Age-specific risk factors of severe pneumonia among pediatric patients hospitalized with community-acquired pneumonia

Pathogen distribution and infection patterns in pediatric severe pneumonia: A targeted next-generation sequencing study

OBJECTIVE

Severe pneumonia in children represents a significant clinical challenge due to its high incidence and associated mortality. This study aimed to assess the distribution of pathogens and patterns of infection in pediatric patients with severe pneumonia.

METHODS

This study included 110 pediatric patients diagnosed with severe pneumonia, who were admitted to Guangxi Maternal and Child Health Hospital between July 2021 and November 2023. Pathogen-targeted next-generation sequencing (tNGS) was employed to identify respiratory pathogens in these cases.

RESULTS

Pathogens were detected in 109 out of 110 cases, yielding a positive detection rate of 99.09%. Among these cases, 25 (22.72%) involved single-pathogen infections, while 84 (76.36%) were characterized by mixed infections. The infection pattern in children with severe pneumonia was relatively common with bacterial-viral coinfection (28.2%, 31/110). A total of 39 pathogens were identified from the 110 children with severe pneumonia, with the top three pathogens being Mycoplasma pneumoniae (30.91%, 34/110), Human Respiratory Syncytial Virus Type A (26.36%, 29/110), and Human Herpesvirus (18.18%, 20/110). Notably, 38.2% (13/34) of the cases were found to have macrolide-resistant Mycoplasma pneumoniae (MRMP). Additionally, 40% (44/110) of the children required admission to the intensive care unit (ICU).

CONCLUSION

The application of tNGS demonstrates significant utility in the detection of pathogens in pediatric patients with severe pneumonia. The predominant pathogens identified in this study are Mycoplasma pneumoniae, Human Respiratory Syncytial Virus, and Human Herpesvirus. Furthermore, mixed infections involving multiple pathogens were observed in 76.36% of the cases, and a substantial proportion (40%) of these patients necessitated intensive care.

Factors based on Cox regression modeling to analyze the prognostic impact of fiberoptic bronchoscopic bronchoalveolar lavage on children with severe pneumonia

OBJECTIVE

This study aimed to identify factors influencing the prognosis of children with severe pneumonia (SP) after fiberoptic bronchoscopic bronchoalveolar lavage (BAL).

METHODS

The clinical data of 155 children with SP treated with fiberoptic bronchoscopic BAL at Xi'an International Medical Center Hospital between January 2022 and January 2024 were retrospectively analyzed. Children were categorized into the survival group (n = 122) and the death group (n = 33) according to their clinical outcomes within 28 days after treatment. General patient data and the initial laboratory results after admission were collected. Univariate and multivariate Cox regression analyses were performed to identify independent predictors of 28-day prognosis. The predictive ability of each index was evaluated using the receiver operating characteristic (ROC) curve analysis and the Delong test. The relationship between each index and the prognosis of children with SP was analyzed using the Kaplan-Meier curve.

RESULTS

The death group had significantly younger patients, longer pneumonia course, shorter pregnancy cycle, and higher levels of procalcitonin (PCT), white blood cell count (WBC), C-protein reaction (CPR), and systemic immune-inflammation index (SII) compared to the survival group (P<0.05). Cox regression analysis identified age (HR = 0.959, P = 0.014), pneumonia course (HR = 2.270, P<0.001), pregnancy cycle (HR = 2.736, P = 0.015), PCT (HR = 2.728, P = 0.001), WBC (HR = 1.283, P = 0.001), and SII (HR = 1.009, P<0.001) as independent predictors of 28-day mortality in children with SP. Among these, pneumonia course, PCT, and SII demonstrated higher predictive efficacy in adverse outcomes, with areas under the ROC curve (AUC) of 0.827, 0.822, and 0.868, respectively, outperforming age, pregnancy cycle, and WBC (P<0.05). Kaplan-Meier survival curves showed that patients with older age, shorter pneumonia course, full-term birth, and those with lower WBC, PCT, and SII levels had significantly higher survival rates compared to their counterparts (P<0.05).

CONCLUSION

Age, pneumonia course, pregnancy cycle, WBC, PCT, and SII were independent predictors of survival in children with SP after fiberoptic bronchoscopic BAL, among which pneumonia course, PCT, and SII showed a higher predictive efficacy for the prognosis of children with SP.

