PAKISTAN PEDIATRIC JOURNAL

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1 Vol. 38(1) March, 2014 Print: ISSN Online: ISSN X PAKISTAN PEDIATRIC JOURNAL A JOURNAL OF PAKISTAN PEDIATRIC ASSOCIATION Indexed in EMBASE/Excerpta Medica & Index medicus WHO IMEMR

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3 ORIGINAL ARTICLE Disease Pattern And Bacteriological Profile Of Childhood Pneumonia ATTIA BARI, AIZZA ZAFAR, ASMA MUSHTAQ, Tahir Masood Ahmad, Iftikhar Ejaz, Hasan Ejaz Author s affiliations Correspondence to: Attia Bari H/No C, Faisal Town Lahore, Pakistan drattiabari@gmail.com INTRODUCTION ABSTRACT Community acquired pneumonia (CAP) remains a common yet serious illness despite the availability of potent new antibiotics and other effective therapies 1. Pneumonia is the leading cause of mortality among children under five years of age despite effective vaccines and nutritional and environmental interventions 2. It can be caused by bacterial, viral, or parasitic Pak Pediatr J 2014; 38(1): Objective: This study was planned to assess the disease pattern and bacteriological profile of childhood pneumonia Study design: Prospective observational study. Place and Duration of study: The department of Pediatric Medicine of the Children s Hospital and ICH Lahore from January 2010 to December Patients and Methods: Out of 179 children with blood culture positive pneumonia 122 (68.2%) were males and 57(31.8%) were females. Age range was from 2 months to 5 years. The common presenting symptoms were fever, cough, breathing difficulty and poor oral intake. Maximum number of subjects of pneumonia cases were in 2 months-1 year of age group 134 (74.9%). Pneumonia was diagnosed by radiological investigations and microbiological analyses of blood samples performed to assess the bacteriological profile. The most common pathogen identified was Coagulase negative staphylococci (CoNS) 120 (67%). The other pathogens identified were Staphylococcus aureus, Streptococcus pneumoniae and gram negative organisms. All patients were treated with intravenous antibiotics. Average hospital stay was 6.9 days. Majority 160 (89.4%) patients were discharged home 10 (5.6%) patients left against medical advise (LAMA) and 9 (5%) patients died. Conclusion: Severe pneumonia affected children < 1 year of age with a male preponderance and CoNS, Staphylococcus aureus, Streptococcus pneumonaie and gram negative organisms were the most common pathogens identified. The mortality was observed mostly under one year of age and the bacterial pathogens isolated in these cases were Staphylococcus aureus and gram negative pathogens. Key words: Pneumonia, microbiological analysis, bacteriological profile infection as well as by noninfectious agents. Most severe cases of pneumonia are caused by bacteria, of which the most important are Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae 3. In developing countries, where patients are often treated without seeing a doctor, the WHO defines clinical pneumonia simply as an acute episode of cough or difficulty in breathing associated with an

4 48 Bari A, Zafar A, Mushtaq A, Ahmad TM, Ejaz I, Ejaz H increased respiratory rate 4. Pneumonia is a substantial cause of morbidity and mortality in childhood throughout the world, rivaling diarrhea as a cause of death in developing countries 5. With 158 million episodes of pneumonia per year, of which 154 million are occurring in developing countries, pneumonia is estimated to cause 3 million deaths, or an estimated 29% of all deaths, among children younger than 5 years worldwide. Most cases occur in India (43 million), China (21 million) and Pakistan (10 million), with additional high numbers in Bangladesh, Indonesia and Nigeria (6 million each). The incidence of pneumonia in South East Asia is estimated to be 0.36 (IQR: ) episodes per child year, however data is limited for many areas of the region. Of all community cases, 7-13% are severe enough to be life-threatening and require hospitalization 6. Most