Etiology and Risk Factors Determining Poor Outcome of Severe Pneumonia in Under-Five Children

Objectives To determine the etiology of severe pneumonia (pneumonia with chest indrawing) in under-five children, and to study the risk factors for poor outcomes viz., 'treatment failure', 'need for change in antibiotics', 'prolonged hospital stay', 'need for mechanical ventilation' and 'mortality.' Methods Children (age 2 mo to 5 y) with pneumonia and chest drawing were enrolled prospectively from October 2012 through September 2013. Clinical history was recorded, and examination, anthropometry and investigations (including chest X-ray, blood culture and nasopharyngeal swab culture) were performed. Children were managed as per standard guidelines, and recovery outcomes were recorded in form of 'treatment failure' (defined as persistence of features of severe pneumonia after 72 h or worsening of clinical condition before 72 h), need for change of antibiotics and prolonged (>5 d) hospital stay. The associations between the clinical, anthropometric and diagnostic risk factors and the recovery outcomes were evaluated by univariate and multivariate logistic regression analysis. Results Out of 120 children enrolled in the study, 36 (42%) were culture positive (nasopharyngeal/blood); most common bacteria isolated were Streptococcal pneumoniae and Staphylococcal aureus, respectively. Treatment failure was seen in 15 (12.5%), 34 (28.3%) needed change of antibiotics, and 50 (41.6%) children required prolonged hospitalization. Low birth weight, overcrowding, general danger signs (lethargy/unable to drink), clinical rickets, crepitation, leukocytosis and positive blood culture were significant risk factors for treatment failure, prolonged hospital stay and antibiotics change. On multivariate logistic regression analysis, respiratory rate of >70/min (OR 19.94, 95% CI 1.42-280.29), lethargy/unconsciousness (OR 114.2, 95% CI 3.14-4147.92), and positive blood culture (OR 15.24, 95% CI 2.53-91.67) had more chances of treatment failure. Duration of hospital stay was prolonged in those who had inability to drink (OR 3.89, CI 1.37-10.99) or abnormal chest X-ray (OR 8.45, CI 3.56-20.04). Children with rickets (OR 3.69, CI 1.14-11.96), and those with abnormal chest X-ray (OR 9.66, CI 2.62-35.53) had a higher odds of change in antibiotics. Presence of wheeze was a protective factor for treatment failure (OR 0.03, CI 0.00-0.37) and change of antibiotics (OR 0.24, CI 0.07-0.74). Conclusions Staphylococcus aureus and Streptococcus pneumoniae are the predominant organisms causing severe pneumonia in our setting. Children with risk factors such as respiratory rate >70/min, rickets, lethargy/unconsciousness, not able to drink, abnormal chest X-ray or positive blood culture are likely to have a delayed recovery or need of change of antibiotics, whereas those with wheeze are likely to recover faster with less chances of treatment failure.