Diagnostic testing and antibiotic stewardship for pneumonia in children worldwide: current developments and next steps

Early diagnosis of bacterial pneumonia plays a pivotal role in the management. We evaluated the diagnostic accuracy of procalcitonin (PCT) as compared with C-reactive protein (CRP) for the early diagnosis of bacterial pneumonia in children. In total, 92 children consisting of 46 patients of bacterial pneumonia were admitted in the Military hospital, Rawalpindi, Pakistan and equal number of controls were included. Patient's investigations were carried out at admission. PCT and CRP were analyzed on Vidas analyzer and Immulite 1000, respectively. Out of 46 pneumonia patients, 28 were male and 18 female, with a median age of 4 years. PCT levels were significantly high median (range) of 2.69 ng/ml (0.30-13.00) vs. 0.45 ng/ml (0.10-2.00) in controls. Serum CRP levels were moderately elevated with median (range) 6.5 mg/l (0.30-60) vs. 0.30 mg/l (0.30-5.0) in controls. The area under receiver characteristic curves for PCT and CRP were 0.89 (95% CI=0.83-0.96) and 0.79 (95% CI=0.70-0.88), respectively. In total, 38 patients were diagnosed to have bacterial pneumonia with PCT (sensitivity 83% at cutoff > or = 1 ng/ml) and 26 children with CRP (sensitivity 57% at cutoff > or = 6 mg/L). PCT has better diagnostic accuracy than CRP and can be utilized for early diagnosis of bacterial pneumonia in children.

BackgroundIn developing countries, pneumonia is one of the leading causes of death in children under five years of age and hence timely and accurate diagnosis is critical. In North America, pneumonia is also a common source of childhood morbidity and occasionally mortality. Clinicians traditionally have used the chest radiograph as the gold standard in the diagnosis of pneumonia, but they are becoming increasingly aware that it is not ideal. Numerous studies have shown that chest radiography findings lack precision in defining the etiology of childhood pneumonia. There is no single test that reliably distinguishes bacterial from non-bacterial causes. These factors have resulted in clinicians historically using a combination of physical signs and chest radiographs as a ‘gold standard’, though this combination of tests has been shown to be imperfect for diagnosis and assigning treatment. The objectives of this systematic review are to: 1) identify and categorize studies that have used single or multiple tests as a gold standard for assessing accuracy of other tests, and 2) given the ‘gold standard’ used, determine the accuracy of these other tests for diagnosing childhood bacterial pneumonia.Methods and FindingsSearch strategies were developed using a combination of subject headings and keywords adapted for 18 electronic bibliographic databases from inception to May 2008. Published studies were included if they: 1) included children one month to 18 years of age, 2) provided sufficient data regarding diagnostic accuracy to construct a 2×2 table, and 3) assessed the accuracy of one or more index tests as compared with other test(s) used as a ‘gold standard’. The literature search revealed 5,989 references of which 256 were screened for inclusion, resulting in 25 studies that satisfied all inclusion criteria. The studies examined a range of bacterium types and assessed the accuracy of several combinations of diagnostic tests. Eleven different gold standards were studied in the 25 included studies. Criterion validity was calculated for fourteen different index tests using eleven different gold standards. The most common gold standard utilized was blood culture tests used in six studies. Fourteen different tests were measured as index tests. PCT was the most common measured in five studies each with a different gold standard.ConclusionsWe have found that studies assessing the diagnostic accuracy of clinical, radiological, and laboratory tests for bacterial childhood pneumonia have used a heterogeneous group of gold standards, and found, at least in part because of this, that index tests have widely different accuracies. These findings highlight the need for identifying a widely accepted gold standard for diagnosis of bacterial pneumonia in children.

The drug effect and safety of azithromycin combined with lung physical therapy in the treatment of bacterial pneumonia in children were studied. A total of 112 cases were selected and divided into a study group and a control group with 56 cases in each group. The control group used azithromycin and the study group received assisted lung physical therapy. The drug effects, symptom disappearance time, inflammatory factors, lung function indicators and adverse reaction incidence of the two groups were compared. The results showed that the drug effect of the study group was higher than that of the control group, the level of inflammatory factors was lower than that of the control group, the symptom disappearance time was shorter and the lung function indicators were better. The incidence of adverse drug reactions in the two groups was comparable. Using the same drug azithromycin, under the action of pulmonary physical therapy, azithromycin can better exert its efficacy without affecting the safety of the drug.

