Clinical Characteristics and Etiology of Community-acquired Pneumonia in US Children, 2015–2018

Abstract

Background: Pneumonia has a major impact on childhood health and health care costs. This study was designed to obtain contemporary information on the clinical characteristics and etiology of community-acquired pneumonia (CAP) in children from both inpatient and outpatient settings in the USA. Methods: We conducted a prospective, multicenter, observational study of CAP among previously healthy children 2 months to 18 years of age in 6 children's hospitals in Ohio from 2015 to 2018. For pathogen detection, nasopharyngeal swabs were collected from all subjects. Blood and pleural fluid cultures were available per standard of care. Results: We enrolled a convenience sample of 441 patients: 380 hospitalized and 61 outpatients. Tachypnea and radiologic findings of consolidation and pleural effusion were more frequent among inpatients than outpatients. A pathogen was detected in 64.6% of patients: viruses in 55.6%, atypical bacteria in 8.8% and pyogenic bacteria in 4.3%. Eighteen (4.1%) patients had both viruses and bacteria detected. Rhinovirus/enterovirus (RV; 18.6%) and respiratory syncytial virus (RSV; 16.8%) were the viruses most frequently detected, and Mycoplasma pneumoniae (8.2%) and Streptococcus pneumoniae (2.3%) were the most common bacteria. Except for S. pneumoniae, which was identified more frequently in inpatients, there were no significant differences between inpatients and outpatients in the proportions of children with specific pathogens detected. Conclusions: Rhinovirus/enterovirus and RSV among viruses and M. pneumoniae and S. pneumoniae among bacteria were the most common pathogens detected in children with CAP. Tachypnea and chest radiographs with consolidation and/or pleural effusion were associated with hospitalization.

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“…Detection of RhV and AdV is common, both in healthy children and children with LRI, and their attributable role to LRI is often questionable. [34][35][36] Furthermore, the co-detection of RhV and AdV with other viruses is common, and the co-presence with any of the PDA-viruses usually bears the clinical presentation typical of the specific coinfecting PDA-virus. In contrast, we found that co-detection of ≥2 PDA-viruses was rare (1•3%).…”

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“… 11–14 Furthermore, there are no features on history or physical examination that are highly specific for either viral or bacterial causes and validated radiographic criteria for reliably distinguishing between viral and bacterial pneumonia do not exist 13 (despite the fact that bacterial disease is more often associated with consolidations 15 ), which makes the determination of the optimal management strategy for CAP challenging. Unlike adults, children commonly develop viral pneumonia 16 or bacterial-viral coinfections 15 17 18 ; one large study enrolling children hospitalised for CAP at 3 US centres showed that 66% had a respiratory virus detected and 26% had proven coinfections. 19 Consequently, even though recent randomized controlled trials (RCTs) have shown that short-course treatment is equally effective as longer courses of antibiotics for paediatric CAP, 20–22 it seems likely that current treatment strategies are still resulting in a large proportion of children receiving antimicrobials that will do nothing to attenuate their illnesses.…”

“… 16 Increased C reactive protein (CRP) is associated with bacterial infection, but not sufficiently strongly to rule bacterial CAP in or out as a stand-alone test. 15 24–30 Urinary pneumococcal antigen (UAg) testing was previously not specific for pneumococcal disease in children 31 ; however, this may no longer be true in the post-13-valent pneumococcal conjugate vaccine (PCV13) era with changes in S. pneumoniae colonisation patterns. 32 Furthermore, a recent prospective cohort study of children hospitalised with CAP in Colombia (where pneumococcal vaccination rates are low) showed that only 18% had a positive UAg result (as compared with 8% of controls).…”

“…Since routine diagnostics do not reliably differentiate between bacterial and viral infection, it is not surprising that most children diagnosed with CAP at our institution are treated with antibiotics, a common practice in North America. 15 37 38 Unfortunately, many of these children have primary viral infections and receive antibiotics that will not help but may cause harm. Minimising inappropriate antimicrobial prescribing is an important strategy to attenuate the increase in circulating antimicrobial resistance, 39 40 which explains the interest in exploring the effectiveness of shorter courses of antimicrobials for numerous infections 41 and subsequent changes to treatment guidelines.…”

“…Although chest radiography (CXR) is widely assumed to be diagnostic, the inter-rater and intra-rater reliability for the identification of CXR infiltrates other than clear lobar consolidations is not good 11–14. Furthermore, there are no features on history or physical examination that are highly specific for either viral or bacterial causes and validated radiographic criteria for reliably distinguishing between viral and bacterial pneumonia do not exist13 (despite the fact that bacterial disease is more often associated with consolidations15), which makes the determination of the optimal management strategy for CAP challenging. Unlike adults, children commonly develop viral pneumonia16 or bacterial-viral coinfections15 17 18; one large study enrolling children hospitalised for CAP at 3 US centres showed that 66% had a respiratory virus detected and 26% had proven coinfections 19.…”