INTRODUCTION:
The incidence of community-acquired
pneumonia (CAP) is gradually decreasing due to appropriate antibiotic
therapy, vaccination, and improvements in community health
services1. CAP is one of the most important causes of
morbidity and mortality particularly in children aged below 5
years2. The hospitalization rate of children with CAP
is between 9.5% and 42%, and the average hospitalization duration is 9
days3. In 10% of hospitalized patients, CAP is
accompanied by simple parapneumonic effusion (PPE) (≤10 mm, without
fibrous septation4,5. Regardless of the need for
hospitalization, CAPs are associated with complicated community-acquired
pneumonia (CCAP) with local complications, such as PPE, empyema (EMP),
necrotizing pneumonia (NP), lung abscess (LA), and bronchopleural
fistula (BPF)4 In approximately 7% of patients, CAP
progresses to NP, characterized by consolidation and parenchymal
necrosis6. Then, NP may rapidly worsen to cavitation
(pneumatocele) with peripheral and single lobe involvement and BPF when
the pleural space is affected; therefore, patients should be closely
monitored for complications7.
CCAP causes include immune
deficiencies, malnutrition, congenital cystic lung malformations, and
foreign body aspiration (FBA). However, it is also observed in
previously healthy children8. CCAP risk factors
include prolonged fever before hospitalization; antipyretic,
acetaminophen, and ibuprofen use; age <2 years; asymmetric
chest pain during the initial admission; high acute phase reactant
levels; leukopenia; and iron deficiency anemia9-11.
CAP and CCAP patients present with consolidation, atelectasis,
cavitation, and effusion are observed on chest radiography (CXR). Hence,
imaging can provide important information. However, consolidation may
not be clearly observed on CXR during the early stages of
NP7,. Nevertheless, thoracic USG is performed to
assess low-volume effusions that are overlooked on CXR. Therefore, it
can be used as a guide during thoracentesis and GT
insertion12. Thoracic computed tomography (CT) scan is
conducted to obtain differential diagnosis including tumor and
congenital airway malformations and to facilitate surgical planning for
large pneumatoceles that are unresponsive to
treatment,13. In addition, by appropriately
identifying CT, LA, and NP, the duration, content and treatment type can
be modified13.
BPF should be considered in NP patients who had persistent
(>24 h) air leakage during
follow-up14,15. LA is characterized by subfebrile
fever and chest pain. Further, it has a less noisy clinic than NP and
may cause pneumothorax similar to NP and BPF. However, mediastinal shift
is rarely observed. NP and/or LA patients subsequently experience
clinical and radiological improvements. In addition, surgical
intervention is commonly required due to complications such as
pneumothorax, BPF, and pneumatocele14-16.
With appropriate antibiotic therapy and supportive treatments, simple
pleural effusion can improve in CAPs patients15 Due to
local and systemic complications and surgical interventions (mainly NP
and LA), CCAP patients require long-term antibiotic
treatment15,17. NPs and LAs are managed with similar
antibiotic protocols; however, as the healing process in LA is slow, it
requires longer antibiotic treatment18.
Chest tube drainage is the primary approach for symptomatic patients,
even in those with small pleural effusion and
loculations18,19. If adequate pleural fluid drainage
cannot be achieved with GT in septal pleural effusion and EMP patients,
the hospitalization duration is shortened using
fibrinolytics20. Video-assisted thoracic surgery
(VATS) can be performed when adequate drainage cannot be achieved with
CDF21. Since there is a BPF risk during CDF,
particularly when accompanied by NP and LA, treatment should be
discontinued immediately22. VATS in the early period
is associated with a lower BPF risk in NPs with EMP and septal pleural
effusion23,24. Aspiration and drainage can be applied
if there is no clinical improvement with antibiotic therapy and if
complications including mediastinal shift develop in LA patients. The
risk of fistulation into the pleural space after drainage is lower than
that of NPs24. However, advanced surgical intervention
should be considered in large pneumatoceles that do not respond to
conservative treatment for severe BPF6,25,26.
The current study aimed to examine the CCAP progression risk factors by
assessing the clinical and laboratory characteristics of children with
CAP and the treatment strategies used for managing complications in
patients who are unresponsive to treatment.