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A three-step diagnosis of pediatric pneumonia at the emergency department using clinical predictors, C-reactive protein, and pneumococcal PCR

Abstract

Recommendations for the management of community-acquired pneumonia (CAP) advocate that, in the absence of the clinical and laboratory findings typical of bacterial CAP, antibiotics are not required. However, the true value of the clinical and laboratory predictors of pediatric CAP still needs to be assessed. This prospective cohort study in three emergency departments enrolled 142 children with radiological pneumonia. Pneumonia with lung consolidation was the primary endpoint; complicated pneumonia (bacteremia, empyema, or pleural effusion) was the secondary endpoint. We showed that three clinical signs (unilateral hypoventilation, grunting, and absence of wheezing), elevated procalcitonin (PCT), C-reactive protein (CRP), negative nasopharyngeal viral PCR, or positive blood pneumococcal PCR (P-PCR) were significantly associated with both pneumonia with consolidation and complicated pneumonia. Children with negative clinical signs and low CRP values had a low probability of having pneumonia with consolidation (13%) or complicated pneumonia (6%). Associating the three clinical signs, CRP >80 mg/L and a positive P-PCR ruled in the diagnosis of complicated pneumonia with a positive predictive value of 75%.

Conclusion: A model incorporating clinical signs and laboratory markers can effectively assess the risk of having pneumonia. Children with negative clinical signs and low CRP are at a low risk of having pneumonia. For children with positive clinical signs and high CRP, a positive blood pneumococcal PCR can more accurately confirm the diagnosis of pneumonia.

What is Known:
• Distinguishing between bacterial and viral pneumonia in children is challenging.
• Reducing the inappropriate use of antibiotics is a priority.
What is New:
• Children with negative clinical signs and low C-reactive protein (CRP) values have a low probability of having pneumonia.
• Children with high CRP values can be tested using a pneumococcal PCR to rule in the diagnosis of pneumonia with a high positive predictive value.

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Fig. 1

Abbreviations

CAP:

Community-acquired pneumonia

CI:

Confidence interval

CRP:

C-reactive protein

IQR:

Interquartile range

LytA:

Autolysin A

NP viral PCR:

Nasopharyngeal viral PCR

OR:

Odds ratio

PCR:

Polymerase chain reaction

PCT:

Procalcitonin

PCV-7:

Seven-valent pneumococcal conjugate vaccine

Ply:

Pneumolysin

P-PCR:

Pneumococcal (Streptococcus pneumoniae) PCR

PPV:

Positive predictive value

NPV:

Negative predictive value

SP:

Streptococcus pneumoniae = S. pneumoniae = pneumococcus

WBC:

White blood cell

WB-LytA:

Whole-blood Autolysin A pneumococcal PCR

WB-Ply:

Whole-blood Pneumolysin pneumococcal PCR

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Acknowledgements

We declare that all the authors have seen and approved the final manuscript, contributed significantly to the work, and that the manuscript has neither been previously published nor is it being considered for publication elsewhere. GA and AGL had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. We would like to thank and acknowledge the extensive help of Ms. Florence Hugon for the organization of files, follow-up, transport and storage of samples, and for her fantastic energy.

Author information

We declare that all the authors have contributed to this study. AG, AGL, KK, MG, RT, and GA participated in the design. AG, AGL, KK, MG, RT, VM, LL, and SM participated actively in implementing the study and collecting data. KK, VM, and GA contributed to the construction and cleaning of the database. GA performed most of the statistical analyses and wrote the initial manuscript. All authors participated in the revision of the manuscript and the design of figure and tables. AGL and AG actively supervised the whole process.

Correspondence to Gabriel Alcoba.

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Funding

This study was funded by the Geneva University Hospitals, Division of Pediatric Emergency Medicine (Professor Alain Gervaix).

Ethical approval

All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Written informed consent was obtained from all the participants’ parents, and the teenage participants themselves, before enrollment.

Conflict of interest

The authors declare that they have no conflict of interest.

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Communicated by Communicated by Nicole Ritz

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Alcoba, G., Keitel, K., Maspoli, V. et al. A three-step diagnosis of pediatric pneumonia at the emergency department using clinical predictors, C-reactive protein, and pneumococcal PCR. Eur J Pediatr 176, 815–824 (2017). https://doi.org/10.1007/s00431-017-2913-0

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Keywords

  • S. pneumoniae
  • M. pneumoniae
  • Respiratory viruses
  • PCR
  • Pneumonia
  • C-reactive protein
  • Procalcitonin
  • Children