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. |