Predictors of case fatality in pediatric populations with bacterial pneumonia
DOI:
https://doi.org/10.5281/zenodo.22811714Keywords:
pediatric pneumonia, case fatality, hypoxaemia, severity score, antimicrobial resistanceAbstract
Background: Bacterial pneumonia remains the leading infectious cause of death in children under five, concentrated in a minority of children whose presentation carries identifiable risk [1,2].
Objective: To synthesize published evidence on clinical, host, and health-systems predictors of case fatality among children hospitalized with bacterial or clinically severe pneumonia.
Methods: Narrative synthesis of systematic reviews, severity-score validation studies, and hospital cohorts of childhood pneumonia mortality from low- and middle-income settings, supplemented by vaccine-impact and resistance literature.
Findings: Hypoxaemia, severe malnutrition, young age, altered consciousness, and HIV infection or exposure recur as the most consistent predictors of death [6,18,13]; composite scores such as RISC improve on single predictors but need local recalibration [8,22], and rising pneumococcal resistance threatens the treatment pathways risk stratification is meant to trigger [15], even as conjugate vaccination shrinks the at-risk population [25].
Conclusions: A short, measurable list of predictors explains much of the variation in pneumonia case fatality, but their value depends on continued access to effective antibiotics and oxygen therapy, and existing severity tools need periodic recalibration against contemporary, post-vaccine case mixes [23,4].
References
Rudan, I., Boschi-Pinto, C., Biloglav, Z., Mulholland, K., Campbell, H. (2008) Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization, 86(5): 408-416. DOI: 10.2471/BLT.07.048769 in
Walker, C.L.F., Rudan, I., Liu, L., Nair, H., Theodoratou, E., Bhutta, Z.A., et al. (2013) Global burden of childhood pneumonia and diarrhoea. Lancet, 381(9875): 1405-1416. DOI: 10.1016/S0140-6736(13)60222-6
Liu, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J.E., et al. (2016) Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet, 388(10063): 3027-3035. DOI: 10.1016/S0140-6736(16)31593-8
GBD 2016 Lower Respiratory Infections Collaborators (2018) Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016. Lancet Infectious Diseases, 18(11): 1191-1210. DOI: 10.1016/S1473-3099(18)30310-4
McAllister, D.A., Liu, L., Shi, T., Chu, Y., Reed, C., Burrows, J., et al. (2019) Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015. Lancet Global Health, 7(1): e47-e57. DOI: 10.1016/S2214-109X(18)30408-X
Djelantik, I.G.G., Gessner, B.D., Sutanto, A., Steinhoff, M., Linehan, M., Moulton, L.H., Arjoso, S. (2003) Case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. Journal of Tropical Pediatrics, 49(6): 327-332. DOI: 10.1093/tropej/49.6.327
Scott, J.A.G., Brooks, W.A., Peiris, J.S.M., Holtzman, D., Mulholland, E.K. (2008) Pneumonia research to reduce childhood mortality in the developing world. Journal of Clinical Investigation, 118(4): 1291-1300. DOI: 10.1172/JCI33947
Reed, C., Madhi, S.A., Klugman, K.P., Kuwanda, L., Ortiz, J.R., Finelli, L., Fry, A.M. (2012) Development of the Respiratory Index of Severity in Children (RISC) score among young children with respiratory infections in South Africa. PLoS One, 7(11): e27793. DOI: 10.1371/journal.pone.0027793
World Health Organization (2014) Revised WHO classification and treatment of childhood pneumonia at health facilities: evidence summaries. Geneva: World Health Organization.
