Differences upon admission and in hospital course of children hospitalized with community-acquired pneumonia with or without radiologically-confirmed pneumonia: a retrospective cohort study

Abstract

BackgroundThe use of chest radiograph (CXR) for the diagnosis of childhood community-acquired pneumonia (CAP) is controversial. We assessed if children with CAP diagnosed on clinical grounds, with or without radiologically-confirmed pneumonia on admission, evolved differently.MethodsChildren aged ≥ 2 months, hospitalized with CAP diagnosed on clinical grounds, treated with 200,000 IU/Kg/day of aqueous penicillin G for ≥ 48 h and with CXR taken upon admission, without pleural effusion, were included in this retrospective cohort. One researcher, blinded to the radiological diagnosis, collected data on demographics, clinical history and physical examination on admission, daily hospital course during the first 2 days of treatment, and outcome, all from medical charts. Radiological confirmation of pneumonia was based on presence of pulmonary infiltrate detected by a paediatric radiologist who was also blinded to clinical data. Variables were initially compared by bivariate analysis. Multi-variable logistic regression analysis assessed independent association between radiologically-confirmed pneumonia and factors which significantly differed during hospital course in the bivariate analysis. The multi-variable analysis was performed in a model adjusted for age and for the same factor present upon admission.Results109 (38.5 %) children had radiologically-confirmed pneumonia, 143 (50.5 %) had normal CXR and 31 (11.0 %) had atelectasis or peribronchial thickening. Children without radiologically-confirmed pneumonia were younger than those with radiologically-confirmed pneumonia (median [IQR]: 14 [7–28 months versus 21 [12–44] months; P = 0.001). None died. The subgroup with radiologically-confirmed pneumonia presented fever on D1 (33.7 vs. 19.1; P = 0.015) and on D2 (31.6 % vs. 16.2 %; P = 0.004) more frequently. The subgroup without radiologically-confirmed pneumonia had chest indrawing on D1 (22.4 % vs. 11.9 %; P = 0.027) more often detected. By multi-variable analysis, Fever on D2 (OR [95 % CI]: 2.16 [1.15-4.06]) was directly and independently associated with radiologically-confirmed pneumonia upon admission.ConclusionThe compared subgroups evolved differently.

Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis

“…These two features are particularly useful in the evaluation of pediatric patients, both in the emergency department and in a hospital ward. However, CXR shows a non-optimal ability to distinguish alveolar pneumonia from interstitial pneumonia (a sensitivity of about 43%); it generates ionizing radiation as well and, moreover, interobserver agreement is not perfect [7,[35][36][37][38]. So, an inexpensive, accurate and fast (possibly bedside) diagnostic tool that can be used for this purpose is needed.…”

Advances in the diagnosis of pneumonia in children

“…65 Evidence for the accuracy of MRI and interobserver agreement in interpreting pneumonia in children is agreement in the interpretation of chest radiographs is poor. [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] In a recent review, 10 of 12 pediatric studies showed only fair to moderate interobserver agreement. 38 Agreement is worse for reporting of an "infiltrate" in children under 5 years, 23 and it remains moderate even when using WHO standardized radiological criteria for pneumonia.…”

“…Ultrasound has several advantages over other imaging modalities: it can be performed at POC, it is feasible and less costly than chest radiography, it is less affected by movement or crying than other imaging modalities, it can be done in sleeping children, 35 and it is free of ionizing radiation. [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] Although ultrasound performed by non-radiologists is controversial, it has become a useful tool for physicians, emergency medicine doctors, and intensivists. 44 Lung ultrasound involves scanning a child in the anterior, lateral, and posterior areas of each hemithorax.…”

A Multisite Intervention for Pediatric Community‐acquired Pneumonia in Community Settings

“…First, the pathway does not recommend obtaining blood cultures for patients presenting with uncomplicated CAP, even for those requiring admission, as several studies have demonstrated that obtaining blood cultures is unnecessary for these patients . Additionally, the pathway does not recommend obtaining chest radiographs (CXR) for afebrile patients presenting to the ED with wheezing, as CXRs may not differentiate viral from bacterial etiologies in these patients …”