children with signs of pneumonia in developing countries need antibiotics, as they are more likely to have a bacterial etiology. Management of pneumonia remained empiric and challenging because the precise etiology is unknown. Despite progress in diagnostic techniques and laboratory tests, it takes at least a few days to identify causative micro-organisms in blood and etiology of about half of all patients with CAP remain uncertain. This study was planned to assess the disease pattern and bacteriological profile of childhood pneumonia. PATIENTS AND METHODS This was a hospital based prospective descriptive study, conducted at The Children s Hospital and Institute of Child Health Lahore. Children 2 months to 5 years of age admitted to General Medical Ward with diagnosis of pneumonia on the basis of clinical and radiological findings and positive blood culture from January 2010 to December 2012 were enrolled. Cases were identified as suspected cases of pneumonia if the child had clinical symptoms such as fever, cough, respiratory difficulty, nasal flaring and having increased respiratory rate (children <2 months; >60/minute, 2 11 months, >50 per minute and 13 to 60 months, >40 per minute) with lower chest in drawing with or without inability to drink or cyanosis 4. Children with co-morbidities like meningitis or chronic respiratory diseases were excluded. The cases were enrolled and a detailed history and thorough clinical examination was undertaken for each patient. Their clinical features were noted focusing mainly age, gender, presenting symptoms, examination findings, total hospital stay and outcome of patient. In all patients relevant laboratory data including complete blood count (CBC), chest X- ray (CXR), and blood culture sensitivity (C/S) were performed. The disease pattern was assessed clinically, and was confirmed by radiological and microbiological methods. The patients were managed with intravenous antibiotics along with supportive treatment. Antibiotics were changed to second line according to blood culture and sensitivity report. Outcome of patients was noted in form of discharged, died or left against medical advice (LAMA). Information recorded in a pre-designed proforma and data was analyzed. Statistical Analysis: The results were analyzed using SPSS version 16 software. Variables were summarized using frequencies and percentages for categorical variables, and median, and range for continuous variables. The chi-square test was used for statistical analysis. RESULTS During this study period 953 patients that were clinically suspected as per WHO case defining criteria for pneumonia in the age range of 2 months to 5 years were admitted to our unit. Out of 953 admissions 179 children having positive blood cultures were enrolled and evaluated in this study. Out of these 179 children 122 (68.2%) were males and 57 (31.8%) were females with M:F ratio of 2:1. About two-third (134/179) of patients (74.9%) were below 1 year of age (Table 1). The common presenting symptoms were fever, cough, breathing difficulty and poor feeding. Median length of hospital stay (LOS) was 6.9 days with a range of 4 20 days. The patients admitted with radiological diagnosis of bronchopneumonia were 112 (62.6%) and 67 (37.4%) with lobar pneumonia (Table 1). The patients with bronchopneumonia had significantly shorter length of hospital stay of <7 days 67% as compared to patients with lobar pneumonia 43% (p value 0.006) (Table 2). There was no gross difference in culture positivity between lobar

