Review Management of severe community-acquired Thorax: first published as 10.1136/thx.2010.142604 on 21 October 2010. Downloaded from pneumonia of children in developing and developed countries Nicola Principi, Susanna Esposito Department of Maternal and ABSTRACT Medline, Current Contents and the reference lists Paediatric Sciences, Universita` Childhood community-acquired pneumonia (CAP) is of the relevant articles. The search terms were degli Studi di Milano, common, and recent data have shown that the number of ‘community-acquired pneumonia’, ‘severe pneu- Fondazione IRCCS Ca’ Granda ’ ‘ ’ Ospedale Maggiore Policlinico, children with severe CAP is increasing worldwide. monia and complicated pneumonia . Only articles Milan, Italy Regardless of geographical area, severe cases are those written in English and related to the paediatric at the highest risk of hospitalisation, prolonged population (aged 0e18 years) were considered. Correspondence to hospitalisation and death, and therefore require prompt Given the large number of published papers, we Nicola Principi, Department of identification and the most effective treatment in order to have restricted ourselves to citing the most recent Maternal and Paediatric e Sciences, Universita` degli Studi reduce CAP-related morbidity and mortality. This review papers (2003 9) unless they were useful for back- di Milano, Fondazione IRCCS Ca’ evaluates the available data concerning the diagnosis and ground purposes. Since opportunistic agents may Granda Ospedale Maggiore treatment of severe and/or complicated cases of cause the majority of episodes in the immuno- Policlinico, Via Commenda 9, paediatric CAP in developed and developing countries. It compromised host, we will not deal with pneu- 20122 Milano, Italy; [email protected] also underlines the fact that any evidence-based monia in children with impaired host defences. recommendations require more research in various areas, Received 12 May 2010 including the aetiology of severe cases and the reasons for ASSESSING SEVERE CAP Accepted 2 September 2010 the complications, the better definition of first-choice Published Online First The estimated incidence of childhood hospital- 21 October 2010 antibiotic treatment and when surgery may be useful, and isation due to CAP is 8.7% of all cases of CAP in the role of chest physiotherapy. developing countries4 and 0.3% in the developed world.67However, it is not possible to compare the two because the criteria used to define CAP and its severity, and the prevalence of risk factors for the INTRODUCTION development of severe CAP, are very different (see Community-acquired pneumonia (CAP) is table 1). common among children all over the world, but its Given the limited availability of radiological http://thorax.bmj.com/ incidence and mortality rate are significantly higher equipment in the developing world, CAP is usually in developing countries than in the industrialised diagnosed only on the basis of clinical signs and e world.1 3 It has been estimated that there are symptoms.8 This often leads to an overestimate of about 151 million new episodes a year among Third the total number of cases because it is often World children aged <5 years, leading to an inci- confused with other respiratory diseases, mainly dence of 0.29 episodes per child-year and bronchiolitis. However, it may also be under- a mortality rate of 1.3e2.6%,12or >2 million per estimated because the poor organisation of the year. In industrialised countries the total number of health services in many developing countries means on September 30, 2021 by guest. Protected copyright. new episodes in the same age group is about 4 that many children with severe CAP are not million (an incidence of 0.05 episodes per child- admitted to hospital but die at home. year), and the risk of mortality is extremely low in The fact that the severity of CAP is defined on the otherwise healthy children and relatively important basis of clinical signs and symptoms can also lead to only in subjects with severe chronic underlying erroneous estimates because it has been shown that diseases.34 chest indrawing and increased respiratory rate have These differences are due to a number of factors. positive and negative predictive values as indicators First, the incidence of risk factors such as malnu- of lung consolidation of only 45% and 83%,9 and trition, crowding, low birth weight, HIV and the these percentages may be significantly lower in lack of measles and pneumococcal immunisation is children aged >36 months.10 As shown in table 1, much higher among children in developing developing countries use the WHO classification to e countries.1 4 Second, they are more likely to be define CAP severity, and severe CAP is diagnosed affected by other likely or possible