Dirlewanger, Mirjam

Fanconi, Sergio

Gehri, Mario

Krahenbuhl, Jean-Daniel

Vaudaux, Bernard

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RESEARCH LETTERMirjam Dirlewanger Æ Jean-Daniel KrahenbuhlSergio Fanconi Æ Bernard Vaudaux Æ Mario GehriCommunity-acquired pneumonia in children aged 2 monthsto 5 years: application of the WHO guidelinesin a developed country setting (Switzerland)Received: 15 February 2002 / Revised: 16 April 2002 and 24 May 2002 /Accepted: 28 May 2002 / Published online: 6 July 2002 Springer-Verlag 2002In developed countries, the high morbidity associated withrespiratory tract infections and the diﬃculty to discrim-inate viral from bacterial aetiology support the use ofguidelines based on the observation of clinical signs, suchas the World Health Organisation algorithm. Tachypnoeais the cardinal clinical sign on which early diagnosis ofpneumonia is to be based in order to allow prompt initi-ation of appropriate antibiotic therapy.A key issue in managing respiratory tract infections(RTI) is to detect cases of bacterial community-acquiredpneumonia (CAP) requiring antibiotic treatment [1,2].The only validated guideline in children is that proposedby the World Health Organisation (WHO) [6] which isbased on the observation of ﬁve clinical parameters: re-spiratory rate (the absence of tachypnoea rules outCAP), chest retraction, cyanosis, feeding diﬃculty andabsence of wheezing. Diverse combinations of these ﬁveparameters deﬁne three stages of severity, each calling fora distinct therapeutic regimen. In order to test the rele-vance of the WHO guidelines for a developed country,we applied them in our general paediatric emergencyclinic in the light of routine investigations. In childrenwith suspected CAP, after clearing the nose and when thechild had returned to a quiet state, respiratory rate wascounted for 1 min on two separate occasions. Tachyp-noea was deﬁned as any respiratory rate >50/min inchildren younger than 1 year or >40/min in childrenaged 1–5 years. All children aged 2 months to 5 yearswith WHO criteria for CAP were prospectively enrolled.Children on antibiotics or having received antibioticswithin the previous 2 weeks, those with an underlyingchronic disease and those with wheezing were excluded.A chest X-ray ﬁlm (antero-posterior and lateralviews) was obtained in all children. White blood cell(WBC) count, C-reactive protein (CRP) and blood cul-tures were obtained in children with stage 2 and 3pneumonia. Amoxyclavulanate was used for initial oraltherapy (stage 1) and follow-up oral therapy (stages 2and 3), and ceftriaxone for initial parenteral therapy(stages 2 and 3). Simple statistical analysis was doneusing the chi-squared test (level of signiﬁcance deﬁned asP<0.05).Over the 6 months study period, 47 children fulﬁllingthe WHO criteria of pneumonia were enrolled. Themedian age was 28 months (range, 4 to 59 months).Seventeen children (36%) were classiﬁed as stage 1pneumonia, 22 (47%) as stage 2, and 8 (17%) as stage 3(Table 1). Clinical outcome was favourable in all chil-dren.The overall poor sensitivity of auscultation, whichproved normal in 70% of children is worth noting.Auscultation was able to detect only 33% of consoli-dations evidenced on chest ﬁlms. Chest X-ray ﬁlmsproved to have an excellent sensitivity with abnormalﬁndings in 98% of cases. A consolidation was evidencedin 92% of children meeting the WHO clinical criteria ofpneumonia. In one child with stage 3 pneumonia andabnormal auscultatory ﬁndings, the chest X-ray ﬁlm wasnormal on initial work-up but showed a consolidation24 h later. This delay in the anatomical consolidationprocess has been well described in the literature [1]. Wedid not study the speciﬁcity of the chest X-ray examin-ation (proportion of ﬁlms showing a consolidation inchildren without tachypnoea). To our knowledge, onlyone investigation has speciﬁcally addressed the issue andcame up with a value of 67% [5]. Pleural eﬀusions werefound in