Skip to main content

Table 1 Retrospective studies in children with necrotizing pneumonia and where participant numbers exceeded 20 subjects

From: Necrotizing pneumonia: an emerging problem in children?

Study Subjects Causes Imaging results WBC count and inflammatory markers Management Course Comments
Wong et al. [36]
Taiwan.
Single tertiary center.
Almost 5 yr. review
July 1995–March 1999.
No. = 21
12 (57%) males.
Mean (SD) age = 2.4 (1.3) yrs.
No co-morbidities.
Pathogen detected in 9 (43%) cases.
Blood culture +ve in 2 (9.5%) cases
- S. pneumoniae 2
Hib 1
Pleural culture +ve in 5 (24%) cases
- S. pneumoniae 2
S. aureus 2
Hib 1
Four-fold increase in M. pneumoniae serum antibody titres and negative bacterial cultures n = 2 (9.5%).
All had CT scans confirming NP diagnosis.
PPE 20 (95%)
- 6 (30%)
loculated
empyema
BPF 8 (38%)
Abscess 4 (19%).
NR. Antibiotics and chest tube drainage only 9 (43%).
Thoracoscopy (VATS) 10 (48%)
- pulmonary
segmental
resection 2.
Antibiotics alone 2 (9.5%).
Medically treated:
- mean (SD) fever
duration before
hospitalization 6.8
(3.3) days
- mean (SD) total
fever duration 9.5
(3.5) days
- mean (SD)
hospital LOS 21.7
(5.5) days
Plus surgery:
- mean (SD) fever
duration before
hospitalization
14.9 (9.6) days
- mean (SD) total
fever duration
16.5 (8.5) days
- mean (SD)
hospital LOS 30.0
(8.0) days
*P < 0.05.
Fever (95%), cough (52%) and respiratory distress (43%) were the most common presenting symptoms.
The 10 children undergoing VATS had more severe disease than those medically treated and had failed conservative treatment.
At 6 mths, 19/21 (90%) had normal chest radiographs, 2 had small residual pneumatoceles.
Hacimustafaoglu et al. [37]
Turkey.
Single tertiary center.
4 yr. review of prospective collected data.
No. = 36.
Mean (SD) age
= 3.8 (3.3) yrs.
(Range 9 mths-14 yrs).
No co-morbidities.
Pleural fluid
S. pyogenes 1
S. pneumoniae 3.
All had received antibiotics before admission to hospital.
CT scans required for diagnosing NP.
Lungs involved
- right 20 (55%)
left 12 (33%)
both 4 (11%).
PPE 34 (94%)
- septated 80%
loculated 33%
BPF 20 (55%).
Mean (SD) peripheral WBC count
= 19.3 (8.7) × 109/L.
Mean (SD) CRP
= 136 (117) mg/L.
Pleural fluid (mean (SD))
-glucose 1.3 (1.2) mmol/L.
LDH 793 (682) IU/L.
Thoracotomy 24 (67%) Mean (SD) symptom duration
before presentation = 11.9 (8.5) days.
Mean (SD) febrile days = 8.9 (4.3) after hospitalization.
Mean (SD) hospital LOS = 26 (9) days.
Mortality rate 5.5%.
Diagnosis of NP by CT scan made on average 6 days after admission and 17 days after symptom onset.
Sawicki et al. [28]
United States.
Single tertiary center.
15 yr. review
January 1990–February 2005.
No. = 80.
45 (53%) males.
Median (IQR) age
= 3.6 (2.4–6.2) yrs.
Most were healthy
- 14 asthma
1 CNLD
1 cerebral palsy
2 PID.
Cases increased from 3 per yr. in 1990–93 to 14 per yr. in 2003–4.
Pathogen detected, in 38 cases (48%), 19 from testing pleural fluid in 50 cases.
S. pneumoniae 18
(13 by culture)
MSSA 5
MRSA 3
Fusobacterium 1
P. aeruginosa 1
CONS 4
S. anginosus 6
group.
54 (68%) had received antibiotics before admission to hospital.
CT scans required for diagnosing NP.
-PPE 69 (86%)
-BPF 10 (13%).
Mean (SD) peripheral WBC count
= 18.4 (8.9) × 109/L.
Mean (SD) CRP
= 133 (93) mg/L.
Mean (SD) haemoglobin
= 10.4 (1.6) g/L.
Mean (SD) serum albumen
= 20 (16) g/L.
Pleural fluid
(mean (SD) or median (IQR))
- pH 7.08 (0.33)
-glucose 0.5 (0.1–3.6) mmol/L
-LDH 2810 (1413–9530) IU/L
-Cell count 9.6 (1.2–56) × 106/L
-Pleural neutrophils 70 (23)%.
