Etiology and Risk Factors Determining Poor Outcome of Severe Pneumonia in Under–Five Children
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To determine the etiology of severe pneumonia (pneumonia with chest indrawing) in under-five children, and to study the risk factors for poor outcomes viz., ‘treatment failure’, ‘need for change in antibiotics’, ‘prolonged hospital stay’, ‘need for mechanical ventilation’ and ‘mortality.’
Children (age 2 mo to 5 y) with pneumonia and chest drawing were enrolled prospectively from October 2012 through September 2013. Clinical history was recorded, and examination, anthropometry and investigations (including chest X-ray, blood culture and nasopharyngeal swab culture) were performed. Children were managed as per standard guidelines, and recovery outcomes were recorded in form of ‘treatment failure’ (defined as persistence of features of severe pneumonia after 72 h or worsening of clinical condition before 72 h), need for change of antibiotics and prolonged (>5 d) hospital stay. The associations between the clinical, anthropometric and diagnostic risk factors and the recovery outcomes were evaluated by univariate and multivariate logistic regression analysis.
Out of 120 children enrolled in the study, 36 (42%) were culture positive (nasopharyngeal/blood); most common bacteria isolated were Streptococcal pneumoniae and Staphylococcal aureus, respectively. Treatment failure was seen in 15 (12.5%), 34 (28.3%) needed change of antibiotics, and 50 (41.6%) children required prolonged hospitalization. Low birth weight, overcrowding, general danger signs (lethargy/unable to drink), clinical rickets, crepitation, leukocytosis and positive blood culture were significant risk factors for treatment failure, prolonged hospital stay and antibiotics change. On multivariate logistic regression analysis, respiratory rate of >70/min (OR 19.94, 95%CI 1.42–280.29), lethargy/unconsciousness (OR 114.2, 95%CI 3.14–4147.92), and positive blood culture (OR 15.24, 95%CI 2.53–91.67) had more chances of treatment failure. Duration of hospital stay was prolonged in those who had inability to drink (OR 3.89, CI 1.37–10.99) or abnormal chest X-ray (OR 8.45, CI 3.56–20.04). Children with rickets (OR 3.69, CI 1.14–11.96), and those with abnormal chest X-ray (OR 9.66, CI 2.62–35.53) had a higher odds of change in antibiotics. Presence of wheeze was a protective factor for treatment failure (OR 0.03, CI 0.00–0.37) and change of antibiotics (OR 0.24, CI 0.07–0.74).
Staphylococcus aureus and Streptococcus pneumoniae are the predominant organisms causing severe pneumonia in our setting. Children with risk factors such as respiratory rate >70/min, rickets, lethargy/unconsciousness, not able to drink, abnormal chest X-ray or positive blood culture are likely to have a delayed recovery or need of change of antibiotics, whereas those with wheeze are likely to recover faster with less chances of treatment failure.
KeywordsSevere pneumonia Risk factors Treatment failure
Dr. Rajeev, Department of Community Medicine, for statistical analyses.
DS and PG conceptualized the study and its design. SKJ, VGR, RS and NG: participated in data collection and diagnostic work-up of study participants. MP and DS analyzed and interpreted the data. MP and SKJ drafted the manuscript, which was revised after critical inputs from PG, DS, RS, VGR and NG. All authors approved the final version of the manuscript, as submitted.
Compliance with Ethical Standards
Conflict of Interest
Source of Funding
- 1.Revised WHO classification and treatment of childhood pneumonia at health facilities. Evidence summary; 2014. Available at: http://www.who.int/gho/child_ health/en/index.html. Accessed 24 Sept 2016.
- 2.UNICEF. Under-five and infant mortality rates and number of deaths. Available at: http://data.unicef.org/child-mortality/under-five.html. Accessed 29 Sept 2016.
- 3.Facility based IMNCI (F-IMNCI) Participants Manual. New Delhi: Ministry of Health & Family Welfare, Govt. of India; 2009. Available at: http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/Participants%20Manual.pdf. Accessed 13 Oct 2016.
- 5.Shah D, Sachdev HPS. Measuring undernutrition and overnutrition in children. In: Vir SC, editor. Public Health Nutrition in Developing Countries. 1 ed. New Delhi: Woodhead Publishing India Pvt Ltd; 2011. p. 108–150.Google Scholar
- 7.Agarwal R, Singh V, Yewale V. RTI Facts. IAP Consensus Guidelines on Rational Management of Respiratory Tract Infections in Children. Mumbai: Indian Academy of Pediatrics; 2006.Google Scholar
- 9.Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press; 2011.Google Scholar
- 15.Djelantik IG, Gessner BD, Sutanto A, Steinhoff M, Linehan M, Moulton LH, et al. Case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. J Trop Pediatr. 2003;49:327–32.Google Scholar
- 16.Addo-Yobo E, Anh DD, El-Sayed HF. Outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the MASS study. Trop Med Int Health. 2011;16:995–1006.Google Scholar
- 17.Kusel MMH, Merci MH, de Klerk, Nicholas H, Holt, Patrick G et al. Role of Respiratory Viruses in Acute Upper and Lower Respiratory Tract Illness in the First Year of Life: A Birth Cohort Study. Pediatr Infect Dis J. 2006;25:680–6.Google Scholar
- 18.Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. Viral pneumonia. Lancet. 2011;377:1264–75.Google Scholar