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Clinical features to diagnose pneumonia in children under 5: A systematic review

Author(s) Clotilde Rambaud-Althaus1, Amani Shao2, Blaise Genton3, Valerie Dacremont 4
Affiliation(s) 1Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Geneva, Switzerland, 2Amani research center, National Institute of Medical Research, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 3Department of Ambulatory Care and Community Medicine – Infectious Disease Service, University Hospital, Lausanne, Switzerland, Lausanne, Switzerland, 4Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Lausanne, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Infectious Diseases
Summary Pneumonia is the leading cause of child mortality. In low income countries only the clinical diagnosis is available. We undertook a systematic literature review to assess the diagnostic accuracy of WHO non-severe pneumonia case definition for children less than 5 years of age to identify which clinical features best predict pneumonia. Our preliminary results indicate that chest in-drawing and fast breathing appeared to be rule-in signs in the selected studies. The specificity of the WHO pneumonia case definition remained low, resulting in over-treatment of non-pneumonia cases.
Background Pneumonia is the leading cause of child mortality. Early identification and treatment of pneumonia in primary health care facilities is essential to decrease the number of deaths. In low income countries, primary care health workers have access to neither radiology nor laboratory support, and pneumonia diagnosis relies on simple clinical features. In the context of antibiotics resistance, the accuracy of the diagnosis is fundamental. The more accurate the diagnostic test will be, the more pneumonia cases will be identified and the less non-pneumonia conditions will be prescribed unnecessary antibiotics. The current WHO definition of pneumonia relies on cough, chest indrawing and fast breathing. Recent published studies suggest that antibiotics may not be beneficial to children with WHO non-severe pneumonia (cough + fast breathing), and that severe (but not very severe) pneumonia (cough + chest indrawing without general danger signs) may be safely managed at home with oral antibiotics.
Objectives Our aim was to review the accuracy of WHO non-severe pneumonia clinical case definition, and to identify which clinical features have value in predicting the diagnosis of pneumonia in children younger than 5 years presenting in outpatient facilities.
Methodology We undertook a systematic review, searching electronic databases (Medline, Embase, Cochrane database of systematic reviews) and reference lists of relevant studies. 1296 potentially relevant articles were identified. Studies were selected on the basis of 6 criteria: design (studies assessing diagnostic accuracy), targeted disease (pneumonia), participants (children aged 2 to 59 months), setting (ambulatory care), index tests assessed (clinical features), and sufficient data reported. Quality assessment was done using the Quality Assessment of Diagnostic Accuracy Studies criteria. In each individual study, we only considered for analyses the index tests that were not part of participants’ inclusion criteria. For each clinical feature, we calculated sensitivity, specificity, and positive and negative likelihood ratio (LR+ and LR-). Clinical features were considered as a rule-in sign if the positive likelihood ratio was above 5.0, and the rule-out sign was if the negative likelihood ratio was less than 0.2.
Results We included 14 studies in the analysis, assessing a total of 14 different clinical features. Likelihood ratios were highly varied in the included studies. Within the included studies, chest indrawing (1 study, LR+ 30.32), respiratory rate above 50 breaths/min in children aged 1 to 5 years (2 studies, LR+ 5.17 and 19.83), and caretaker reported breathlessness (1 study, LR+ 9.50) were identified as rule-in sign in individual studies. Only 2 studies reported clinical features with LR-
Conclusion No single clinical feature accurately predicted the diagnosis of pneumonia. The current WHO definition of non-severe pneumonia lead to substantial overtreatment of non-pneumonia cases, which is an issue with regards to the rapid spread of antibiotic resistance. Point-of-care tests identifying bacterial pneumonia are highly desirable to further improve diagnosis accuracy.

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