5 Pneumonia, microbiological analysis, bacteriological profile 49 pneumonia and bronchopneumonia. Pathogens isolated in patients with lobar pneumonia were 19.3% and patients with bronchopneumonia had 18% culture positivity (Table 3). Coagulase negative staphylococci (CoNS) was the predominating organism 120 (67%), followed by Staphylococcus aureus 23 (12.8%), Streptococcus pneumoniae 6 (3.3%), Pseudomonas 6 (3.3%), Klebsiella 4 (2.2%). Acinetobacter 4 (2.2%), E. coli 4 (2.2%) and 10% were other organisms like Streptococcus pyogenes, Burkholderia cepacia, Salmonella, Enterobacter, Listeria, Pantoea and Moraxella catarrhalis (Fig. 1). All patients were treated with intravenous antibiotics. Out of 179 patients, 160 (89.4%) patients were discharged home, 10 (5.6%) got LAMA and 9 (5%) patients died. The pathogens isolated from children who died were positive for Staphylococcus aureus 2, CoNS 2, Burkholedia cepacia 1, Pseudomonas 1, Acinetobacter 1, E. coli 1 and Klebsiella 1. TABLE 1: Demographics, imaging study and outcome of 179 children with Blood Culture Positive Pneumonia Category Total n= 179 (%) Age 2 months- 1 year 134 (74.9) 1.1 year-3 years 37 (20.6) 3.1 years- 5 years 08 (04.5) Sex (M:F) Male Female Duration of hospital stay Mean duration of stay < 7 days 8-14 days > 14 days Radiological findings Bronchopneumonia Lobar pneumonia Out come Discharged Left against medical advice (LAMA) Died 2:1 122 (68.2) 57 (31.8) (58) 60 (33.5) 15 (8.5) 112 (62.6) 67 (37.4) 160 (89.4) 10 (5.6) 09 (5.0) TABLE 2: Pneumonia in correlation to age and duration of stay Category Diagnosis p value Bronchopneumonia Lobar pneumonia Age < 1 year 83(74.1%) 51(76.1%) year 26(23.2%) 11(16.4%) >3 year 3(2.7%) 5(7.5%) Duration of stay < 7 day 75(67.0%) 29(43.3%) days 31(27.7%) 29(43.3%) >10 days 6(5.4%) 9(13.4%) TABLE 3: Blood Culture Positivity in Childhood Pneumonia Type of Pneumonia Total Patients Positive Blood Culture Percentage Bronchopneumonia Lobar Pneumonia Total Table 4: Microbiological diagnosis based on blood cultures according to age Age Blood cultures (years) CoNS S. aureus S. Pseudomonas Klebsiella E. coli Others Total pneumoniae < 1 yr yrs yrs Total (%) 120 (67.0) 23 (12.8) 6 (3.3) 6 (3.3) 4 (2.2) 4 (2.2) 16 (8.9) 179 (100.0)

6 50 Bari A, Zafar A, Mushtaq A, Ahmad TM, Ejaz I, Ejaz H 3% 3%2%2% 13% 9% 68% CoNS Staphaureus S. pneumoniae Pseudomonas Klebsiella E. coli Others Fig 1: Distribution of organisms isolated from blood culture DISCUSSION Bronchopneumonia is a common pediatric problem, usually encountered by pediatricians and primary care physicians. Pneumonia is a widespread and common infectious lung disease that causes inflammation, which can lead to reduced oxygenation, shortness of breath, and death. An estimated nearly 1 2 million children younger than 5 years died in 2011 from pneumonia 6. Most of these deaths occurred in developing countries where access to care is limited and interventions that have improved care in developed countries are scarce. Despite substantial increases in our understanding of the clinical syndrome of pneumonia and its etiologies, its accurate diagnosis is challenging when clinical indicators are relied on, and improves only modestly with addition of laboratory, microbiological, or radiographical tests. The disease pattern and bacteriology associated with pneumonia were investigated in this study. The demographic analysis shows a high proportion of patients having male gender 122 (68.2%) and female 57 (31.8%), with a male to female ratio of 2:1. This may signify the male dominance and sex discrimination in South East Asia. A preponderance of males 3:2 was noted in study done by Karambelkarand, and a study from Pakistan (63.9 male) 7,8. A study published in BMC also showed higher positivity (63.5%) in male children 9. Only one study done by Qayyum showed a preponderance of females (58%) 10. In our study, (74.9%) of our patients (n=134) were below 1 year of age confirming that pneumonia is more likely to occur in young children than in older children. Pneumonia incidence is most strongly and consistently associated with young age, with the highest reported rates in children aged 2-6 months in a study published in Lancet 11. Our study is also consistent with study by Tiewsoh in which (71.5%) were infants less than 12 months of age and study by Hazir 63.2% of patients were < 1 year but in an Indian study conducted by Karambelkar 71% of hospitalized children with pneumonia were 1-5 years of age and only 4% were < 1 year of age 7-9. The microbial diagnosis of pneumonia in our study was confirmed in 179 (18.78%) of patients with standard blood cultures. Our results were comparable with a study done by Falade et al, in which blood culture was positive in 18% cases 12. Agarwal reported blood culture positivity in 21.9% 13. Blood cultures were reported positive in 17% and 15% in studies by G R, and T. Karalanglin repectively which is similar to the findings in the present study 7,9. A much higher percentage i.e 29% blood culture positivity is reported in another study from India 14. In our study, a high proportion (81%) of all pneumonia grew no bacterial pathogen. This finding is consistent with a number of previous studies suggesting that the negative cultures are not the result of limitations in routine microbiology laboratory procedures 7,9,12,13. The negative cultures more likely are due to the widespread use of antibiotics (including inappropriately chosen or dosed antibiotics) as well the potential for severe viral lower respiratory tract disease and bacterial super infections. The pathogen spectrum identified on blood culture according to age group is shown in (Table 4). Our study identified culture positivity in 179/953 (18.78 %) of patients and CoNS was the most common organism isolated in 120/179 (67%) followed by Staphylococcus aureus 23/179 (12.8%), 6/179 (3.3%) each of Streptococcus pneumoniae and Pseudomonas, 4/179 (2.2%) gram negative organisms each of Klebsiella and E. coli, and 16/179 (8.9%) were other organisms like Acinetobacter, Streptococcus pyogenes,

7 Pneumonia, microbiological analysis, bacteriological profile 51 Enterobacter, Burkholdaria cepacia, Listeria, Salmonella, Serratia, Pantoea and Moraxella catarrhalis. In the present study none of the cultures were found to be positive for Haemophillus influenzae type b, probably because of fastidious growth requirements of the organism. Considering maximum number of blood cultures positive for CoNS it may be due to skin contamination. In our study second commonest pathogen isolated is Staphylococcus aureus and this was consistent with the study done by Johnson in which Staphylococcus aureus was the commonest pathogen isolated followed by Klebsiella and Streptococcus pneumoniae 15. In a study by T. Karalanglin showed Streptococcus pneumoniae as the commonest organism followed by Staphylococcus aureus, Acinetobacter, Enterobacter, Klebsiella and Pseudomonas 9. In a study by Bashir the commonest pathogen (10/29) was Pseudomonas followed by Staphylococcus aureus, E. coli, Klebsiella, Streptococcus pyogenes, Streptococcus pneumoniae and Acinetobacter 14. Reports from third world communities of Asian sub-continent have ascribed a greater aetiologic role to Staphylococcus aureus 9,14,15. Studies by Berkley and Juven showed Streptococcus pneumoniae as the commonest isolate 16,17. Previous reviews or case series describing bacterial organisms isolated from children with pneumonia suggest that Gram-positive as well as Gram-negative organisms may invade the respiratory tract 9,14,15,18. The average length of hospital stay in our study was 6.9 days and was comparable to that of Aliya and T Karalanglin 9,19. The case-fatality rate in our study was 5%. The maximum deaths 6 (66.7%) were <1 year of age, 2 (22.2%) were in age group of 1-3 years only 1 (11.1%) patient who died was 3.5 years of age and this was comparable with the study done by G.R in which mortality was observed in 3%, all under 3 years of age and a study by Aliya showed deaths in 4% of admitted patients and 82% of deaths occurred among infants 7,19. Higher death rates were observed in a study by T Karalanglin (10.5%) and Jhonson (10.8%) died 9,15. The bacterial pathogens isolated in these cases who died were Staphylococcus aureus and gram negative pathogens. The limitation of the present study was that only hospitalized patients with severe and very severe pneumonia were included. Patients treated on outpatient department were not included. CONCLUSION