Fiona Hampton

Epidemiology of community-acquired pneumonia in children seen in hospital

There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0-15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14.4 (95% CI 13.4-15.4)/10,000 children per year and 33.8 (95% CI 31.1-36.7) for <5-year-olds; with an incidence for admission to hospital of 12.2 (95% CI 11.3-13.2) and 28.7 (95% CI 26.2-31.4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16.1 (95% CI 14.9-17.3) and 41.0 (95% CI 37.7-44.5) in the 0-4 years age group, whilst incidence for hospital admission was 13.5 (95% CI 12.4-14.6) and 32 (95% CI 29.1-35.1) respectively. In the <5 years age group incidence of lobar pneumonia was 5.6 (95% CI 4.5-6.8)/10,000 per year and severe disease 19.4 (95% CI 17.4-21.7)/10,000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1.50, 95% CI 1.07-2.11) and with prematurity, OR 4.02 (95% CI 1.16-13.85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.

Children with pneumonia – how do they present and how are they managed?

Objective: To describe the spectrum of clinical features and management of community acquired pneumonia in the UK. Design: Prospectively recorded clinical details for all children with possible pneumonia and chest x ray (CXR) changes in 13 hospitals in the North of England between 2001 and 2002. Results: 89% of 711 children presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia and dyspnoea all correlated with each other and prompted appropriate interventions. Admission in children, not infants, was independently associated with RR, oxygen saturation, lobar CXR changes and pyrexia. Neither C-reactive protein, lobar CXR changes or pyrexia were associated with severity. Children over 1 year old with perihilar CXR changes more often had severe disease (p = 0.001). Initial intravenous antibiotics were associated with lobar CXR changes in infants and children and with dyspnoea, pyrexia and pleural effusion in children. The presence of pleural effusion increased duration of antibiotic treatment (p<0.001). Cefuroxime was the most often used intravenous antibiotic in 61%. Oral antibiotics included a penicillin in 258 (46%), a macrolide in 192 (34%) and a cephalosporin in 117 (21%). Infants stayed significantly longer (p<0.001) as did children with severe disease (p<0.01), effusions (p = 0.005) or lobar CXR changes (p⩽0.001). Conclusions: There is a high rate of intravenous antibiotic administration in hospital admissions for pneumonia. Despite lobar CXR changes not being independently associated with severe disease, initial lobar CXR changes and clinical assessment in children independently influenced management decisions, including admission and route of antibiotics.

Impact of the 7-valent pneumococcal conjugate vaccine on the incidence of childhood pneumonia

SUMMARY In September 2006, the 7-valent pneumococcal conjugate vaccine (PCV7) was added to the UK immunization programme. We aimed to evaluate the impact of PCV7 on the incidence of all-cause community-acquired pneumonia (CAP) in children. A prospective survey was undertaken in 2008–2009 at 11 hospitals in North East England of children aged 0–16 years with radiologically confirmed pneumonia. Data were compared to those from a similar survey undertaken in the same hospitals in 2001–2002. A total of 542 children were enrolled, of which 74% were aged <5 years. PCV7 uptake was 90·7%. The incidence of pneumonia was 11·8/10 000 [95% confidence interval (CI) 10·9–12·9], and the hospitalization rate was 9·9/10 000 (95% CI 9·0–10·9). Compared to 2001, there was a 19% (95% CI 8–29) reduction in the rate of CAP in those aged <5 years, and in those <2 years a 33·1% (95% CI 20–45) reduction in the incidence of CAP and 38·1% (95% CI 24–50) reduction in hospitalization rates. However, for those unvaccinated aged ⩾5 years, there was no difference in the incidence of CAP and hospitalization rate between both surveys. Since 2001, the overall reduction in incidence was 17·7% (95% CI 8–26) and for hospitalization 18·5% (95% CI 8–28). For the <5 years age group there was a lower incidence of CAP in PCV7-vaccinated children (25·2/10 000, 95% CI 22·6–28·2) than in those that were not vaccinated (37·4/10 000, 95% CI 29·2–47·1). In conclusion, PCV7 has reduced both incidence and rate of hospitalization of pneumonia in children, particularly in the <2 years age group.

Aetiology of paediatric pneumonia after the introduction of pneumococcal conjugate vaccine

We describe the aetiology of community-acquired pneumonia in children before and after the introduction of the pneumococcal conjugate vaccination (PCV) programme in 2006. Prospective studies were conducted in 2001–2002 (pre-vaccine) and 2009–2011 (post-vaccine) of children aged 0–16 years with radiologically confirmed pneumonia seen in hospital. Investigations included culture, serology, immunofluorescence antibody and urine antigen testing, with an increased use of PCR assays and expanded panels of pathogens in the post-vaccine study. 241 and 160 children were enrolled in the pre- and post-vaccine studies, respectively (73% aged <5 years). Identification of a causative pathogen was higher post-vaccination (61%) than pre-vaccination (48.5%) (p=0.019). Rates of bacterial infections were not different between post- and pre-vaccine studies (17.5% versus 24%, p=0.258). Viral (31%) and mixed (12.5%) infections were found more often post-vaccination (19.5%, p=0.021) than pre-vaccination (5%, p=0.015). Rates of identified pneumococcal infections were comparable between pre- and post-vaccine studies (14.7% versus 17.4%, p=0.557). Diagnosis of pneumococcal infection post-vaccination improved when PCR was used compared to culture (21.6% versus 6%, p=0.0004). Serotypes included in PCV13 but not PCV7 were identified in 75% (18 out of 24) post-vaccination. Infection with nonvaccine pneumococcal serotypes continues to be a significant cause of pneumonia in children in the UK. Aetiology of community-acquired pneumonia in children following a pneumococcal conjugate vaccination programme http://ow.ly/p9Wub