Izadnegahdar, R., Cohen, A.L., Klugman, K.P., Qazi, S.A. (2013) Childhood pneumonia in developing countries. Lancet Respiratory Medicine, 1(7): 574-584. DOI: 10.1016/S2213-2600(13)70075-4
Lazzerini, M., Sonego, M., Pellegrin, M.C. (2015) Hypoxaemia as a mortality risk factor in acute lower respiratory infections in children in low and middle-income countries: systematic review and meta-analysis. PLoS One, 10(9): e0136166. DOI: 10.1371/journal.pone.0136166
Chisti, M.J., Tebruegge, M., La Vincente, S., Graham, S.M., Duke, T. (2009) Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Tropical Medicine & International Health, 14(10): 1173-1189. DOI: 10.1111/j.1365-3156.2009.02364.x
Preidis, G.A., McCollum, E.D., Mwansambo, C., Kazembe, P.N., Schutze, G.E., Kline, M.W. (2011) Pneumonia and malnutrition are highly predictive of mortality among African children hospitalized with human immunodeficiency virus infection or exposure in the era of antiretroviral therapy. Journal of Pediatrics, 159(3): 484-489. DOI: 10.1016/j.jpeds.2011.02.033
Duke, T. (2005) Neonatal pneumonia in developing countries. Archives of Disease in Childhood - Fetal and Neonatal Edition, 90(3): F211-F219. DOI: 10.1136/adc.2003.048108
Alhusseini, L.B., Sadeghi Ghazi Chaki, S., Noshak, M.A., Azizian, K., Kouhsari, E. (2025) Cell wall-inhibiting antibiotics resistance in Streptococcus pneumoniae causing invasive diseases: a global systematic review and meta-analysis in pediatric populations. Italian Journal of Pediatrics, 51: 322. DOI: 10.1186/s13052-025-02161-x
Brandileone, M.C.C., Vieira, V.S.D., Casagrande, S.T., Zanella, R.C., Guerra, M.L.L.S., Bokermann, S., et al. (1997) Prevalence of serotypes and antimicrobial resistance of Streptococcus pneumoniae strains isolated from Brazilian children with invasive infections. Microbial Drug Resistance, 3(2): 141-146. DOI: 10.1089/mdr.1997.3.141
Jroundi, I., Mahraoui, C., Benmessaoud, R., Moraleda, C., Tornimbene, B., Valles, X., et al. (2014) Risk factors for a poor outcome among children admitted with clinically severe pneumonia to a university hospital in Rabat, Morocco. International Journal of Infectious Diseases, 28: 164-170. DOI: 10.1016/j.ijid.2014.07.027
Sonego, M., Pellegrin, M.C., Becker, G., Lazzerini, M. (2015) Risk factors for mortality from acute lower respiratory infections (ALRI) in children under five years of age in low and middle-income countries: a systematic review and meta-analysis of observational studies. PLoS One, 10(1): e0116380. DOI: 10.1371/journal.pone.0116380
Chisti, M.J., Duke, T., Robertson, C.F., Ahmed, T., Faruque, A.S.G., Bardhan, P.K., et al. (2012) Clinical predictors and outcome of hypoxaemia among under-five diarrhoeal children with or without pneumonia in an urban hospital, Dhaka, Bangladesh. Tropical Medicine & International Health, 17(1): 106-111. DOI: 10.1111/j.1365-3156.2011.02890.x
Bassat, Q., Lanaspa, M., Machevo, S., O'Callaghan-Gordo, C., Sigauque, B., Nhampossa, T., et al. (2016) Hypoxaemia in Mozambican children under five years of age admitted to hospital with clinical severe pneumonia: clinical features and performance of predictor models. Tropical Medicine & International Health, 21(9): 1147-1156. DOI: 10.1111/tmi.12738
Ayieko, P., English, M. (2006) In children aged 2-59 months with pneumonia, which clinical signs best predict hypoxaemia? Journal of Tropical Pediatrics, 52(5): 307-310. DOI: 10.1093/tropej/fml036
Hooli, S., Colbourn, T., Lufesi, N., Costello, A., Nambiar, B., Thammasitboon, S., et al. (2016) Predicting hospitalised paediatric pneumonia mortality risk: an external validation of RISC and mRISC, and local tool development (RISC-Malawi) from Malawi. PLoS One, 11(12): e0168126. DOI: 10.1371/journal.pone.0168126
Wilkes, C., Bava, M., Graham, H.R., Duke, T. (2023) What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review. Journal of Global Health, 13: 05003. DOI: 10.7189/jogh.13.05003
Enarson, P.M., Gie, R.P., Enarson, D.A., Mulholland, E.K. (2014) Reducing deaths from severe pneumonia in children in Malawi by improving delivery of pneumonia case management. PLoS One, 9(7): e102955. DOI: 10.1371/journal.pone.0102955
Kleynhans, J., Tempia, S., Shioda, K., von Gottberg, A., Weinberger, D.M., Cohen, C. (2021) Estimated impact of the pneumococcal conjugate vaccine on pneumonia mortality in South Africa, 1999 through 2016: an ecological modelling study. PLoS Medicine, 18(2): e1003537. DOI: 10.1371/journal.pmed.1003537
Chisti, M.J., Salam, M.A., Smith, J.H., Ahmed, T., Pietroni, M.A.C., Shahunja, K.M., et al. (2015) Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial. Lancet, 386(9998): 1057-1065. DOI: 10.1016/S0140-6736(15)60249-5
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