Below are the citation and abstract of a new review in The Lancet. I was struck to see the contrast (apparently unintended) between the opening and closing sentences of this 13-page review, highlighting.
The first sentence of the full text reads: 'Community-acquired pneumonia (CAP) remains the largest single cause of morbidity and mortality worldwide in children aged between 28 days (ie, outside the neonatal period).'
And the last reads: 'The prognosis of CCAP [complicated CAP] is usually excellent, with no clinical, radiological, or lung function consequences in almost all children. Mortality is rare and usually limited to patients with previous underlying disease. Families should be assured of the favourable long-term outcome.'
Elsewhere the authors acknowledge that 'most data [on CCAP] are from high-income countries, and should only be extrapolated to low-income and middle-income countries with caution'. Indeed. For me these brief extracts highlight the chasm in health care for children in different settings. What do you think?
CITATION: Complicated pneumonia in children
Fernando M de Benedictis et al.
The Lancet - Review, volume 396, issue 10253, p786-798, september 12, 2020
DOI: https://doi.org/10.1016/S0140-6736(20)31550-6 (restricted access)
SUMMARY: Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48–72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.
Best wishes, Neil
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CHIFA profile: Neil Pakenham-Walsh is the coordinator of the HIFA campaign (Healthcare Information For All) and assistant moderator of the CHIFA forum. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org