Analysis of risk factors for prolonged stay in the intensive care unit after cardiac surgery in children with pneumonia

AIM

Preoperative pneumonia in children with CHD may lead to longer stays in the ICU after surgery. However, research on the associated risk factors is limited. This study aims to evaluate the pre-, intra-, and postoperative risk factors contributing to extended ICU stays in these children.

METHODS

This retrospective cohort study collected data from 496 children with CHD complicated by preoperative pneumonia who underwent cardiac surgery following medical treatment at a single centre from 2017 to 2022. We compared the clinical outcomes of patients with varying ICU stays and utilised multivariate logistic regression analysis and multiple linear regression analyses to evaluate the risk factors for prolonged ICU stays.

RESULTS

The median ICU stay for the 496 children was 7 days. Bacterial infection, severe pneumonia, and Risk Adjustment for Congenital Heart Surgery-1 were independent risk factors for prolonged ICU stays following cardiac surgery (P < 0.05).

CONCLUSION

CHD complicated by pneumonia presents a significant treatment challenge. Better identification of the risk factors associated with long-term postoperative ICU stays in these children, along with timely diagnosis and treatment of respiratory infections in high-risk populations, can effectively reduce ICU stays and improve resource utilisation.

Increased Incidence of Rhinovirus Pneumonia in Children During the COVID-19 Pandemic in Mexico

Background: Human rhinovirus (HRV), traditionally recognized as the primary etiological agent of the common cold, has become the second most important viral agent in bronchopulmonary conditions, such as pneumonia and asthma exacerbations. During the COVID-19 pandemic, several viruses exhibited changes in their epidemiological behavior. This study aims to evaluate the clinical and epidemiological characteristics of children with HRV pneumonia before and during the pandemic in Mexico. Methods: A comparative ambispective longitudinal epidemiological study of two cohorts (prepandemic and pandemic periods) was carried out. Two databases were compared: one from 2010 to 2013 and the other from 2021 to 2023. Children under 5 years of age diagnosed with HRV pneumonia were included. Student's t-test, χ 2 tests, and logistic regression were used to assess risk factors associated with severe pneumonia. Incidence density was calculated as HRV cases per 10 new cases of pneumonia per month for each year. Results: During the pandemic, the age of presentation shifted from 5 months to 16 months. There was a higher incidence of HRV pneumonia in children during the pandemic, particularly in the second half of 2021, with a peak in July and August. In addition, there was an increase in severity (53% vs. 63%, p=0.006) and coinfections (51.3% vs. 76% p < 0.001). A higher prevalence of all risk factors was observed in the second cohort. Conclusions: During the pandemic, a shift toward older age, a higher percentage of coinfections, and increased severity associated to HRV pneumonia were observed. These findings highlight the need for the development and implementation of targeted prevention and treatment measures for HRV.

Recurrent upper respiratory tract infections in early childhood: a newly defined clinical condition

BACKGROUND

Recurrent Upper Respiratory Tract Infections (R-URTIs) pose a significant challenge in pediatric healthcare, affecting both children and their families. This study aimed to investigate the prevalence, risk factors, and clinical implications of R-URTI in children aged 0-5 years.

METHODS

This observational study involved a sample of 483 children aged 0-5 years, focusing on establishing a practical and dynamic definition of R-URTI. Family pediatricians prospectively collected socio-demographic information, medical history, and recorded the occurrence of URTI episodes. Children were followed from recruitment until March 2021, predating the COVID-19 outbreak.

RESULTS

A substantial prevalence of R-URTIs was found, estimating it at 5-10% among this age group. To define R-URTI, a practical and dynamic criterion was proposed: children experiencing a minimum of four URTI episodes, each lasting four days or more, within a six-month period, with intervals of well-being in between.

CONCLUSIONS

The study highlighted that specific risk factors for R-URTI were elusive, suggesting that this condition may affect children regardless of their family or clinical history. Moreover, the study's stratification by age group and times of observation facilitated patient-specific clinical decision-making. The proposed definition may represent a valuable tool for clinicians in diagnosing and addressing R-URTI cases.

The severity of pneumonia and its association with socio-demographic factors among children under five years old in Wasit governorate hospitals, Iraq

Background

Pneumonia is the leading infectious cause of death among children under five globally.

