| Abstract |
Background: Although the incidence of community-acquired pneumonia has declined over the past 20 years, it remains the leading infectious cause of morbidity and mortality worldwide, particularly in infants and children younger than 5 years of age. (1) According to the World Health Organization (WHO), community pneumonia accounted for 14% of deaths of children under 5 years of age and 22% of deaths of children aged 1-5 years in 2019. With appropriate management, most cases will be successfully managed and adequately cured, but a small proportion will develop a complication, either pulmonary or extra-pulmonary. (2) Severe complicated pneumonia is a condition characterized by local complications in the chest (pulmonary complications, e.g. parapneumonic effusion, necrotizing pneumonia, and pulmonary abscess, bronchopulmonary fistula, pneumothorax and pneumothorax), and systemic complications (e.g., bacteremia, multiorgan failure, acute respiratory distress syndrome (ARDS), diffuse intravascular coagulation, etc.). (3,4)
The occurrence of complications may be due to treatment failure caused by resistance of the microorganism to empirical therapy, or due to the presence of an underlying condition such as cystic fibrosis, immunodeficiency, congenital thoracic dysplasia, or more often due to their development at the onset of the infection. (5) In some cases, prolonged hospitalization with admission to PICU and invasive procedures such as mechanical ventilation due to respiratory failure and chest tube insertion in case of parapneumonic collections may be required. Early recognition of the severity of the disease is particularly important, so that mild cases are not overtreated, but patients with an increased risk of complications are treated more aggressively from the outset. (6)
Objective: Tο study the clinical, laboratory and imaging parameters in children with lower respiratory tract infection requiring hospitalization in ICU, with or without interventional procedures, as well as the correlation of presence and grade of imaging findings with disease severity and outcome.
Methods: This is a single-center retrospective observational study of patients admitted to the Pediatric Intensive Care Unit of Heraklion University General Hospital from January 2017 to November 2023. Children aged between 1 month to 18 years, who were admitted to the PICU due to lower respiratory tract infection were included in the study. The physical and electronic records of patients were reviewed and the epidemiological, clinical, laboratory and imaging characteristics, complications, therapeutic interventions (conservative/surgical) and outcome were recorded. Admission radiographs and all available radiographs during the patients' hospitalization in the ICU were scored according to the RALE score (radiographic score originally used in ARDS and related to the extent and radiolucency of parenchymal lesions) and a modified RALE scoring system that took into account the presence of pleural effusion, mediastinal displacement and necrosis.
Results: In this retrospective study of 67 children admitted to the PICU with severe community-acquired pneumonia, the mean age was 5.1 years (±4.2) and 53.7% (n=36) of them was boys. Approximately 29.9% (n=20) had a comorbidity, mostly multiple comorbidities (66.7%, n=12). The most common symptoms were fever (83.6%), cough (65.7%) and respiratory distress (80.6%, n=54). Predominantly isolated microorganisms included Streptococcus pneumoniae and rhinoviruses/enteroviruses. 73.1% of patients (n=49) received a combination of >3 antibiotics (cephalosporins, macrolides, oxazolidinones). At least one complication occurred to 71.6% (n=48) of children, such as pleural effusion (53.7%), necrotizing pneumonia (26.9%) and pneumothorax (11.9%). Patients with necrosis (n=18) had higher WBC (p=0.005) and CRP (p=0.016) and lower Hb (p=0.005), and were less frequently on mechanical ventilation (5.6% vs 67.3%, p<0.001). Oxygenation of patients with necrotic pneumonia differed significantly on the day of admission and the worst day of hospitalization from patients without necrosis, who were more burdened (PF ratio (PaO2/FiO2) on admission p=0.04 and worst day p<0.001). RALE and modified RALE score were significantly higher in patients with necrotic pneumonia on day 1 and day 3 of hospitalization (p=0.012). Conduct of thoracic CT scan (n=29) was associated with higher modified RALE scores (p=0.001). CXR-mRALE score upon PICU admission &ggggt;28.5 could independently predict progress to necrotic pneumonia (AUC-ROC 0.865, 95%CI 0.664-1.065 , p<0.001), and >19.5 could predict thoracic drainage (AUC-ROC 0.963, 95%CI 0.862-1.063, p<0.001). Crude Mortality was 7.5% (n=5) and was associated with lower SpO2 (p=0.023) and higher Lac (p<0.001). The presence of comorbidities and the use of mechanical ventilation were identified as independent factors of prolonged PICU and hospital stay.
Conclusion: The RALE and modified RALE radiographic scores were significantly higher in the first days of PICU hospitalization in children with necrotic pneumonia, contributing to the prediction of necrosis, chest tube placement and CT scan. Imaging scores were not associated with length of PICU or hospital stay, nor with mortality. The presence of comorbidities and the need for mechanical ventilation were identified as independent risk factors for prolonged ICU and hospital stay.
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