From: Necrotizing pneumonia: an emerging problem in children?
Study | Subjects | S. pneumoniae serotypes | Imaging results | Management | Course | Comments |
---|---|---|---|---|---|---|
Hsieh et al. [39] Taiwan. Single tertiary center. 5 yr. review May 1998–July 2003. | No. = 15. 2 (13%) males. Median age 49 mths (Range 9–85 mths). | 10 isolates available for serotyping. Serotype 14 (50%) 3 (30%) 6A (10%) 18C (10%). 11 isolates available for penicillin MICs. 7 (64%) had non-penicillin (MIC ≥1 mg/L) susceptibility. | CXR + CT scans performed. Lungs involved - right 10 (67%) left 5 (33%) multi-lobar 5 (33%). PPE 14 (93%) PTX 1 (7%) | Procedures for PPE 14 (93%). Chest tube drainage only 6 (43%). VATS 8 (57%). | Median febrile days before presentation = 4 days (Range 2–11 days). Median febrile days in hospital = 9 days (Range 4–30 days). Median hospital LOS = 18 days (Range 5–40 days). Mean (SD) antibiotic days for 14 survivors = 24 (8) days (Range 12–38 days). 1 died from HUS and pulmonary gangrene. | Diagnosis of NP made on a median of 6 days (range 1–12) after admission. 13 (87%) received cefotaxime or ceftriaxone 10 (67%) received vancomycin 7 (47%) received both vancomycin and a cephalosporin together as directed therapy. |
Fretzayas et al. [40] Greece. Single tertiary center. 6 yr. review January 1999–December 2004. | No. = 10. 5 (50%) males. Mean age 3.1 yrs. Representing 1.3% of all cases of lobar pneumonia in children aged <14 yrs. and 20% of bacteraemic pneumonia cases. | All had +ve blood cultures, 5/7 pleural fluid cultures were also +ve. Serotyping NR. | All had CXR evidence of NP, which was then confirmed by chest CT scans. Epyema present in 7 patients. Chest US aided diagnosis in all 8 cases where it was used. | Empyema drained by thoracentesis or by indwelling continuous intercostal tube drainage. None underwent thoracotomy. | Toxic appearance, persistent fever and abnormal chest findings were seen for a mean 23 days. Hospital LOS 15–35 days. 4 patients examined 1 yr. later had normal spirometry. | NP should be considered in those with continuation of fever, persistently raised or increasing blood inflammatory indices and abnormal auscultatory findings for >5-days, despite antibiotics and especially if bacteremia and empyema are present. |
Bender et al. [29] United States. Single tertiary center. 9 yr. review January 1997–March 2006. | No. = 33. 18 (55%) males. Mean age 40 mths. Co-morbidities 2 (6%). Cases increased over time: 5/39 (13%) confirmed PNP cases in 1997–2000 vs 28/85 (33%) in 2001–2006 (OR 3.34, 95%CI 1.11–12). | Blood and pleural fluid isolates. 28/33 (85%) were non-PCV7 vaccine serotypes - 2/5 (40%) 1997–2000- 27/28 (96%) 2001–06. Commonest serotypes - serotype 3 11 (33%) 19 4 (12%) 19A 4 (12%) 1 3 (9%). All penicillin susceptible. | CXR or CT scans performed. PPE 32 (97%). | Procedures for PPE 32 (93%). Chest tube drainage only 19 (59%). Chest tube + surgery 11 (34%). | Nursed in intensive care 18 (55%). Mean hospital LOS = 14 days. 1 (3%) death | May have included a small number of cases with lung abscess. Serotype 3 was most often associated with NP with 11/14 (79%) children with culture-confirmed pneumonia developing cavities. Compared with other serotypes, serotype 3 was more likely to be associated with PNP (OR = 14.7, 95% CI 3.4–86). |