all three clinical stages of pneumonia. Overall,an eﬀusion was detected in 17 % of cases. It was morefrequent in stage 3 pneumonia with 50% of childrenhaving some degree of pleural eﬀusion. There were nostatistically signiﬁcant diﬀerences between groups,probably because numbers of subjects were insuﬃcientto reach statistical signiﬁcance.Eur J Pediatr (2002) 161: 460–461DOI 10.1007/s00431-002-0993-xM. Dirlewanger Æ J-D. Krahenbuhl Æ S. FanconiB. Vaudaux Æ M. Gehri (&)Department of Paediatrics; Centre HospitalierUniversitaire Vaudois, Hoˆpital de l’Enfance de Lausanne,Bugnon 21, 1011 Lausanne, SwitzerlandE-mail: Mario.Gehri@chuv.hospvd.chTel.: +41-21-3143718Fax: +41-21-3143671Tachypnoea is as good a diagnostic criterion as thecombination of clinical and radiological signs of con-solidation. This ﬁnding does strongly question the use ofroutine chest X-ray examination in the initial evaluationof children suspected to have a CAP. A WBC countabove the cut-oﬀ point of 15 g/l and CRP values greaterthan 60 mg/l [3] were found in 53% and 67% of patientswith stage 2 or 3 pneumonia respectively. The propor-tion of cases with WBC counts and CRP values abovethe deﬁned cut-oﬀ points was 88% in children with stage3 pneumonia. In our opinion, the ﬁnding of elevatedWBC counts and CRP levels does not provide muchadditional information and we consider these investi-gations to be of limited usefulness.Investigating the microbial aetiology of RTIs was notthe aim of this study. We limited our investigations toobtaining blood cultures in stage 2 and 3 pneumonia.They were positive for Streptococcus pneumoniae in 5%of patients with stage 2 pneumonia as opposed to 38%of children with stage 3 disease. This suggests that theprobability is low for blood culture results to havea practical impact on management. In our viewblood cultures should not be obtained in stage 1 or 2pneumonia. Further work should aim at validating thesimple clinical approach of RTIs advocated by theWHO in view of speciﬁc causative pathogens in order todetermine the proportion of viral infections being in-appropriately treated with antibiotics, and at evaluatingthe diagnostic usefulness in this ﬁeld of new biologicalmarkers of infection such as procalcitonin [4].References1. Coote N, McKenzie S (2000) Diagnosis and investigation ofbacterial pneumonia. Paediatr Respir Rev 1: 8–132. Health PT (2000) Epidemiology and bacteriology of bacterialpneumonia. Paediatr Respir Rev 1: 4–73. McCracken Jr GH (2000) Etiology and treatment of pneumo-nia. Pediatr Infect Dis J 19: 273–2774. Moulin F, Raymond J, Lorrot M, Gendrel D (2000) Procalci-tonin in children admitted to hospital with community acquiredpneumonia. Arch Dis Child 83: 320–3245. Palafox M, Guiscafre´ H, Reyes H, Munoz O, Martinez H(2000) Diagnostic value of tachypnoea in pneumonia deﬁnedradiologically. Arch Dis Child 82: 41–456. World Health Organisation (1994) Program for control of acuterespiratory infections, 6th program report. WHO/ARI/94.33Table 1. Summary of resultsWHO stage 1 2 3 Subtotal Total17 (36) 22 (47) 8 (17) 47AuscultationNormal (n) (%) 13 (76) 16 (73) 4 (50) 33 (70) 47Abnormal (n) (%) 4 (24) 6 (27) 4 (50) 14 (30)Chest X-ray ﬁlmNormal (n) 0 0 1 1 47Consolidation (n) 16 20 7 43Diﬀuse inﬁltrate (n) 1 2 0 3Correlation between auscultationand X-ray consolidation (%)25 30 57 33Pleural eﬀusion (n) (%) 2 (12) 2 (9) 4 (50) 8 (17)WBC count >15 g/l (n) (%) NA 9 (41) 7 (88) 16 (53)CRP level >60 mg/l (n) (%) NA 13 (59) 7 (88) 20 (67)Blood culture positive for Streptococcuspneumoniae (n) (%)NA 1 (5) 3 (38) 2 (12)461

Community-acquired pneumonia in children aged 2 months to 5 years: application of the WHO guidelines in a developed country setting (Switzerland)

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Community-acquired pneumonia in children aged 2 months to 5 years: application of the WHO guidelines in a developed country setting (Switzerland)

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