Predicting Severe Pneumonia Outcomes in Children.
Substantial morbidity and excessive care variation are seen with pediatric pneumonia. Accurate risk-stratification tools to guide clinical decision-making are needed.



We developed risk models to predict severe pneumonia outcomes in children (<18 years) by using data from the Etiology of Pneumonia in the Community Study, a prospective study of community-acquired pneumonia hospitalizations conducted in 3 US cities from January 2010 to June 2012. In-hospital outcomes were organized into an ordinal severity scale encompassing severe (mechanical ventilation, shock, or death), moderate (intensive care admission only), and mild (non-intensive care hospitalization) outcomes. Twenty predictors, including patient, laboratory, and radiographic characteristics at presentation, were evaluated in 3 models: a full model included all 20 predictors, a reduced model included 10 predictors based on expert consensus, and an electronic health record (EHR) model included 9 predictors typically available as structured data within comprehensive EHRs. Ordinal regression was used for model development. Predictive accuracy was estimated by using discrimination (concordance index).



Among the 2319 included children, 21% had a moderate or severe outcome (14% moderate, 7% severe). Each of the models accurately identified risk for moderate or severe pneumonia (concordance index across models 0.78-0.81). Age, vital signs, chest indrawing, and radiologic infiltrate pattern were the strongest predictors of severity. The reduced and EHR models retained most of the strongest predictors and performed as well as the full model.



We created 3 risk models that accurately estimate risk for severe pneumonia in children. Their use holds the potential to improve care and outcomes.
Departments of Pediatrics, derek.williams@vanderbilt.edu.
Derek J
DJ
Williams
Biostatistics.
Yuwei
Y
Zhu
Health Policy, and.
Carlos G
CG
Grijalva
Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
Wesley H
WH
Self
Biostatistics.
Frank E
FE
Harrell
Centers for Disease Control and Prevention, Atlanta, Georgia.
Carrie
C
Reed
Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah.
Chris
C
Stockmann
Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.
Sandra R
SR
Arnold
Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah.
Krow K
KK
Ampofo
Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, Georgia; and.
Evan J
EJ
Anderson
Centers for Disease Control and Prevention, Atlanta, Georgia.
Anna M
AM
Bramley
Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Richard G
RG
Wunderink
Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.
Jonathan A
JA
McCullers
Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah.
Andrew T
AT
Pavia
Centers for Disease Control and Prevention, Atlanta, Georgia.
Seema
S
Jain
Departments of Pediatrics.
Kathryn M
KM
Edwards
D000367:Age Factors; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000453:epidemiology; D005260:Female; D006760:Hospitalization; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007902:Length of Stay; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D015233:Models, Statistical; D010343:Patient Admission; D063868:Patient Outcome Assessment; D011014:Pneumonia / Q000453:epidemiology*; D011379:Prognosis; D011446:Prospective Studies; D012121:Respiration, Artificial; D018570:Risk Assessment; D012720:Severity of Illness Index; D012769:Shock / Q000453:epidemiology; D014481:United States / Q000453:epidemiology; D055986:Vital Signs
Pediatrics. 2014 Jul;134(1):100-9
24958590
Clin Infect Dis. 2007 Jan 1;44(1):41-9
17143813
Crit Care. 2009;13(4):R135
19678924
Arch Intern Med. 1998 Jun 22;158(12):1350-6
9645830
N Engl J Med. 2015 Feb 26;372(9):835-45
25714161
Respirology. 2007 Sep;12(5):754-8
17875067
Eur J Intern Med. 2012 Jul;23(5):398-406
22726367
Chest. 2007 Aug;132(2):410-7
17573487
Ann Emerg Med. 2012 Jan;59(1):35-41
21907451
Crit Care Med. 1996 May;24(5):743-52
8706448
J Am Med Inform Assoc. 2003 Nov-Dec;10(6):523-30
12925543
Pediatrics. 2013 Apr;131(4):e1150-7
23478871
Pediatrics. 2014 Sep;134(3):539-45
25113291
PLoS One. 2013 Nov 11;8(11):e78602
24244325
Clin Infect Dis. 2011 Oct;53(7):e25-76
21880587
J Antimicrob Chemother. 2011 Feb;66(2):416-23
21081545
Ann Emerg Med. 2015 Nov;66(5):511-20
25725592
Pediatrics. 2006 Feb;117(2):176-80
16452342
Clin Infect Dis. 2008 Aug 1;47(3):375-84
18558884
Thorax. 2003 May;58(5):377-82
12728155
Acad Emerg Med. 2013 Sep;20(9):957-60
24033659
Arch Pediatr Adolesc Med. 2012 Dec;166(12):1155-64
23027409
PLoS One. 2012;7(1):e27793
22238570
Curr Infect Dis Rep. 2014 Dec;16(12):451
25348745
JAMA Intern Med. 2013 Sep 23;173(17):1584-91
23896675
Intensive Care Med. 2003 Feb;29(2):278-85
12541154
Pediatr Infect Dis J. 2012 Oct;31(10):1036-41
22653486
JAMA. 2000 Feb 9;283(6):749-55
10683053
N Engl J Med. 1997 Jan 23;336(4):243-50
8995086
Arch Intern Med. 1997 Jan 13;157(1):36-44
8996039
Hosp Pediatr. 2015 Sep;5(9):474-9
26330246
J Antimicrob Chemother. 2008 Feb;61(2):442-51
18065412
Acad Emerg Med. 2013 Mar;20(3):240-6
23517255
J Emerg Med. 2012 Feb;42(2):133-8
20542398
Ir Med J. 2008 May;101(5):144-6
18624261