Maria-Regina A. Cardoso

Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children

Objective To examine the ability of the criteria proposed by the WHO to identify pneumonia among cases presenting with wheezing and the extent to which adding fever to the criteria alters their performance. Design Prospective classification of 390 children aged 2–59 months with lower respiratory tract disease into five diagnostic categories, including pneumonia. WHO criteria for the identification of pneumonia and a set of such criteria modified by adding fever were compared with radiographically diagnosed pneumonia as the gold standard. Results The sensitivity of the WHO criteria was 94% for children aged <24 months and 62% for those aged ≥24 months. The corresponding specificities were 20% and 16%. Adding fever to the WHO criteria improved specificity substantially (to 44% and 50%, respectively). The specificity of the WHO criteria was poor for children with wheezing (12%). Adding fever improved this substantially (to 42%). The addition of fever to the criteria apparently reduced their sensitivity only marginally (to 92% and 57%, respectively, in the two age groups). Conclusion The authors results reaffirm that the current WHO criteria can detect pneumonia with high sensitivity, particularly among younger children. They present evidence that the ability of these criteria to distinguish between children with pneumonia and those with wheezing diseases might be greatly enhanced by the addition of fever.

Procalcitonin is useful in identifying bacteraemia among children with pneumonia.

Abstract Empirical antibiotic use is prescribed in managing children with pneumonia worldwide. We assessed the usefulness of procalcitonin (PCT) and interferon-alpha (IFN-α) in differentiating viral from bacterial pneumonia. Among 159 hospitalized children, pneumonia was diagnosed based on clinical complaints plus pulmonary infiltrate. Aetiology was investigated for 9 viruses and 4 atypical and 3 typical bacteria. PCT and IFN-α were measured in the serum sample collected on admission. Eight patients had bacteraemic infections, 38 had non-bacteraemic typical infections, and 19 patients had atypical bacterial infections. Viral and unknown aetiology was established in 57 (36%) and 34 (21%) cases, respectively. Three patients with bacterial infection without collected blood culture were excluded. IFN-α (IU/ml) was detectable in 20 (13%) cases. The difference among median PCT values of the bacteraemic (4.22; 1.56–7.56), non-bacteraemic typical bacterial (1.47; 0.24–4.07), atypical bacterial (0.18; 0.06–1.03) and only viral (0.65; 0.11–2.22) subgroups was significant (p = 0.02). PCT was ≥2 ng/ml in 52 (33%) cases. The presence of IFN-α was associated with PCT <2 ng/ml (90% vs. 64%, p = 0.02). The negative predictive value (95% confidence interval) of PCT ≥2 ng/ml was 95% (89–100%), 89% (78–100%), 93% (85–100%) for differentiation of bacteraemic from viral, atypical bacterial and non-bacteraemic typical bacterial infection, respectively, and 58% (49–68%) for differentiation between bacterial and viral infection. PCT may be useful in identifying bacteraemia among children hospitalized with community-acquired pneumonia. IFN-α was uncommonly detected.

Human bocavirus infection diagnosed serologically among children admitted to hospital with community-acquired pneumonia in a tropical region.

Human bocavirus (HBoV) is a human virus associated with respiratory disease in children. Limited information is available on acute infection with HBoV among children admitted to hospital with community‐acquired pneumonia in tropical regions and the current diagnosis is inadequate. The aims were to diagnose and describe acute HBoV infections among children hospitalized for community‐acquired pneumonia. In Salvador, Brazil, 277 children with community‐acquired pneumonia were prospectively enrolled. Paired serum samples were tested by IgG, IgM, and IgG‐avidity enzyme immunoassays (EIAs) using recombinant HBoV VP2. HBoV DNA was detected in nasopharyngeal aspirates and serum by a quantitative polymerase‐chain reaction (PCR). HBoV DNA was detected in nasopharyngeal aspirates of 62/268 (23%) children and 156/273 (57%) were seropositive. Acute primary HBoV infection was reliably diagnosed (bearing at least two acute markers: Positive IgM, a fourfold increase/conversion of IgG, low IgG avidity or viremia) in 21 (8%) of 273 patients, 90% of 20 had HBoV DNA in nasopharyngeal aspirates, 83% with a high DNA load. The median age of infection with HBoV was 16 months, range 5–36. Community‐acquired pneumonia was confirmed radiographically in 85% of 20 patients with acute HBoV infection diagnosed serologically. HBoV DNA was found in nasopharyngeal aspirates of 42/246(17%) children without an acute primary HBoV infection and available nasopharyngeal aspirate. Four children with HBoV secondary immune responses were detected, lacking both IgM and viremia. HBoV infection was diagnosed accurately in children aged 5–36 months with community‐acquired pneumonia confirmed radiographically. PCR of nasopharyngeal aspirates is not a reliable marker of acute HBoV infection. J. Med. Virol. 84:253–258, 2012.

