Chest Infections: Pneumonia Diagnosis and Outcomes |

It’s A Different World: Microbiological Flora of Children With Community-Acquired Pneumonia Admitted to a Tertiary Pediatric ICU FREE TO VIEW

Manzilat Akande, MD; Todd Karsies, MD
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Nationwide Children's Hospital, Columbus, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):148A. doi:10.1016/j.chest.2016.08.157
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SESSION TITLE: Pneumonia Diagnosis and Outcomes

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 26, 2016 at 02:45 PM - 04:15 PM

PURPOSE: Community acquired pneumonia (CAP) is a significant cause of morbidity and mortality in children. A recent large study described the microbiology with findings consistent with current pediatric CAP treatment guidelines (viral pathogens in 2/3 of patients and bacteria in only 15%) [1]. There are limited data about the etiologies in severe CAP, something this study did not adequately address. Due to inconsistencies between our experience and existing data, we evaluated the etiology of CAP in our PICU with the hypothesis that application of non-ICU data and guidelines were not appropriate and could result in incorrect antibiotic selection in critically ill children with CAP.

METHODS: We conducted a retrospective chart review of 231 patients admitted in a single tertiary care PICU with CAP based on both clinical and radiological findings. Inclusion criteria were those used by the Jain study, which included some patients we otherwise would have considered to have hospital acquired pneumonia (HCAP). Results of blood, respiratory and pleural specimens collected for clinical purposes were analyzed.

RESULTS: 213 (94%) patients had microbiologic testing, and 117 (54%) had at least one pathogen identified. Blood cultures were obtained for 84% of patients, pleural cultures in 9.5%, and lower respiratory cultures in 57%. 95 (41%) patients had a least one bacteria, with 77% identified in respiratory cultures. 17% of patients with a bacterial pathogen also had a viral infection. Of those with a bacterial etiology, 28% were polybacterial; 42% Gram positive, 42% Gram negative, and 15% grew both. Staphylococcus aureus (12%) was the most common, followed by Pseudomonas aeruginosa (10%), Haemophilus influenzae (4%), Moraxella catarrhalis (4%) and Streptococcus pneumoniae (2%). Other bacteria were rarely seen. 34 (15%) tested positive for a virus, with Respiratory syncytial virus (RSV) being the most common (50%), followed by Influenza (21%), Parainfluenza (15%), Adenovirus (12%) and Human metapneumovirus(3%). 52% of those with RSV had bacterial co-infection. Viral etiology without bacterial co-infection occurred in only 20 (9%) patients. Mycoplasma pneumonia was identified in 4 patients. Bacteremia occurred in 20 (9%) patients--25% due to S. aureus and 15% to S. pneumonia.

CONCLUSIONS: Our findings show that pathogens causing CAP in the PICU differ from pediatric CAP overall. Our higher bacterial rate may be due to more common respiratory cultures but it may also be that critically ill children have higher rates of bacterial CAP than the general hospital population. While some identified pathogens (e.g. Pseudomonas, Stenotrophomonas) likely represent HCAP rather than CAP, our high rates of S. aureus as well as Gram negative bacteria suggest that PICU antibiotic strategies should differ from non-ICU pediatric CAP. Ultimately, risk stratification pre-ICU admission might help to tailor early empiric antibiotics use and potentially halt the clinical progression of severe CAP.

CLINICAL IMPLICATIONS: Current pediatric CAP data differ from our ICU findings, suggesting antibiotic strategies different from current CAP guidelines may be needed

Reference 1. Jain S et al., Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015; 372: 835-45

DISCLOSURE: The following authors have nothing to disclose: Manzilat Akande, Todd Karsies

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