Accuracy of the Interpretation of Chest Radiographs for the Diagnosis of Paediatric Pneumonia

Introduction World Health Organization (WHO) radiological classification remains an important entry criterion in epidemiological studies of pneumonia in children. We report inter-observer variability in the interpretation of 169 chest radiographs in children suspected of having pneumonia. Methods An 18-month prospective aetiological study of pneumonia was undertaken in Northern England. Chest radiographs were performed on eligible children aged ≤16 years with clinical features of pneumonia. The initial radiology report was compared with a subsequent assessment by a consultant cardiothoracic radiologist. Chest radiographic changes were categorised according to the WHO classification. Results There was significant disagreement (22%) between the first and second reports (kappa = 0.70, P<0.001), notably in those aged <5 years (26%, kappa = 0.66, P<0.001). The most frequent sources of disagreement were the reporting of patchy and perihilar changes. Conclusion This substantial inter-observer variability highlights the need for experts from different countries to create a consensus to review the radiological definition of pneumonia in children.

Pneumococcal diagnosis and serotypes in childhood community-acquired pneumonia☆ , ☆☆

The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced routinely in the UK from September 2006 and replaced by PCV13 in 2010. In a prospective study from 2009 to 2011 of 160 children aged ≤16 years with radiologically confirmed pneumonia, likely pneumococcal infections were identified in 26%. Detection of pneumococci was improved with polymerase chain reaction compared to culture (21.6% versus 6% of children tested, P = 0.0004). Where serotyping was possible, all (n = 23) were non-PCV7 but PCV13 serotypes; 1 (43.5%), 3 (21.7%), 7A/F, and 19A (17.4% each).

Validity of using Hospital Episode Statistics data on monitoring disease trends

We read with interest the article by Koshy et al .1 The findings are important in documenting changes in admission rates of childhood pneumonia and empyema since the introduction of heptavalent pneumococcal conjugate vaccine (PCV7). We are concerned that undue emphasis has been placed on Hospital Episode Statistics (HES) data to define the aetiology of childhood pneumonia, particularly ‘bacterial pneumonia’.2 Given the magnitude of the case numbers reported, it would appear that the analyses are based on all pneumonia …

Impact of Heptavalent Pneumococcal Conjugate Vaccine On the Incidence of Childhood Pneumonia Seen in Hospital in the North East of England

Background Community-acquired pneumonia (CAP) is a common childhood infection. In September 2006, heptavalent pneumococcal conjugate vaccine (PCV7) was added into the UK national immunisation programme. Data from this study were compared with those from a similar study undertaken in the same hospitals in 2000–2001 to describe the disease epidemiological trend. Aim To evaluate the impact of PCV7 on the incidence of all causes childhood CAP. Methods A prospective population-based study including 11 hospitals in the North East of England from August 2008 to July 2009. Eligible cases were all children aged 0–16 years who presented with clinical and radiological features of pneumonia. Demographic and clinical details were recorded. Results Five hundred and seventy-six cases were initially identified, 34 of them had normal chest x-ray and were removed after validation, leaving a total of 542 cases eligible for enrolment (57.7% males; 73.8% under-five). The rate of empyema complication was 5.3%. Lobar consolidation was reported in 29.9%, and pleural effusion was present in 9.6% of the chest x-rays. PCV7 uptake was 88.9% among the eligible group, which is similar to that recorded nationally in the NHS Immunisation Statistics for England 2008–2009. In comparison with the data from 2001 study, there were 28% fewer cases of CAP in 2009 study. The incidence of CAP decreased from 14.4 cases per 10 000 children in 2001 to 11.8 cases per 10 000 children in 2009 (95% CI 0.74 to 0.92). Conclusion This study suggests that following the introduction of PCV7, the incidence of childhood pneumonia seen in hospital has decreased since 2001.

Clinical Significance of Inflammatory Markers and Radiological Features in Predicting the Aetiology of Community-Acquired Pneumonia in Children

Background: Community-acquired pneumonia (CAP) is a common childhood infection. Inflammatory markers and radiological features have not previously been found useful in distinguishing bacterial from viral aetiology. Predicting the causative pathogens would help provide targeted management.Aim: To investigate clinical significance of inflammatory markers and radiological features in predicting the aetiology of childhood CAP.Methods: A prospective study of children with CAP seen in hospital in North East England from August 2000 to July 2001. Chest x-rays were reported by Radiologists according to the WHO criteria of lobar, patchy or perihilar infiltrates. Aetiology was decided by definite diagnostic criteria. Inflammatory markers included C-reactive protein (CRP), total white cell count (WCC) and neutrophil count. A discriminate analysis approach was used to classify cases on the basis of age, CRP and WCC for different chest x-ray categories forming the basis of a model for prediction of aetiology.Results: A total of 404 subjects aged 0-15 years were enrolled. Definite infections were 16.6% bacterial, 15.1% viral and 3.5% mixed viral-bacterial. Compared to viral, bacterial infections had higher mean values of CRP (p< 0.001), total WCC (p=0.002) and neutrophil count (p=0.001). The discriminate models using lobar, patchy and perihilar features had a respective accuracy rate of 95.8%, 85.5% and 91% in predicting if CAP is caused by bacterial or viral pathogens when used to reclassify the raw data.Conclusion: Children with bacterial pneumonia had higher inflammatory markers. This discriminate prediction model is a potentially useful tool in clinical management and epidemiological studies of childhood pneumonia.