Objective

The study aims to determine socio-demographic factors associated with the severity of pneumonia among children under five in Wasit Governorate.

Methods

A cross-sectional study and convenience sampling (non-probability) were conducted among 477 children admitted to Wasit governorate hospitals. This sample was distributed throughout five hospitals selected using convenience sampling techniques, including AL-Zahra Hospital, AL-Numaniyah General Hospital, AL-Karama Teaching Hospital, Martyr Fairouz General Hospital, and AL-Kut Gynecology Hospital. It was conducted from October 1st, 2022, to May 1st, 2023. Through questionnaires, data were collected and analyzed through descriptive and inferential statistics.

Results

The results showed that the participants' distribution according to pneumonia severity was such that the majority of children (81%) included in the study suffered from pneumonia. 14% of children suffered from very severe pneumonia, and 5% suffered from severe pneumonia. The children at risk of developing pneumonia were within the age group of 1-11 months (55.6%), were male (60.6%), and resided in urban areas (63.7%). Both the mother and the father had completed their primary education (50.9% and 47.4%, respectively), and 99.4% and 97.5% of the mothers were married and housewives. More than half of the fathers, 59.5%, were self-employed, and 25.6% suffered from house overcrowding. In addition, 65% had low socioeconomic status. There was a significant relationship between pneumonia severity and the father's occupation and socioeconomic status.

Conclusions

This study concludes that pneumonia was the most common diagnosis at admission. Among the risk factors studied, low socioeconomic status and the father's occupation were significant risk factors for pneumonia in children.

Viral Detection Is Associated With Severe Disease in Children With Suspected Community-Acquired Pneumonia

OBJECTIVE

To evaluate the role of virus detection on disease severity among children presenting to the emergency department (ED) with suspected community-acquired pneumonia (CAP).

METHODS

We performed a single-center prospective study of children presenting to a pediatric ED with signs and symptoms of a lower respiratory tract infection and who had a chest radiograph performed for suspected CAP. We included patients who had virus testing, with results classified as negative for virus, human rhinovirus, respiratory syncytial virus (RSV), influenza, and other viruses. We evaluated the association between virus detection and disease severity using a 4-tiered measure of disease severity based on clinical outcomes, ranging from mild ( discharged from the ED) to severe (receipt of positive-pressure ventilation, vasopressors, thoracostomy tube placement, or extracorporeal membrane oxygenation, intensive care unit admission, diagnosis of severe sepsis or septic shock, or death) in models adjusted for age, procalcitonin, C-reactive protein, radiologist interpretation of the chest radiograph, presence of wheeze, fever, and provision of antibiotics.

RESULTS

Five hundred seventy-three patients were enrolled in the parent study, of whom viruses were detected in 344 (60%), including 159 (28%) human rhinovirus, 114 (20%) RSV, and 34 (6%) with influenza. In multivariable models, viral infections were associated with increasing disease severity, with the greatest effect noted with RSV (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.30-4.81) followed by rhinovirus (aOR, 2.18; 95% CI, 1.27-3.76). Viral detection was not associated with increased severity among patients with radiographic pneumonia (n = 223; OR, 1.82; 95% CI, 0.87-3.87) but was associated with severity among patients without radiographic pneumonia (n = 141; OR, 2.51; 95% CI, 1.40-4.59).

CONCLUSIONS

The detection of a virus in the nasopharynx was associated with more severe disease compared with no virus; this finding persisted after adjustment for age, biomarkers, and radiographic findings. Viral testing may assist with risk stratification of patients with lower respiratory tract infections.

Pathogen spectra in hospitalised and nonhospitalised children with community-acquired pneumonia

Background

Paediatric community-acquired pneumonia (CAP) is a leading cause of paediatric morbidity. However, particularly for outpatients with paediatric CAP, data on aetiology and management are scarce.

Methods

The prospective pedCAPNETZ study multicentrically enrols children and adolescents with outpatient-treated or hospitalised paediatric CAP in Germany. Blood and respiratory specimens were collected systematically, and comprehensive analyses of pathogen spectra were conducted. Follow-up evaluations were performed until day 90 after enrolment.

