe disease and/or pneumonia of unusual origin, or had previous β-lactam antibiotic therapy. Data were analyzed from March 1 to July 8, 2020.

INTERVENTIONS

Five days of high-dose amoxicillin therapy followed by 5 days of placebo (intervention group) vs 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin (control group).

MAIN OUTCOMES AND MEASURES

Clinical cure at 14 to 21 days.

RESULTS

Among the 281 participants, the median age was 2.6 (interquartile range, 1.6-4.9) years (160 boys [57.7%] of 279 with sex listed). Clinical cure was observed in 101 of 114 children (88.6%) in the intervention group and in 99 of 109 (90.8%) in the control group in per-protocol analysis (risk difference, -0.016; 97.5% confidence limit, -0.087). Clinical cure at 14 to 21 days was observed in 108 of 126 (85.7%) in the intervention group and in 106 of 126 (84.1%) in the control group in the intention-to-treat analysis (risk difference, 0.023; 97.5% confidence limit, -0.061).

CONCLUSIONS AND RELEVANCE

Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02380352.

Prevalence of human respiratory syncytial virus, parainfluenza and adenoviruses in East Africa Community partner states of Kenya, Tanzania, and Uganda: A systematic review and meta-analysis (2007-2020)

Background

Viruses are responsible for a large proportion of acute respiratory tract infections (ARTIs). Human influenza, parainfluenza, respiratory-syncytial-virus, and adenoviruses are among the leading cause of ARTIs. Epidemiological evidence of those respiratory viruses is limited in the East Africa Community (EAC) region. This review sought to identify the prevalence of respiratory syncytial virus, parainfluenza, and adenoviruses among cases of ARTI in the EAC from 2007 to 2020.

Methods

A literature search was conducted in Medline, Global Index Medicus, and the grey literature from public health institutions and programs in the EAC. Two independent reviewers performed data extraction. We used a random effects model to pool the prevalence estimate across studies. We assessed heterogeneity with the I² statistic, and Cochran’s Q test, and further we did subgroup analysis. This review was registered with PROSPERO under registration number CRD42018110186.

Results

A total of 12 studies met the eligibility criteria for the studies documented from 2007 to 2020. The overall pooled prevalence of adenoviruses was 13% (95% confidence interval [CI]: 6–21, N = 28829), respiratory syncytial virus 11% (95% CI: 7–15, N = 22627), and parainfluenza was 9% (95% CI: 7–11, N = 28363). Pooled prevalence of reported ARTIs, all ages, and locality varied in the included studies. Studies among participants with severe acute respiratory disease had a higher pooled prevalence of all the three viruses. Considerable heterogeneity was noted overall and in subgroup analysis.

Conclusion

Our findings indicate that human adenoviruses, respiratory syncytial virus and parainfluenza virus are prevalent in Kenya, Tanzania, and Uganda. These three respiratory viruses contribute substantially to ARTIs in the EAC, particularly among those with severe disease and those aged five and above.

Clinical profile and risk factors of recurrent pneumonia in children at Qena governorate, Egypt

BACKGROUND

There is a scarce research study on recurrent pneumonia in children, particularly in the developing world. This study aimed to analyse the clinical characteristics, risk factors and underlying causes of recurrent pneumonia in children.

METHODS

It was a case-control study involved 87 children with ≥2 episodes of radiographically confirmed pneumonia in a single year or ≥3 episodes at any time with a radiographic clearing of densities between attacks. Controls were 87 age and gender-matched children who had never suffered pneumonia. Demographic and clinical characteristics of patients and controls were compared and evaluated for the detection of possible underlying conditions that may be the incriminated risk factor of pneumonia recurrence.

RESULTS

During one-year study, 763 patients were admitted with pneumonia and 87 (11.4%) of them met the definition of recurrent pneumonia. There were 48 (55.2%) males and 39 (44.8%) females. The mean age at diagnosis of recurrent pneumonia was 7.15 ± 1.72 years. Prematurity, small birth weight and presence of respiratory distress at birth were significantly different between patients and controls. Aspiration, congenital heart disease, gastroesophageal reflux, oro-motor incoordination, wheezing and asthma were significant risk factors for recurrent pneumonia.

CONCLUSION

Our study showed that 11.40% of children with pneumonia had recurrent form and that most of them had an underlying illness. The most common detected risk factors for recurrent pneumonia were rural residence, low socioeconomic standard, over-crowding, prematurity and presence of respiratory distress at birth. Aspiration, congenital heart diseases, wheezing and asthma were found to be the main underlying illnesses associated with pneumonia recurrences.

