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Severity of Pneumonia in Under 5-Year-Old Children from Developing Countries: A Multicenter, Prospective, Observational Study

Wednesday, 23rd of August 2017 Print

Excerpt below; full text is at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508893/                        

Am J Trop Med Hyg. 2017 Jul 12; 97(1): 68–76.

Published online 2017 May 1. doi:  10.4269/ajtmh.16-0733

Severity of Pneumonia in Under 5-Year-Old Children from Developing Countries: A Multicenter, Prospective, Observational Study

Thomas Bénet,1,2 Valentina Sanchez Picot,1 Shally Awasthi,3 Nitin Pandey,3 Ashish Bavdekar,4 Anand Kawade,4Annick Robinson,5 Mala Rakoto-Andrianarivelo,6 Maryam Sylla,7 Souleymane Diallo,8 Graciela Russomando,9 Wilma Basualdo,10 Florence Komurian-Pradel,1 Hubert Endtz,1,11 Philippe Vanhems,1,2 Gláucia Paranhos-Baccalà,1 and for the GABRIEL Network

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Abstract.

Pneumonia is the leading cause of death in children. The objectives were to evaluate the microbiological agents linked with hypoxemia in hospitalized children with pneumonia from developing countries, to identify predictors of hypoxemia, and to characterize factors associated with in-hospital mortality. A multicenter, observational study was conducted in five hospitals, from India (Lucknow, Vadu), Madagascar (Antananarivo), Mali (Bamako), and Paraguay (San Lorenzo). Children aged 2–60 months with radiologically confirmed pneumonia were enrolled prospectively. Respiratory and whole blood specimens were collected, identifying viruses and bacteria by real-time multiplex polymerase chain reaction (PCR). Microbiological agents linked with hypoxemia at admission (oxygen saturation < 90%) were analyzed by multivariate logistic regression, and factors associated with 14-day in-hospital mortality were assessed by bivariate Cox regression. Overall, 405 pneumonia cases (3,338 hospitalization days) were analyzed; 13 patients died within 14 days of hospitalization. Hypoxemia prevalence was 17.3%. Detection of human metapneumovirus (hMPV) and respiratory syncytial virus (RSV) in respiratory samples was independently associated with increased risk of hypoxemia (adjusted odds ratio [aOR] = 2.4, 95% confidence interval [95% CI] = 1.0–5.8 and aOR = 2.5, 95% CI = 1.1–5.3, respectively). Lower chest indrawing and cyanosis were predictive of hypoxemia (positive likelihood ratios = 2.3 and 2.4, respectively). Predictors of death were Streptococcus pneumoniae detection by blood PCR (crude hazard ratio [cHR] = 4.6, 95% CI = 1.5–14.0), procalcitonin ≥ 50 ng/mL (cHR = 22.4, 95% CI = 7.3–68.5) and hypoxemia (cHR = 4.8, 95% CI = 1.6–14.4). These findings were consistent on bivariate analysis. hMPV and RSV in respiratory samples were linked with hypoxemia, and S. pneumoniae in blood was associated with increased risk of death among hospitalized children with pneumonia in developing countries.

Introduction

Despite reduced mortality rates in recent years, pneumonia is the foremost cause of death from infectious diseases in under 5-year-old children worldwide, accounting for 15% of total deaths, mostly in developing countries.1 Hypoxemia, frequently associated with pneumonia and a marker of disease severity, leads to 3- to 4-fold increased risk of death in children with pneumonia.2 A Cochrane review3 has reported that systematic hypoxemia screening with pulse oximetry and appropriate oxygen supply are effective in preventing death from pneumonia in children.

A large simulation study estimated that systematic pulse oximetry may globally prevent almost 150,000 deaths from pneumonia annually.4 However, the microbiological agents linked with hypoxemic pneumonia are poorly recognized. The identification of such etiological agents would serve to better target preventive (i.e., vaccination) and curative measures (i.e., antibiotics and antiviral drugs), reducing the global burden of hypoxemia and pneumonia. Because of its high incidence and related mortality, particular attention must be paid to hypoxemic pneumonia in developing countries. Pulse oximetry is still rarely available in health-care settings of developing countries.5 In the absence of oximeter, hypoxemia can be detected by several clinical signs or symptoms, including cyanosis and increased respiratory rate. However, none is sensitive and specific enough to reliably detect hypoxemia.68 Most studies of hypoxemia in children with pneumonia were performed in one country and rarely investigated the relationship between hypoxemia and microbiological results, so it would be useful to reassess them in a more recent multicontinental investigation.2

The risk factors of death among children with pneumonia in developing countries have already been identified,9,10 but rarely regarding the relationship between microbiological findings and mortality. Assessment of clinical, para-clinical, and microbiological predictors of death would be useful to prioritize public health campaigns. Identification of microbiological agents associated with death and/or hypoxemia would be useful to better focus therapeutic measures. Indeed, hypoxemic pneumonia can be treated with oxygen in conjunction with other measures, whereas non-hypoxemic pneumonia with poor vital prognosis might need other regimens, such as antibiotics/antivirals or intensive care.

The objectives of the present study are to assess the microbiological agents linked to hypoxemia in hospitalized children with pneumonia in developing countries, to identify clinical and para-clinical predictors of hypoxemia and to pinpoint factors associated with death within 2 weeks after admission.

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