Results

Between December 2014 and August 2020, we enrolled 486 children with paediatric CAP at eight study sites, 437 (89.9%) of whom had radiographic evidence of paediatric CAP. Median (interquartile range) age was 4.5 (1.6-6.6) years, and 345 (78.9%) children were hospitalised. The most prevalent symptoms at enrolment were cough (91.8%), fever (89.2%) and tachypnoea (62.0%). Outpatients were significantly older, displayed significantly lower C-reactive protein levels and were significantly more likely to be symptom-free at follow-up days 14 and 90. Pathogens were detected in 90.3% of all patients (one or more viral pathogens in 68.1%; one or more bacterial strains in 18.7%; combined bacterial/viral pathogens in 4.1%). Parainfluenza virus and Mycoplasma pneumoniae were significantly more frequent in outpatients. The proportion of patients with antibiotic therapy was comparably high in both groups (92.4% of outpatients versus 86.2% of hospitalised patients).

Conclusion

We present first data on paediatric CAP with comprehensive analyses in outpatients and hospitalised cases and demonstrate high detection rates of viral pathogens in both groups. Particularly in young paediatric CAP patients with outpatient care, antibiotic therapy needs to be critically debated.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.

Incidence of recovery from severe pneumonia and its predictors among children 2-59 months admitted to pediatric ward of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia: A retrospective Cohort study

Background

Pneumonia is a major reason for hospital admission among children, particularly in resource-poor areas. A hospital stay (length of stay) alone is found to contribute for 46.8% of a household cost for single episode of severe pneumonia. The aim of this study was to determine the incidence of recovery from severe pneumonia and predictors among children 2-59 months of age admitted to pediatric ward of Ayder Comprehensive Specialized Hospital (ACSH).

Methods

A retrospective facility-based cohort study was conducted among under-five-year-old children admitted in ACSH. Three years medical records from July 7, 2015 to July 6, 2018 were reviewed. A total of 285 children with severe pneumonia admitted to pediatric ward of ACSH were included. Kaplan-Meier Survival Curve was used to estimate recovery time. The independent effects of covariates on recovery time are analyzed using multivariate Cox-proportional adjusted model.

Result

The median survival time was four days (95% CI = 3.732 - 4.268). The incidence of recovery was 92.3%. Co-morbidity (AOR: 3.47, 95%CI, 2.21, 5.4), malnutrition (AOR = 1.9, 95%CI, 1.2, 3.1), duration of chief complaint (AOR = 0.72, 95%CI: 0.54, 0.94), and vaccination (AOR = 0.32, 95% CI, 0.13, 0.81) were significant predictors of time to recovery from severe pneumonia.

Conclusion

High recovery rate and short length of hospital stay was observed in this study. Increased duration of chief complaint, presence of co-morbidity, being malnourished, and vaccination were factors that associated with time to recovery. Therefore focuses have to be given in increasing the community's health seeking behavior to visit health facility early and especial attention should be given for children with co-morbidity, malnutrition, and unvaccinated children.

Epidemiology of community-acquired pneumonia among hospitalised children in Indonesia: a multicentre, prospective study

OBJECTIVE

To identify aetiologies of childhood community-acquired pneumonia (CAP) based on a comprehensive diagnostic approach.

DESIGN

'Partnerships for Enhanced Engagement in Research-Pneumonia in Paediatrics (PEER-PePPeS)' study was an observational prospective cohort study conducted from July 2017 to September 2019.

SETTING

Government referral teaching hospitals and satellite sites in three cities in Indonesia: Semarang, Yogyakarta and Tangerang.

PARTICIPANTS

Hospitalised children aged 2-59 months who met the criteria for pneumonia were eligible. Children were excluded if they had been hospitalised for >24 hours; had malignancy or history of malignancy; a history of long-term (>2 months) steroid therapy, or conditions that might interfere with compliance with study procedures.

MAIN OUTCOMES MEASURES

Causative bacterial, viral or mixed pathogen(s) for pneumonia were determined using microbiological, molecular and serological tests from routinely collected specimens (blood, sputum and nasopharyngeal swabs). We applied a previously published algorithm (PEER-PePPeS rules) to determine the causative pathogen(s).