Seasonal patterns of viral and bacterial infections among children hospitalized with community-acquired pneumonia in a tropical region

Abstract Community-acquired pneumonia (CAP) is a common cause of morbidity among children. Evidence on seasonality, especially on the frequency of viral and bacterial causative agents is scarce; such information may be useful in an era of changing climate conditions worldwide. To analyze the frequency of distinct infections, meteorological indicators and seasons in children hospitalized for CAP in Salvador, Brazil, nasopharyngeal aspirate and blood were collected from 184 patients aged <5 y over a 21-month period. Fourteen microbes were investigated and 144 (78%) cases had the aetiology established. Significant differences were found in air temperature between spring and summer (p = 0.02) or winter (p < 0.001), summer and fall (p = 0.007) or winter (p < 0.001), fall and winter (p = 0.002), and on precipitation between spring and fall (p = 0.01). Correlations were found between: overall viral infections and relative humidity (p = 0.006; r = 0.6) or precipitation (p = 0.03; r = 0.5), parainfluenza and precipitation (p = 0.02; r = −0.5), respiratory syncytial virus (RSV) and air temperature (p = 0.048; r = −0.4) or precipitation (p = 0.045; r = 0.4), adenovirus and precipitation (p = 0.02; r = 0.5), pneumococcus and air temperature (p = 0.04; r = −0.4), and Chlamydia trachomatis and relative humidity (p = 0.02; r = −0.5). The frequency of parainfluenza infection was highest during spring (32.1%; p = 0.005) and that of RSV infection was highest in the fall (36.4%; p < 0.001). Correlations at regular strength were found between several microbes and meteorological indicators. Parainfluenza and RSV presented marked seasonal patterns.

Sole infection by human metapneumovirus among children with radiographically diagnosed community-acquired pneumonia in a tropical region

Please cite this paper as: Nascimento‐Carvalho et al. (2011) Sole infection by human metapneumovirus among children with radiographically diagnosed community‐acquired pneumonia in a tropical region. Influenza and Other Respiratory Viruses 5(4), 285–287

Simkania negevensis infection among Brazilian children hospitalized with community-acquired pneumonia

a convenient and usefully intermittent therapy, which the majority of individuals find acceptable. In our study we were concerned to identify a relatively large minority of individuals in whom the justification for pentamidine prophylaxis was not adequately documented or substantiated and this has led to a review of our procedures and a formalisation of our criteria for admission to the pentamidine clinic. The default rate on attendance for the clinic was worst in the HIV positive population and reflected the rather haphazard and chaotic lifestyles of some of these patients rather than any apparent difficulty in accessing the service for other reasons. The minimum cost of a single monthly appointment at the pentamidine clinic was £47.00, which compares with £2.81 for a one-month course of cotrimaxazole, 960 mg taken three times weekly. Thus pentamidine is an expensive alternative to the gold standard therapy. Highlighting this has been a trigger to initiating a review of reasons why patients are on pentamidine rather than alternative drugs. The identification of the proportions of patients coming from different disciplines has been of value in establishing payment pathways to support the service.

The inter-observer variation of chest radiograph reading in acute lower respiratory tract infection among children†

This study assessed the inter‐observer agreement in the interpretation of several radiographic features in the chest radiographs (CXR) of 803 children aged 2–59 months with non‐severe acute lower respiratory tract infection (ALRI). Inclusion criteria comprised: report of respiratory complaints, detection of lower respiratory findings, and presence of pulmonary infiltrate on the CXR taken on admission and read by the pediatrician on duty. Data on demographic and clinical findings on admission were collected from children included in a clinical trial on the use of amoxicillin (ClinicalTrials.gov Identifier NCT01200706). CXR was later read by two independent pediatric radiologists blinded to clinical information and pneumonia was finally diagnosed if there was agreement on the presence of pulmonary infiltrate or pleural effusion. The kappa index (κ) of agreement was calculated. The radiologists agreed that 774 (96.4%) and 3 (0.4%) CXR were appropriate or inappropriate for reading, respectively, and that 222 (28.7%) and 459 (59.3%) CXR presented or did not present pneumonia. In intent to treat analysis, that is, considering the 803 enrolled patients, κ for the presence of pneumonia was 0.725 (95% CI: 0.675–0.775). The overall agreement was 78.7% (normal CXR [nu2009=u2009385, 60.9%], pneumonia [nu2009=u2009222, 35.1%], other radiological diagnosis [nu2009=u200922, 3.5%], inappropriate for reading [nu2009=u20093, 0.5%]). The most frequent radiological findings were alveolar infiltrate (33.2%) and consolidation (32.9%) by radiologist 1 and consolidation (28.3%) and alveolar infiltrate (19.3%) by radiologist 2. Concordance for consolidation was 86.7% (ku2009=u20090.683, 95%CI: 0.631–0.741). Agreement was good between two pediatric radiologists when diagnosis of pneumonia among children with non‐severe ALRI was compared. Pediatr Pulmonol. 2013; 48:464–469.

Differences in Evolution of Children with Non-severe Acute Lower Respiratory Tract Infection With and Without Radiographically Diagnosed Pneumonia.