Procedures for PPE – 69 (86%).
Chest tube drainage only 47 (68%).
Chest drainage + surgery 16 (23%).
Thoracentesis only 6 (9%).
Intensive care 25 (31%); 1 ECMO.
Median (IQR) pleural drainage days = 6 (4.5–9.5).
Median (IQR) febrile days = 6 (3–9).
Median (IQR) hospital LOS
= 12 (9–17) days.
Median (IQR) antibiotic days
= 28 (20–40).
No deaths.
Fever (96%) and cough (84%) were main symptoms, at a mean onset of
9 days before presentation.
8 (10%) readmitted within 2wks of being discharged;
64 seen 6mths post discharge, all well, 12 had PFTS, 3 had mild obstructive and 1 mild restrictive defects.
CXR and CT scans markedly improved and near normal at 6 mths.
Macedo et al. [38]
Brazil.
Single tertiary center.
6 yr. review
July 2002–June 2008.
No. = 24.
12 (50%) males.
Median age 2 yrs.
(Range 1–9 yrs).
Pleural fluid culture
-S. pneumoniae 6
-MSSA 3
-P. aeruginosa 1.
CXR, CT and US performed. PPE 24 (100%) PTX 11 (46%) BPF 16 (67%). NR. All underwent thoracoscopy.
Prior chest drainage had been undertaken in 19 (79%) of the children.
Median chest drainage time = 18 days (Range 1–30 days).
Median hospital LOS = 19 days. 7–49 days). No deaths reported.
Subjects were children undergoing thoracoscopy for a loculated empyema and/or PTX and in whom a diagnosis of NP was made when a cavity containing necrotic debris was found in the lung tissue.
None underwent a thoracotomy.
Jester et al. [35]
UK.
Single tertiary center.
10 yr. review January 2000–May 2010.
No. = 20.
13 (65%) males.
Median age 2.5 yrs. (Range 0.8–6.8 yrs).
All were referred because of BPF complicating empyema.
Pleural fluid culture or PCR
S. pneumoniae 10 (serotype 3, n = 3)
S. aureus 1
All had received antibiotics for a median duration of 7 days (Range 2–13) prior to referral
All had pre-operative CT scans.
Lobes involved
- right
- lower 10 (50%)
upper 4 (20%)
- left
- lower 3 (15%)
upper 3 (15%).
BPF was found on presentation in 11 (55%), in 4 (20%) during thoracoscopy, and in 5 (25%) post-operatively.
NR. All had a serratus anterior muscle digitation flap inserted. Median post-operative fever was 2 days (Range 1–3 days).
Median duration of chest tube drainage post-operatively was 7 days (Range 5–15 days).
Median hospital LOS = 9 days (Range 7–28 days). No deaths reported.
All were referred because of persistent signs of empyema with clinical deterioration and diagnosis of NP complicated by BPF.
The median follow-up was 4 yrs. (Range 2 mths-10 yrs).
All had normal thoracic volumes on CXR without signs of scoliosis.
Lemaitre et al. [30]
France.
Single tertiary center.
5 yr. review May 2006–April 2011.
No. = 41.
22 (54%) males.
Median age 1.2 yrs. (Range 1 mth- 16 yrs).
1 child had sickle cell anemia.
The rate of NP complicating CAP doubled from 4.5% in 2006–2009 to 9% in 2009–2011.
Blood/pleural/BAL fluid cultures +ve in 21 (51%) cases.
- MSSA 12 - MRSA 1 (All S. aureus strains PVL + ve)
-S. pneumoniae 7 (serotypes 3, 7F, 19A)
-F. nucleatum 1 (14 yr. old with sickle cell anemia).
18 (44%) had received antibiotics before hospital admission.
CXR and CT scans performed.
CXR revealed necrosis on admission in 11 (27%) cases.
CT scan performed on 23 (56%) children and detected NP in 12 not apparent on CXR.
PPE 26 (63%) PTX 8 (20%)
Median peripheral WBC count = 20,000 × 106/L (Range 1700–44,300).
Median CRP = 141 mg/L (Range 5–434).
Procedures for PPE – 26 (63%). - Thoracentesis 10- VATS 6 Median symptoms before presentation = 4 days (Range 1–10 days).
Nursed in intensive care 7 (17%).
Median febrile days in hospital = 7 days (Range 1–25 days). Median hospital LOS = 16 days (Range 7–43 days).
Median antibiotic days = 42 days (Range 31–60 days). No deaths.