RESULTS

188 subjects were enrolled. Based on our algorithm, 48 (25.5%) had a bacterial infection, 31 (16.5%) had a viral infection, 76 (40.4%) had mixed bacterial and viral infections, and 33 (17.6%) were unable to be classified. The five most common causative pathogens identified were Haemophilus influenzae non-type B (N=73, 38.8%), respiratory syncytial virus (RSV) (N=51, 27.1%), Klebsiella pneumoniae (N=43, 22.9%), Streptococcus pneumoniae (N=29, 15.4%) and Influenza virus (N=25, 13.3%). RSV and influenza virus diagnoses were highly associated with Indonesia's rainy season (November-March). The PCR assays on induced sputum (IS) specimens captured most of the pathogens identified in this study.

CONCLUSIONS

Our study found that H. influenzae non-type B and RSV were the most frequently identified pathogens causing hospitalised CAP among Indonesian children aged 2-59 months old. Our study also highlights the importance of PCR for diagnosis and by extension, appropriate use of antimicrobials.

TRAIL REGISTRATION NUMBER

NCT03366454.

Paediatric pneumonia: deriving a model to identify severe disease

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of childhood hospitalisation. Limited data exist on factors predicting severe disease with no paediatric-specific predictive tools.

METHODS

Retrospective cohort (2011-2016) of hospitalised CAP cases. We analysed clinical variables collected at hospital presentation against outcomes. Stratified outcomes were mild (hospitalised), moderate (invasive drainage procedure, intensive care) or severe (mechanical ventilation, vasopressors, death).

RESULTS

We report 3330 CAP cases, median age 2.0 years (IQR 1-5 years), with 2950 (88.5%) mild, 305 (9.2%) moderate and 75 (2.3%) severe outcomes. Moderate-severe outcomes were associated with hypoxia (SaO₂ <90%; OR 6.6, 95% CI 5.1 to 8.5), increased work of breathing (severe vs normal OR 5.8, 95% CI 4.2 to 8.0), comorbidities (4+ comorbidities vs nil; OR 8.8, 95% CI 5.5 to 14) and being indigenous (OR 4.7, 95% CI 2.6 to 8.4). Febrile children were less likely than afebrile children to have moderate-severe outcomes (OR 0.57 95% CI 0.44 to 0.74). The full model receiver operating characteristic (ROC) area under the curve (AUC) was 0.78. Sensitivity analyses showed similar results with clinical or radiological CAP definitions. We derived a clinical tool to stratify low, intermediate or high likelihood of severe disease (AUC 0.72). High scores (≥5) had nearly eight times higher odds of moderate-severe disease than those with a low (≤1) score (OR 7.7 95% CI 5.6 to 10.5).

CONCLUSIONS

A clinical risk prediction tool is needed for child CAP. We have identified risk factors and derived a simple clinical tool using clinical variables at hospital presentation to determine a child's risk of invasive or intensive care treatment with an ROC AUC comparable with adult pneumonia tools.

Association of Socio-Demographic and Climatic Factors with the Duration of Hospital Stay of Under-Five Children with Severe Pneumonia in Urban Bangladesh: An Observational Study

Severe pneumonia is one of the leading contributors to morbidity and deaths among hospitalized under-five children. We aimed to assess the association of the socio-demographic characteristics of the patients and the climatic factors with the length of hospital stay (LoS) of under-five children with severe pneumonia managed at urban hospitals in Bangladesh. We extracted relevant data from a clinical trial, as well as collecting data on daily temperature, humidity, and rainfall from the Meteorological Department of Bangladesh for the entire study period (February 2016 to February 2019). We analyzed the data of 944 children with a generalized linear model using gamma distribution. The average duration of the hospitalization of the children was 5.4 ± 2.4 days. In the multivariate analysis using adjusted estimation of duration (beta; β), extended LoS showed remarkably positive associations regarding three variables: the number of household family members (β: 1.020, 95% confidence intervals (CI): 1.005–1.036, p = 0.010), humidity variation (β: 1.040, 95% Cl: 1.029–1.052, p < 0.001), and rainfall variation (β: 1.014, 95% Cl: 1.008–1.019), p < 0.001). There was also a significant negative association with LoS for children’s age (β: 0.996, 95% Cl: 0.994–0.999, p = 0.006), well-nourishment (β: 0.936, 95% Cl: 0.881–0.994, p = 0.031), and average rainfall (β: 0.980, 95% Cl: 0.973–0.987, p < 0.001). The results suggest that the LoS of children admitted to the urban hospitals of Bangladesh with severe pneumonia is associated with certain socio-demographic characteristics of patients, and the average rainfall with variation in humidity and rainfall.