The present study found that severe pneumonia affected children <1 year of age with a male preponderance. CoNS and Staphylococcus aureus were the most common pathogens identified from culture and other pathogens were Streptococcus pneumoniae and gram negative organisms like Pseudomonas, Klebsiella, E. coli, Salmonella, Burkholderia cepacia, Enterobacter and Acinetobacter. The mortality due to severe pneumonia was observed mostly under one year of age and the bacterial pathogens isolated in these cases were Staphylococcus aureus and gram negative pathogens. ACKNOWLEDGEMENTS Author acknowledges Miss Sakina for her time and efforts in collecting the data. Authors also acknowledge Miss Tehseen for helping in data analysis Author s affiliations Attia Bari, Asma Mushtaq, Prof. Tahir Masood Ahmad, Iftikhar Ejaz, Department of Pediatric Medicine Aizza Zafar, Hasan Ejaz Department of Microbiology The Children s Hospital and The Institute of Child Health, Lahore, Pakistan REFERENCES 1. Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet. 2005; 365: Roth DE, Caulfield LE, Ezzati M, Black RE. Acute lower respiratory infections in childhood: opportunities for reducing the global burden through nutritional interventions. Bull World Health Organ. 2008; 86: Cevey-Macherel M, Galetto-Lacour A, Gervaix A, Siegrist CA, Bille J, Bescher-Ninet B, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr. 2009;168(12):

8 52 Bari A, Zafar A, Mushtaq A, Ahmad TM, Ejaz I, Ejaz H 4. WHO Technical Document.Technical bases for the WHO recommendations on the management of pneumonia in children at firstlevel health facilities: Programme for the control of acute respiratory infections. Geneva: WHO/ARI/91.20, Mulholland K. Childhood pneumonia mortality a permanent global emergency. Lancet. 2007; 370: Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008; 86(5): Karambelkar GR, Agarkhedkar SR, Karwa DS, Singhania SS. Disease pattern and bacteriology of childhood pneumonia in Western India. Int J Pharm Biomed Sci. 2012; 3(4): Hazir T, Qazi, SA, Nisar YB, Maqbool S, Asghar R, Iqbal I et al. Can WHO therapy failure criteria for non-severe pneumoniabe improved in children aged 2 59 months? Int J Tuberc Lung Dis.2006; 10(8): Tiewsoh K, Lodha R, Pandey RM, Broor S, Kalaivani M, Kabra SK. Factors determining the outcome of children hospitalized with severe pneumonia. BMC Pediatr. 2009; 9: Noorani QA, Qazi SA, Rasmussen ZA, Muhammad Y. Use of a pneumonia management tool to manage children with pneumonia at the first level health care facilities. J Pak Med Assoc. 2011; 61(5): Williams BG, Gouws E, Boschi-Pinto C, Bryce J, Dye C Distribution of child deaths from acute respiratory infections. Lancet Infect Dis. 2002; 2: Falade AG, Mulholland EK, Adegbola RA, Greenwood BM. Bacterial isolates from blood and lung aspirate cultures in Gambian children with lobar pneumonia. Ann. TropicalPaediatrics. 1997; 17: Agarwal A. Bacteriological profile, serology & antibiotic sensitivity pattern of microorganisms from community acquired pneumonias. JK science. 2006; 8: Shah BA, Singh G, Naik MA and Dhobi GN. Bacteriological and clinical profile of Community acquired pneumonia in hospitalized patients Lung India. 2010; 27(2): Johnson A, Osinusi K, Aderele WI, et al. Etiologic agents and outcome determinants of community-acquired pneumonia in urban children: a hospital-based study. J Natl Med Assoc. 2008; 100: Berkley JA, Lowe BS, Mwangi I, et al. Bacteremia among children admitted to a rural hospital in Kenya. N Engl J Med. 2005; 352(1): Juvén T, Mertsola J., Waris M., et al. Etiology of community-acquired pneumonia in 254 hospitalized children. Pediatr Infect Dis J. 2000; 19: Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T.Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review Trop Med Int Health. 2009;14(10): Naheed A, Saha SK, Breiman RF, Khatun F. Multihospital Surveillance of Pneumonia Burden among Children Aged <5 Years Hospitalized for Pneumonia in Bangladesh CID. 2009; 48 (2): S82-9.