ObjectiveTo identify differences in the evolution of children with non-severe acute lower respiratory tract infection between those with and without radiographically diagnosed pneumonia.DesignProspective cohort study.SettingA public university pediatric hospital in Salvador, Northeast Brazil.PatientsChildren aged 2-59 months.MethodsBy active surveillance, the pneumonia cases were prospectively identified in a 2-year period. Each case was followed-up for changes in various clinical symptoms and signs. Demographic, clinical and radiographic data were recorded in standardized forms. Exclusion was due to antibiotic use in the previous 48 hours, signs of severe disease, refusal to give informed consent, underlying chronic illness, hospitalization in the previous 7 days or amoxicillin allergy. Chest X-ray (CXR) was later read by at least 2 independent pediatric radiologists.Main Outcome MeasuresRadiographic diagnosed pneumonia based on agreed detection of pulmonary infiltrate or pleural effusion in 2 assessments.ResultsA total of 382 patients receiving amoxicillin were studied, of whom, 372 (97.4%) had concordant radiographic diagnosis which was pneumonia (52%), normal CXR (41%) and others (7%). By multivariate analysis, age (OR=1.03; 95% CI: 1.02–1.05), disease ≥ 5days (OR = 1.04; 95% CI: 1.001-1.08), reduced pulmonary expansion (OR = 3.3; 95% CI: 1.4–8.0), absence of wheezing (OR = 0.5; 95% CI: 0.3–0.9), crackles on admission (OR = 2.0; 95% CI: 1.2–3.5), inability to drink on day 1 (OR = 4.2; 95% CI: 1.05–17.3), consolidation percussion sign (OR = 7.0; 95% CI: 1.5–32.3), tachypnea (OR = 2.0; 95% CI: 1.09–3.6) and fever (OR = 3.6; 95% CI: 1.4–9.4) on day 2 were independently associated with pneumonia. The highest positive predictive value was at the 2nd day of evolution for tachypnea (71.0%) and fever (81.1%).ConclusionPersistence of fever or tachypnea up to the second day of amoxicillin treatment is predictive of radiographically diagnosed pneumonia among children with non-severe lower respiratory tract diseases.

Detection of antibody responses against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis proteins in children with community-acquired pneumonia: effects of combining pneumococcal antigens, pre-existing antibody levels, sampling interval, age, and duration of illness

We evaluated the effects of combining different numbers of pneumococcal antigens, pre-existing antibody levels, sampling interval, age, and duration of illness on the detection of IgG responses against eight Streptococcus pneumoniae proteins, three Haemophilus influenzae proteins, and five Moraxella catarrhalis proteins in 690 children aged <5xa0years with pneumonia. Serological tests were performed on acute and convalescent serum samples with a multiplexed bead-based immunoassay. The median sampling interval was 19xa0days, the median age was 26.7xa0months, and the median duration of illness was 5xa0days. The rate of antibody responses was 15.4xa0% for at least one pneumococcal antigen, 5.8xa0% for H. influenzae, and 2.3xa0% for M. catarrhalis. The rate of antibody responses against each pneumococcal antigen varied from 3.5 to 7.1xa0%. By multivariate analysis, pre-existing antibody levels showed a negative association with the detection of antibody responses against pneumococcal and H. influenzae antigens; the sampling interval was positively associated with the detection of antibody responses against pneumococcal and H. influenzae antigens. A sampling interval of 3 weeks was the optimal cut-off for the detection of antibody responses against pneumococcal and H. influenzae proteins. Duration of illness was negatively associated with antibody responses against PspA. Age did not influence antibody responses against the investigated antigens. In conclusion, serological assays using combinations of different pneumococcal proteins detect a higher rate of antibody responses against S. pneumoniae compared to assays using a single pneumococcal protein. Pre-existing antibody levels and sampling interval influence the detection of antibody responses against pneumococcal and H. influenzae proteins. These factors should be considered when determining pneumonia etiology by serological methods in children.

Respiratory viral infections among children with community-acquired pneumonia and pleural effusion

Abstract Pleural effusion (PE), a complication of community-acquired pneumonia (CAP), is usually attributed to a bacterial infection. Nonetheless, viral infections have not been investigated routinely. We searched for bacterial and viral infections among 277 children hospitalized with CAP. Among these children 206 (74%) had radiographic confirmation, of whom 25 (12%) had PE. The aetiology was established in 18 (72%) PE cases: bacterial (n = 5; 28%), viral (n = 9; 50%), and viral–bacterial (n = 4; 22%) infections were found. Infection by rhinovirus (n = 3), enterovirus, Streptococcus pneumoniae (n = 2 each), Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, influenza A virus, and respiratory syncytial virus (RSV) (n = 1 each) were detected as probable sole infections. Parainfluenza virus 1/3 + influenza A virus and RSV + influenza A virus (n = 1 each) were identified as mixed viral–viral infections. Probable viral non-bacterial infection was identified in a third of the cases with CAP and PE. It is advisable to investigate viral as well as bacterial infections among children with CAP and PE.