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

Julia E Clark ^1*, Hammal Donna ², David Spencer ³ and Fiona Hampton ⁴

¹ Newcastle General Hospital, United Kingdom
² Sir James Spence Institute, United Kingdom
³ Freeman Hospital, United Kingdom
⁴ James Cook University Hospital, United Kingdom

^* To whom correspondence should be addressed. E-mail: julia.clark{at}nuth.nhs.uk.

Accepted 8 January 2007

Abstract

Objective:To describe the spectrum of clinical features and actual management of community acquired pneumonia (CAP) in the UK.

Design:Prospectively recorded clinical details for all children < 16 years with possible pneumonia and chest x-ray (CXR) changes seen by a paediatrician in 13 hospitals in the North of England between 2001 and 2002.

Results:89% of 711 presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema, 4% required ITU 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 (OR1.03 for a one unit increase in RR, 95% CI:[1.01, 1.05]), oxygen saturation (OR0.81 for a one unit increase in Sa02, (95% CI:[0.73, 0.89]), lobar CXR changes (OR5.97, 95% CI:[1.82, 19.62]) and pyrexia (OR2.25, 95% CI:[1.31, 3.86]). Neither CRP, lobar CXR changes or pyrexia were associated with severity. Children over 1 year with perihilar CXR changes more often had severe disease (p=0.001). Lobar CXR changes were associated with initial intravenous antibiotics in infants (OR4.82, 95%CI [1.03, 22.62]) and children (OR2.93, 95%CI[1.59, 5.40]). For children initial intravenous antibiotics were also associated with dyspnoea (OR1.79, 95%CI[1.21, 2.64]), pyrexia (OR2.27, 95%CI[1.55, 3.32]), and pleural effusion (OR6.19, 95%CI[2.17, 17.62]). Presence of pleural effusion increased duration of antibiotic treatment (p<0.0001). Cefuroxime was the most often used intravenous antibiotic in 61%. Orally a "penicillin" was used 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=0.0004).

Conclusions:In hospital admissions for pneumonia there is a high rate of intravenous antibiotic administration. 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.

Keywords: antibiotics, childhood pneumonia, community acquired pneumonia, management, severity

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