Hsieh et al. [32] Taiwan. Single tertiary center. 9 yr. review January 2001–March 2010. | No. = 50. 18 had BPF - 4 (22%) males - mean (SD) age 3.5 (2.7) yrs. co-morbidity 1 (6%) PCV7 available in Taiwan since 2005, but coverage <16% by 2009. None of the PNP cases had received PCV7. Proportions of cases increased between 2004 and 2009. | Blood and pleural fluid isolates (n = 50). Commonest serotypes - serotype 14 19 (38%) 19A 10 (20%) 3 7 (14%) 6B 8 (16%). Commonest STs - ST46 7/19 (37%) serotype 14 isolates CC320 (ST320, ST3164) 10/10 (100%) serotype 19A isolates. 6/18 (33%) with BPF had non-penicillin susceptibility and 3/18 (17%) had ceftriaxone. non-susceptibility | CXR or CT scan. Of 18 children with BPF, all had PPE. Bilateral lung involvement 10 (56%). | Procedures for BPF 18 children subset. 9 developed BPF after removal of chest drains. Chest tube + surgery 15 (83%), pulmonary resection in 12. None received fibrinolytics. | 18 children with BPF. Median febrile days before presentation = 7 days (Range 4–14 days). Median day of BPF diagnosis = 10 days (Range 1–21 days). Nursed in intensive care 9 (50%). Median febrile days in hospital = 13 days (Range 1–34) days. Median hospital LOS = 32 days (Range 11–62 days). None died. | Study focused upon 18 children with BPF, a more critically ill subset. 6 (33%) had HUS. Multivariate analysis found acute respiratory failure (OR = 8.9, 95%CI 2.6–31) and serotype 19A (OR = 5.0, 95%CI 1.2–22) were independent risk factors for BPF. 11/12 resected lung segments had coagulative necrosis with pulmonary infarction. |
Janapatla et al. [25] Taiwan. Single tertiary center. 3 yr. review January 2006–December 2009 Two subsets: a. PNP b. PNP + HUS. | No = 12 PNP. 5 (42%) males. Mean (SD) age = 4.6 (2.4) yrs. (Range 1–8 yrs). PCV7 available in Taiwan since 2005, but coverage <16% by 2009. No. = 17 with PNP + HUS (+ 1 other had empyema). 4 (23%) males. Mean (SD) age = 5.3 (2.8) yrs. (Range 2–10 yrs). | Blood and pleural fluid isolates (n = 12). Commonest serotypes - serotype 14 9 (75%) 3 1 (8%) 19A 2 (17%) Commonest STs - ST876 and ST46 in 7/9 (78%) serotype 14 isolates. S. pneumoniae isolated from blood (n = 16) and pleural fluid (n = 2). Commonest serotypes - serotype 14 9 (50%) 3 5 (28%) 19F 2 (11%). Commonest STs - ST46 in 5/9 (56%) serotype 14 isolates ST 180 in 5/5 (100%) serotype 3 isolates. | All cases of NP confirmed by CT scan. Results NR. CXR or CT scan Results NR. | Chest tube + surgery, either VATS or lobectomy, for 10 (83%) children.  Chest tube alone 2 (11%) children, including the 1 child with empyema alone Chest tube + surgery, either VATS or lobectomy, for 16 (89%) children | Mean (SD) hospital LOS = 26.2 (9.0) days (Range 16–39 days). Deaths, NR.  Mean (SD) hospital LOS = 31.4 (9.0) days (Range 11–65 days). Deaths, NR. | The main focus of this study was on PNP with HUS rather than PNP alone. The 12 children with PNP and 42 with IPD without NP served as controls.  5/18 cases of PNP + HUS had serotype 3 isolates compared with 4/54 IPD + PNP only cases (RR = 3.75, 95%CI 1.1, 12.7). 16/18 HUS isolates carried the nanC gene compared with 22/54 control isolates (RR = 2.18, 95%CI 1.52–3.13). As 16/17 children with HUS had PNP, NanC could be a virulence factor for NP too. |
Hsieh et al. [34] Taiwan. Six tertiary centers. 2 yr. review March 2010–April 2012. | No. = 57 with PNP. 26 (46%) males. Mean (SD) age: a. Mild necrosis (n = 13) 45.4 (16) mths b. Cavitation (n = 27) 49.6 (15.7) mths c. BPF (n = 17) 39.4 (16.1) mths. No co-morbidities. | Blood and pleural fluid positive testing by culture or PCR. Commonest serotypes in pleural fluid: Serotype - 19A (69%)- 3 (12.5%). 12 (21%) had respiratory viruses detected by PCR. | CXR or CT scan. Mild necrosis (non-enhanced areas on contrast CT scans) (n = 13; 23%). Cavitation (including pneumatoceles and abscess) (n = 27; 47%). BPF (n = 17; 30%). | NR. | Mean (SD) duration of fever and hospital LOS- Mild necrosis: 11.4 (6) and 15.2 (4.5) days; Cavitation: 13.9 (6.5) and 18.3 (6.4) days; BPF: 17.8 (7.6) and 32.8 (16.8) days. No deaths. | Pleural fluid pneumococcal load was significantly higher for serotypes 19A and 3 than other serotypes. Severity of necrosis was associated with pleural fluid pneumococcal load and IL-8 levels. |