Atrial Arrhythmias in Patients with Severe COVID-19

The number of confirmed COVID-19 cases has increased drastically; however, information regarding the impact of this disease on the occurrence of arrhythmias is scarce. The aim of this study was to determine the impact of COVID-19 on arrhythmia occurrence. This prospective study included patients with COVID-19 treated at the Leishenshan Temporary Hospital of Wuhan City, China, from February 24 to April 5, 2020. Demographic, comorbidity, and arrhythmias data were collected from patients with COVID-19 (n = 84) and compared with control data from patients with bacterial pneumonia (n = 84) infection. Furthermore, comparisons were made between patients with severe and nonsevere COVID-19 and between older and younger patients. Compared with patients with bacterial pneumonia, those with COVID-19 had higher total, mean, and minimum heart rates (all P < 0.01). Patients with severe COVID-19 (severe and critical type diseases) developed more atrial arrhythmias compared with those with nonsevere symptoms. Plasma creatine kinase isoenzyme (CKMB) levels (P=0.01) were higher in the severe group than in the nonsevere group, and there were more deaths in the severe group than in the nonsevere group (6 (15%) vs. 3 (2.30%); P=0.05). Premature atrial contractions (PAC) and nonsustained atrial tachycardia (NSAT) were significantly positively correlated with plasma CKMB levels but not with high-sensitive cardiac troponin I or myoglobin levels. Our data demonstrate that COVID-19 patients have higher total, mean, and minimum heart rates compared with those with bacterial pneumonia. Patients with severe or critical disease had more frequent atrial arrhythmias (including PAC and AF) and higher CKMB levels and mortality than those with nonsevere symptoms.

Time to Mycoplasma Pneumoniae RNA Clearance for Wheezy vs. Non-Wheezy Young Children with Community-Acquired Pneumonia

OBJECTIVES

We sought to investigate the dynamics of Mycoplasma pneumoniae (Mp) RNA in hospitalized young children with community-acquired pneumonia (CAP) and to explore whether Mp RNA clearance differed for wheezy and non-wheezy group after the onset of azithromycin treatment.

METHODS

We included hospitalized young children (1-72 months of age) with CAP caused by Mp infection. Mp RNA was detected as soon as the patient was admitted and the dynamics of Mp-RNA were monitored after the beginning of azithromycin treatment on Days 4, 7, 14 and 28.

RESULTS

Among 40 hospitalized young children with Mycoplasma pneumoniae pneumonia (Mpp), 16 had wheezing. Time to first positive Mp-RNA confirmation after symptom onset of Mpp was similar for the wheezy group (median 7 days, interquartile range 7-10.5) and the non-wheezy group (median 7 days, interquartile range 5.8-8.3). The duration of positive Mp-RNA detection after the onset of azithromycin treatment was shorter among the wheezy group than in the non-wheezy group (median 4 vs. 7 days; hazard ratio 2.083; 95% confidence interval: 1.023-4.244).

CONCLUSIONS

Mp-RNA clearance was significantly faster among Mpp young children with wheezing than in those without wheezing after the onset of azithromycin treatment.Lay summaryWe sought to investigate the dynamics of Mycoplasma pneumoniae (Mp) RNA in hospitalized young children with community-acquired pneumonia and to explore whether Mp RNA clearance differed for wheezy and non-wheezy group after the onset of azithromycin treatment. Our study suggested that Mp-RNA clearance was significantly faster among Mycoplasma pneumoniae pneumonia young children with wheezing than in those without wheezing after the onset of azithromycin treatment.

Air bronchogram integrated lung ultrasound score to monitor community-acquired pneumonia in a pilot pediatric population

Aims

Chest ultrasound is a non-invasive method for evaluating children with suspected community-acquired pneumonia (CAP). We evaluated the prognostic role of change of ultrasonographic (US) air bronchogram in management of CAP in terms of: rate of complicated CAP, change of empiric antibiotic therapy, relationship to defervescence time, and length of hospitalization.

Methods

Patients with CAP and radiographic evidence of lung consolidation were prospectively enrolled. Chest US examinations were performed within 12 h from admission and after 48 h. A new grading system (USINCHILD score) based on presence and features of air bronchogram was adopted.

Results

Thirty six patients were stratified into two groups according to the presence of an increase of at least 1 grade of US score (Δ US grade), expression of an improvement of lung consolidation. Δ US grade after 48 h ≥ 1 was associated with an increased risk of complicated CAP (p value 0.027) and a longer defervescence time (p value 0.036). Moreover, Δ US grade ≥ 1 was predictive of a short hospitalization (p value 0.008).