Introduction and objectives:Although COVID-19 is milder in young than adults.However, it can cause pneumonia in children eventually requiring hospitalization.Clinical similarity between COVID-19, other viral, and bacterial pneumonia at initial presentation of the disease caused a great challenge.We aimed to differentiate COVID-19 pneumonia from other viral and bacterial pneumonia in children, and to characterize it. Materials and Methods:This study included 300 children, who were hospitalized with clinically and radiologically confirmed pneumonia during COVID-19 pandemic.Clinical symptoms were collected and analyzed.Cultures, real time polymerase chain transcriptase test for some respiratory viruses and SARS-COV2, C-reactive protein, serum procalcitonin, serum ferritin, complete blood counts, and ferritin/procalcitonin ratio were done for all patients.Results: This study showed that COVID-19 pneumonia was only 15 % of all admitted pneumonia cases.It had low proportion of high fever, mild course, significant lymphopenia, significant thrombocytopenia, low procalcitonin, low C-reactive protein, higher ferritin/procalcitonin ratio, and higher neutrophil/lymphocyte ratio, significant high percentage of ground glass, and less percentage of consolidation in CT images. Conclusion:During (COVID-19) outbreak characterization of COVID-19 pneumonia and taking naso-pharyngeal swabs for multi-respiratory pathogen, including SARS-COV-2, help not to attribute pneumonia due to other causes to be due to COVID-19.Pneumonia due to COVID-19 is less common, and less severe than that caused by other viruses or bacteria in children.However, further large-sample studies are needed to have full blown picture about COVID-19 pneumonia in children.

Procalcitonin is a new generation marker used to differentiate bacterial from viral pneumonia. Although it is not a test routinely used in practice, it can be included in diagnosis and treatment algorithm of pneumonia in children. Studies have shown the effectiveness of procalcitonin in determining of duration of antibiotherapy and hospitalization, too. The test is superior to the other laboratory parameters, compared to reactive C protein, inclusively. Depending on the result of the pulmonary x-ray (bacterial pneumonia) admitted patients were included in: study group – patients with increased values of procalcitonin, and control group – patients with normal values ones. The study proposed a comparative analysis; the correlation index was used to demonstrate how laboratory parameters can interact, and the evolutionary trend of studied parameters was analysed. The results are consistent with the literature data, validating the superiority of procalcitonin in establishing the etiologic diagnosis and the treatment evaluation in bacterial pneumonia in children.

PurposeThe aim of this study was to analyze the clinical characteristics of severe Mycoplasma pneumoniae pneumonia and severe bacterial pneumonia in children to provide a basis for clinical recognition and diagnosis.MethodsThis was a retrospective analysis of 130 cases of severe Mycoplasma pneumoniae pneumonia (SMPP), 81 cases of severe Streptococcus pneumoniae pneumonia (SPP) and 105 cases of severe Haemophilus influenzae pneumonia (SHIP) in children. Demographic, clinical, laboratory, and imaging data were compared between groups. One-way analysis of variance or Kruskal-Wallis test was used for continuous variables, chi-square test was used for categorical variables, and rank-sum test was used for ranked data. The level of statistical significance was set at P < 0.05.ResultsAll groups showed male predominance (P < 0.05). The SMPP group had older patients, longer hospital stays, prolonged fever, and higher interleukin-6, lactate dehydrogenase, and D-dimer levels (P < 0.05). Imaging revealed a higher proportion of unilateral solid lung lesions in SMPP, with increased tracheal stenosis, emphysema, pleural effusion, and pulmonary embolism (P < 0.05). Fiberoptic bronchoscopy detected more sputum plugs in SMPP (P < 0.05). Conversely, SPP and SHIP groups had younger patients, more wet rales/wheezing, higher white blood cell counts and neutrophil ratios, and bilateral patchy lung shadows (P < 0.05).ConclusionDifferences in age of onset, laboratory tests, like IL-6, and imaging manifestations between SMPP and severe bacterial pneumonia can help us to recognize them early and thus target treatment more appropriately.