risk factors such when, in addition to all the signs and symptoms as zinc and vitamin A deficiency, poor maternal used to diagnose lower respiratory tract involve- e education and living in polluted areas.1 4 Finally, ment, a child shows lower chest wall indrawing, there are profound differences between developing nasal flaring and (if young) grunting.11 Very severe and developed countries in the organisation and CAP requires at least one more sign or symptom of efficiency of their health systems.5 respiratory, central nervous system or gastrointes- The aim of this review is to consider the available tinal involvement. It has been calculated that, on the data concerning the diagnosis and treatment of basis of these criteria, more than 75% of the children severe cases of paediatric CAP. The data used in this hospitalised because of CAP have severe or very e review were identified by searching PubMed, severe disease.12 15 Thorax 2011;66:815e822. doi:10.1136/thx.2010.142604 815 Review Table 1 Criteria used in developing and developed countries to define However, it has also been shown (in developing and developed Thorax: first published as 10.1136/thx.2010.142604 on 21 October 2010. Downloaded from the severity of community-acquired pneumonia (CAP) countries) that influenza viruses and respiratory syncytial virus e Developing countries play a major role in causing severe and/or complicated CAP.25 27 Severe CAP In children with CAP diagnosed on the basis of fast The recent spread of the new influenza virus A/H1N1 has clearly breathing and on possible evidence of lower respiratory shown that viral infection can cause CAP with a negative tract involvement, severe cases are identified in the 28e30 presence of cough or difficult breathing plus at least one of outcome in all age groups. the following signs: Streptococcus pneumoniae, Haemophilus influenzae (including < lower chest wall indrawing non-typeable strains) and Staphylococcus aureus are the most e < nasal flaring frequently cultured bacteria in severe paediatric cases,31 35 < grunting (in young infants) Very severe CAP In children with a diagnosis of CAP or severe CAP, although some studies have also found that Streptococcus pyogenes 36 37 a diagnosis of very severe CAP is based on the presence of and Gram-negative enteric bacteria are common. The at least one of the following: importance of ‘atypical’ bacteria (Mycoplasma pneumoniae and < central cyanosis Chlamydophila pneumoniae) in severe and/or complicated CAP < inability to breastfeed or drink, or vomiting everything fi < convulsions, lethargy or unconsciousness has not been completely de ned worldwide, largely because of 21 < severe respiratory distress difficulties in identifying them. However, recently published Developed countries data indicate that a considerable number of children with CAP Severe CAP caused by atypical bacteria show a complicated course, mainly Infants Temperature >38.58C because of the presence of pleural effusion.38 Respiratory rate >70 breaths/min The role played by different pathogens has significantly Moderate to severe recession changed over recent years, particularly in the developed world. Nasal flaring However, prevention of CAP is a major effort that is being Cyanosis carried out by different organisations such as the WHO also in Grunting respiration developing countries. The widespread use of Hinfluenzae type Not feeding b vaccine and, more recently, the heptavalent pneumococcal SaO2 <92% > 8 conjugate vaccine (PCV-7) has nearly eliminated CAP due to the Older children Temperature 38.5 C fi 39 40 fi Respiratory rate >50 breaths/min rst and signi cantly reduced the number of cases due to the 41e43 fi Severe difficulty in breathing second pathogen. Considering the ef cacy of these two Nasal flaring vaccines, they have to be strongly recommended 41e43 Cyanosis worldwide. However, S pneumoniae is still the most Grunting respiration important aetiological agent of severe and/or complicated CAP 44e46 Signs of dehydration throughout the world: pneumococcal serotypes 1 and 3 fi SaO2 <92% have been signi cantly more often associated with complicated 42 43 47e49 Adapted from the World Health Organization11 and the British Thoracic Society.7 than with non-complicated CAP, and pneumococcal http://thorax.bmj.com/ SaO2, arterial oxygen saturation. serotypes 5, 7F, 14, and 19A have frequently been associated with severe and/or complicated CAP.50 51 More reliable data regarding the incidence of severe and very severe CAP are probably collected in the developed world where TREATMENT fi 7 In most cases it is not possible to identify the aetiology of CAP in most cases of CAP are con rmed by chest radiography. 1e3 7182234 Furthermore, although there is no childhood score similar to that clinical practice.