Conclusions

USINCHILD score could be an innovative biotechnology tool for the management of pediatric CAP.

Trial registration number and date of registration

NCT03556488, June 14, 2018.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s40477-020-00547-7) contains supplementary material, which is available to authorized users.

Efficacy and safety of interferon on neonates with respiratory syncytial virus pneumonia

Respiratory syncytial virus (RSV) pneumonia is a leading cause of hospitalization and mortality among neonates worldwide, and there are currently no specific clinical treatments for RSV infection. Interferons (IFNs) possess broad-spectrum antiviral properties, and the present study aimed to evaluate the efficacy and safety of IFN-α1b for the treatment of neonatal RSV pneumonia. Neonates with RSV pneumonia were divided into the treatment (126 neonates) and control (160 neonates) groups, the former of which were treated with IFN. Aside from IFN administration, both groups received the same routine treatments. There were no significant differences in patient characteristics between the two groups. All neonates in the two groups displayed symptoms such as a cough (93.0%), tachypnea (90.1%), perilabial cyanosis (67.8%), choking on milk (62.9%) and moist rales (58.4%), and no significant differences in the occurrence of these symptoms were observed between the groups (P>0.05). The percentage of cases with bacterial co-infection was 66.8% (191/286), and the bacterial species in the spectrum primarily included Escherichia coli (21.5%), Klebsiella pneumonia (20.4%), Staphylococcus aureus (17.2%), Acihetobacter baumanii (13.1%) and Pseudomonas aeruginosa (9.9%). There were no significant differences in the co-infection rate or bacterial spectrum between the two groups. The remission time of cough, tachypnea, choking on milk, perilabial cyanosis, moist rales and oxygen inhalation in the treatment group was significantly lower compared with the control group (P<0.05). Although the hospitalization time in the treatment group was shorter compared with the control group, the difference was not significant. There were two patients in the treatment group that developed fever within 2-6 h after receiving IFN-α1b, though no other adverse effects were observed. In conclusion, IFN-α1b treatment improved the symptoms associated with neonatal RSV pneumonia with minimal adverse effects.

Antibiotics for hospitalized children with community-acquired pneumonia in Japan: Analysis based on Japanese national database

INTRODUCTION

Community-acquired pneumonia (CAP) is one of the most common causes of pediatric infection requiring hospitalization. Antimicrobial resistance due to the inappropriate use poses a threat worldwide. Our objective is to analyze and optimize the trends of antibiotics used for pediatric inpatients with CAP in a claims database provided by the Ministry of Health, Labour and Welfare.

METHODS

Our database randomly sampled 10% of the hospitalized patients every October from 2011 to 2014. Patients aged <15 years in whom antibiotic therapy was initiated within two days of admission were listed. Subsequently, we investigated the antibiotics administered on the first day of prescription.

RESULTS

A total of 4,831 antibiotics were prescribed for 3,909 patients. Many patients aged ≤ five years were treated with β-lactams alone whereas many patients aged ≥ six years were treated with a single antibiotic, such as a macrolide, tetracycline, and quinolone, which covers atypical bacteria. Combination therapy was primarily used in children aged ≥ six years (nearly 30%); the main combination was a β-lactam and non-β-lactam covering atypical bacteria. Ampicillin-sulbactam was the most frequently prescribed β-lactam in children of all ages other than infants. Ampicillin, however, was most often prescribed in infants, but its usage rate was low at other ages.

CONCLUSIONS

Antibiotics were appropriately prescribed and were similar to that recommended in the 2011 guidelines for pediatric inpatients with CAP. However, combination therapy was frequently prescribed in children aged ≥ six years. According to the revised guidelines in 2017, ampicillin should be used more frequently for patients hospitalized with CAP.