Bacterial pneumonia imparts a major morbidity and mortality burden on children living with HIV, yet effective prevention and treatment options are underutilized. We explored clinical factors associated with severe recurrent bacterial pneumonia among children living with HIV. Children enrolled in the TREAT Asia Pediatric HIV Observational Database were included if they started antiretroviral therapy (ART) on or after January 1st, 2008. Factors associated with severe recurrent bacterial pneumonia were assessed using competing-risk regression. A total of 3,944 children were included in the analysis; 136 cases of severe recurrent bacterial pneumonia were reported at a rate of 6.5 [95% confidence interval (CI): 5.5-7.7] events per 1,000 patient-years. Clinical factors associated with severe recurrent bacterial pneumonia were younger age [adjusted subdistribution hazard ratio (aHR): 4.4 for <5 years versus ≥10 years, 95% CI: 2.2-8.4, P < 0.001], lower weight-for-age z-score (aHR: 1.5 for <-3.0 versus >-2.0, 95% CI: 1.1-2.3, P = 0.024), pre-ART diagnosis of severe recurrent bacterial pneumonia (aHR: 4.0 versus no pre-ART diagnosis, 95% CI: 2.7-5.8, P < 0.001), past diagnosis of symptomatic lymphoid interstitial pneumonitis or chronic HIV-associated lung disease, including bronchiectasis (aHR: 4.8 versus no past diagnosis, 95% CI: 2.8-8.4, P < 0.001), low CD4% (aHR: 3.5 for <10% versus ≥25%, 95% CI: 1.9-6.4, P < 0.001) and detectable HIV viral load (aHR: 2.6 versus undetectable, 95% CI: 1.2-5.9, P = 0.018). Children <10-years-old and those with low weight-for-age, a history of respiratory illness, low CD4% or poorly controlled HIV are likely to gain the greatest benefit from targeted prevention and treatment programs to reduce the burden of bacterial pneumonia in children living with HIV.

Sentinel surveillance in bacterial pneumonia in children under 5 years old in a fourth-level pediatric hospital in Colombia 2016-2022

BackgroundStreptococcus pneumoniae (S. pneumoniae) is a major cause of bacterial meningitis, septicemia and pneumonia in children. Inappropriate choice of antibiotic can have important adverse consequences for both the individual and the community. Here, we focused on penicillin/cefotaxime non-susceptibility of S. pneumoniae and evaluated appropriateness of targeted antibiotic therapy for children with IPD (invasive pneumococcal diseases) in China.MethodsA multicenter retrospective study was conducted in 14 hospitals from 13 provinces in China. Antibiotics prescription, clinical features and resistance patterns of IPD cases from January 2012 to December 2017 were collected. Appropriateness of targeted antibiotics therapy was assessed.Results806 IPD cases were collected. The non-susceptibility rates of S. pneumoniae to penicillin and cefotaxime were 40.9% and 20.7% respectively in 492 non-meningitis cases, whereas those were 73.2% and 43.0% respectively in 314 meningitis cases. Carbapenems were used in 21.3% of non-meningitis cases and 42.0% of meningitis cases for targeted therapy. For 390 non-meningitis cases with isolates susceptible to cefotaxime, vancomycin and linezolid were used in 17.9% and 8.7% of cases respectively for targeted therapy. For 179 meningitis cases with isolates susceptible to cefotaxime, vancomycin and linezolid were prescribed in 55.3% and 15.6% of cases respectively. Overall, inappropriate targeted therapies were identified in 361 (44.8%) of 806 IPD cases, including 232 (28.8%) cases with inappropriate use of carbapenems, 169 (21.0%) cases with inappropriate use of vancomycin and 62 (7.7%) cases with inappropriate use of linezolid.ConclusionsAntibiotic regimens for IPD definite therapy were often excessive with extensive prescription of carbapenems, vancomycin or linezolid in China. Antimicrobial stewardship programs should be implemented to improve antimicrobial use.

The drug effect and safety of azithromycin combined with lung physical therapy in the treatment of bacterial pneumonia in children were studied. A total of 112 cases were selected and divided into a study group and a control group with 56 cases in each group. The control group used azithromycin and the study group received assisted lung physical therapy. The drug effects, symptom disappearance time, inflammatory factors, lung function indicators and adverse reaction incidence of the two groups were compared. The results showed that the drug effect of the study group was higher than that of the control group, the level of inflammatory factors was lower than that of the control group, the symptom disappearance time was shorter and the lung function indicators were better. The incidence of adverse drug reactions in the two groups was comparable. Using the same drug azithromycin, under the action of pulmonary physical therapy, azithromycin can better exert its efficacy without affecting the safety of the drug.

Empyema is a common suppurative complication of bacterial pneumonia in children. Even with antibiotic treatment and chest tube placement for drainage

Antibiotic overuse in China: call for consolidated efforts to develop antibiotic stewardship programmes

BackgroundAntimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes.MethodWe conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings.ResultsOf the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1).ConclusionsImproving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.

PurposeThis meta-analysis aims to evaluate inappropriate antibiotic prescribing in the Gulf region and determine the effect of pharmacist-led antimicrobial stewardship (AMS) programmes on reducing inappropriateness.MethodArticles were searched, analysed, and quality...

IntroductionAntibiotic overuse is directly related to antibiotic resistance, and primary care is one of the main reasons for this overuse. This study aims to demonstrate that including experts on infectious...