Antibiotics Are Often Enough to Treat Complicated Childhood Pneumonia

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.