Efficacy of Zinc as Adjuvant Therapy in the Treatment of Severe Pneumonia in Hospitalized Children: A Randomized Clinical Trial

Background: Pneumonia remains one of the leading causes of childhood mortality and morbidity in developing countries. Studies showed that zinc supplementation can prevent pneumonia, but its therapeutic effectiveness has not been determined definitively. Objectives: This study evaluated the effect of zinc supplementation as adjuvant treatment on children with severe pneumonia admitted to 17th Shahrivar Training Hospital in Rasht, Iran. Methods: In this double-blind placebo-controlled clinical trial, 120 children aged two to 60 months hospitalized for pneumonia were randomly divided into 2 groups of size 60 each. The first group received zinc sulfate (20 mg daily for children twelve months of age or older and 10 mg daily for children younger than 12 months), and the second group received a placebo for seven days. All patients received standard antibiotic treatment for pneumonia. The children were daily evaluated, and recovery time for fever and tachypnea (as primary outcomes) and duration of hospitalization and mortality rate (as secondary outcomes) were compared between the two groups. Results: The mean age of patients was 14.1 months ± 13.9. The youngest and oldest patients were aged 2 and 60 months, respectively. No significant difference in age and sex distribution was found between the two groups. The zinc receiving group experienced a considerably shorter time of fever (2.1 days vs. 2.84 days, P < 0.05) and tachypnea (1.75 days versus 2.1 days, P = 0.011). There was no significant difference in the duration of admission between the two groups (P = 0.728), and no cases of death occurred in either group. Conclusions: This study showed that adjuvant treatment with zinc in children aged 2 to 60 months with severe pneumonia accelerates recovery from pneumonia. Further studies are needed to investigate the effects of administering zinc as adjunctive therapy for pneumonia in other age groups.

The optimal duration of antimicrobial therapy for lower respiratory tract infection in patients with neuromuscular disorders based on a clone library analysis of the bacterial 16S rRNA gene sequence

Objectives

The aim of this study is to determine the optimal duration of antimicrobial therapy for lower respiratory tract infection (LRTI) in neuromuscular disorder (NMD) patients.

Methods

This prospective study included 13 episodes from 9 NMD patients hospitalized for bacterial LRTI. Sputum samples were collected from these patients during the three consecutive days after their admission. Bacterial cell counts and the proportion of the most predominant bacterium identified by a clone library analysis of the bacterial 16S rRNA gene sequence in the samples obtained before antimicrobial therapy were serially investigated.

Results

All episodes were initially treated with ampicillin/sulbactam. In 12 episodes with a therapeutic effect, the bacterial cell counts in the samples obtained on the third day of therapy were significantly lower than those before therapy (P = 0.0013). In most of these episodes, the most predominant bacterium in the sample obtained before therapy was undetectable by the third day of therapy. In the one patient without a therapeutic effect, neither the bacterial cell counts nor the proportion of the most predominant bacterium in the sample obtained before therapy decrease after therapy.

Conclusion

Short-term antimicrobial therapy is sufficiently effective for LRTI in NMD patients if the initial therapy is effective.

Safety and Efficacy of C-reactive Protein-guided Antibiotic Use to Treat Acute Respiratory Infections in Tanzanian Children: A Planned Subgroup Analysis of a Randomized Controlled Noninferiority Trial Evaluating a Novel Electronic Clinical Decision Algorithm (ePOCT)

BACKGROUND

The safety and efficacy of using C-reactive protein (CRP) to decide on antibiotic prescription among febrile children at risk of pneumonia has not been tested.

METHODS

This was a randomized (1:1) controlled noninferiority trial in 9 primary care centers in Tanzania (substudy of the ePOCT trial evaluating a novel electronic decision algorithm). Children aged 2-59 months with fever and cough and without life-threatening conditions received an antibiotic based on a CRP-informed strategy (combination of CRP ≥80 mg/L plus age/temperature-corrected tachypnea and/or chest indrawing) or current World Health Organization standard (respiratory rate ≥50 breaths/minute). The primary outcome was clinical failure by day (D) 7; the secondary outcomes were antibiotic prescription at D0, secondary hospitalization, or death by D30.

RESULTS

A total of 1726 children were included (intervention: 868, control: 858; 0.7% lost to follow-up). The proportion of clinical failure by D7 was 2.9% (25/865) in the intervention arm vs 4.8% (41/854) in the control arm (risk difference, -1.9% [95% confidence interval {CI}, -3.7% to -.1%]; risk ratio [RR], 0.60 [95% CI, .37-.98]). Twenty of 865 (2.3%) children in the intervention arm vs 345 of 854 (40.4%) in the control arm received antibiotics at D0 (RR, 0.06 [95% CI, .04-.09]). There were fewer secondary hospitalizations and deaths in the CRP arm: 0.5% (4/865) vs 1.5% (13/854) (RR, 0.30 [95% CI, .10-.93]).

CONCLUSIONS

CRP testing using a cutoff of ≥80 mg/L, integrated into an electronic decision algorithm, was able to improve clinical outcome in children with respiratory infections while substantially reducing antibiotic prescription.

CLINICAL TRIALS REGISTRATION

NCT02225769.