Can signs and symptoms guide diagnosis and treatment of community-acquired pneumonia in children? A new Cochrane diagnostic accuracy review

Key message: M. pneumoniae cannot be diagnosed reliably in children and adolescents with community-acquired pneumonia based on individual clinical symptoms and signs. Although absence of wheeze is a statistically significant diagnostic indicator, it does not have sufficient diagnostic value to guide empirical macrolide treatment. Chest pain may be a clinically useful indicator but needs further evaluation.

Clinicians seeing children with suspected pneumonia have to decide on appropriate antibiotic treatment without the benefit of laboratory test results. Macrolide antibiotics are recommended for the treatment of suspected Mycoplasma pneumoniae (M. pneumoniae) infections, a significant cause of community-acquired pneumonia in children and teenagers but difficult to diagnose from signs and symptoms. As a result, antibiotics are sometimes prescribed inappropriately, which may hinder recovery as well as increasing antibiotic resistance.

A new review from the Cochrane Acute Respiratory Infections Group has now been published, assessing whether the presence or absence of clinical signs and symptoms might help clinicians decide which children with suspected community-acquired pneumonia are most (and least) likely to benefit from macrolide treatment when they first present and results of laboratory tests are not available. Seven studies with data from 1491 children were included. They were all prospective observational cohort studies conducted in hospitals.

What did they find?

  • There is evidence from two studies with small numbers of participants that the presence of chest pain approximately doubled the probability of M. pneumoniae
  • Wheeze was 12% more likely to be absent in children with M. pneumoniae
  • Presence of crepitations was associated with M. pneumoniae but this finding was of borderline statistical significance
  • Fever, coryza and cough were not useful diagnostic indicators of M. pneumoniae

How good is the evidence?

Overall, study quality was moderate. Study findings were inconsistent and the review had limited data on which to draw. No studies compared clinical symptoms and signs in children with and without M. pneumoniae and there are no data on the diagnostic value of combinations of clinical symptoms and signs.There were inconsistencies in reporting of clinical signs and symptoms across different studies. Findings may not be generalizable to children presenting in primary care.

Links:

Wang K, Gill P, Perera R, Thomson A, Mant D, Harnden A. Clinical symptoms and signs for the diagnosis of Mycoplasma pneumoniae in children and adolescents with community-acquired pneumonia. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009175. DOI: 10.1002/14651858.CD009175.pub2.

Cochrane summary: http://summaries.cochrane.org/search/site/community-acquired%2520pneumonia

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