NP diagnosis made by a combination of clinical signs of lung infection and radiographic signs of NP with multiple thin-walled cavities within a region of homogenous alveolar consolidation.
The S. pneumoniae serotypes identified in this series are not included in PCV7 available in France at the time of the study.
Krenke et al. [33]
Poland. Single tertiary center.
5 yr. review April 2008–July 2013.
No. = 32. 14 (44%) males.
Median age 4 yrs. (Range 1–10 yrs).
Most were healthy
- 2 asthma
1 obesity and hypertension
1 atrial septal defect.
Blood cultures +ve in 6 (19%) cases.
Pleural fluid cultures +ve in 7 (23%) children.
- S. pneumoniae 8 - MSSA 2 -S. milleri 1- CONS 1 -S. maltophilia 1.
All had received antibiotics before admission to hospital.
CXR ± CT scans performed.
Lungs involved - right 18 (56%) left 10 (31%) both 4 (13%).
PPE 31 (97%) PTX 2 (6%) BPF 8 (25%).
Median (IQR) peripheral WBC count = 21.3 (15.2–24.1) × 109/L.
Median (IQR) CRP = 182 (152–241) mg/L.
Median (IQR) haemoglobin = 8.9 (8.4–9.9) g/L.
Median (IQR) serum albumen = 25 (23.5–27.5) g/L.
Pleural fluid (median (IQR)) - pH 7.3 (7.0–7.5) glucose 2.8 (1.8–3.1) mmol/L -LDH 8670 (2828–14,254) IU/L.
Procedures for PPE – 31 (97%).
Thoracentesis only 2 (6%).
Chest tube drainage 28 (90%), including urokinase in 25 (81%).
VATS 1 (3%).
Median febrile days before presentation = 6 days (Range 1–10 days). Median febrile days in hospital = 9 days (Range 0–22 days).
Median (IQR) chest drainage time = 8.6 (6–11.25) days.
Median hospital LOS = 26 days (Range 13–44 days).
Median (IQR) antibiotic days = 28 (22.5–32.5) days. No deaths.
Rate of NP amongst all CAP admissions was 32/882 (3.6%).
Fever (94%), tachypnea (90%) and cough (77%) most common symptoms.
5 mths later all children had normal physical exams and CXRs showed complete or almost complete resolution of pleural and lung abnormalities.
Erlichman et al. [31]
Israel. Three tertiary centers.
10 yr. review 2001–2010.
No. = 29.
19 (66%) males.
Median age 3.1 yrs.
Case rates increased from <0.5/100,000 in 2001–2003 to ~2/100,000 in 2009–2010.
Blood cultures +ve in 3/29 (10%) cases - S. pneumoniae 3.
Pleural fluid cultures +ve in 9/26 (35%) cases - S. pneumoniae 8- S. pyogenes 1.
All S. pneumoniae isolates typed were serotype 5.  17 (59%) had received antibiotics before admission to hospital.
CXR ± CT scans performed. Median peripheral WBC Count = 14.7 × 109/L. Chest tube drainage 21 (72%), including urokinase in 6 (21%).
VATS 1 (3%).
Median febrile days before presentation = 5 days.
Median febrile days in hospital = 6 days.
Median chest drainage time = 7 days.
Median hospital LOS = 14 days.
Median (IQR) antibiotic days = 13 (7) days.
No deaths.
NP diagnosed by multiple thin-walled cavities within lung consolidation on CXR or lung tissue liquefaction on CT scan.
Jewish ethnicity over-represented by 25 (86%) cases.
  1. BAL bronchoalveolar lavage, BPF bronchopleural fistula, CAP community-acquired pneumonia, CNLD chronic neonatal lung disease, CONS coagulase negative staphylococcus, CRP c-reactive protein, CT computed tomography, CXR chest xray, ECMO extracorporeal membrane oxygenation, Hib Haemophilus influenzae type b, IQR interquartile range, IU international units, LDH lactate dehydrogenase, LOS length of stay, mmol millimoles, MRSA methicillin-resistant Staphylococcus aureus, MSSA methicillin-resistant Staphylococcus aureus, No number, NP necrotizing pneumonia, NR not reported, PCV7 7-valent pneumococcal conjugate vaccine, PID primary immunodeficiency (1 had Schwachman-Diamond syndrome, 1 chronic granulomatous disease), PFT pulmonary function tests, PPE parapneumonic empyema, PTX pneumothorax, PVL Panton-Valentine leucocidin, SD standard deviation, US ultrasound, VATS video-assisted thoracoscopy, WBC white blood cell