Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Apr 2;19(1):71.
doi: 10.1186/s12890-019-0835-5.

Combination of clinical symptoms and blood biomarkers can improve discrimination between bacterial or viral community-acquired pneumonia in children

Mejbah U Bhuiyan  1   2 , Christopher C Blyth  3   4   5   6 , Rachel West  4 , Jurissa Lang  6 , Tasmina Rahman  4   7 , Caitlyn Granland  4 , Camilla de Gier  4   7 , Meredith L Borland  5   8 , Ruth B Thornton  4   7 , Lea-Ann S Kirkham  3   7 , Andrew Martin  5 , Peter C Richmond  3   4   5 , David W Smith  6   7 , Adam Jaffe  9 , Thomas L Snelling  4   5
Affiliations

Combination of clinical symptoms and blood biomarkers can improve discrimination between bacterial or viral community-acquired pneumonia in children

Mejbah U Bhuiyan et al. BMC Pulm Med. .

Abstract

Background: Differentiating bacterial from viral pneumonia is important for guiding targeted management and judicious use of antibiotics. We assessed if clinical characteristics and blood inflammatory biomarkers could be used to distinguish bacterial from viral pneumonia.

Methods: Western Australian children (≤17 years) hospitalized with radiologically-confirmed community-acquired pneumonia were recruited and clinical symptoms and management data were collected. C-reactive protein (CRP), white cell counts (WCC) and absolute neutrophil counts (ANC) were measured as part of routine care. Clinical characteristics and biomarker levels were compared between cases with definite bacterial pneumonia (clinical empyema and/or bacteria detected in blood or pleural fluid), presumed viral pneumonia (presence of ≥1 virus in nasopharyngeal swab without criteria for definite bacterial pneumonia), and other pneumonia cases (pneumonia in the absence of criteria for either definite bacterial or presumed viral pneumonia). The area-under-curve (AUC) of the receiver operating characteristic (ROC) curve for varying biomarker levels were used to characterise their utility for discriminating definite bacterial from presumed viral pneumonia. For biomarkers with AUC > 0.8 (fair discriminator), Youden index was measured to determine the optimal cut-off threshold, and sensitivity, specificity, predictive values (positive and negative) were calculated. We investigated whether better discrimination could be achieved by combining biomarker values with the presence/absence of symptoms.

Results: From May 2015 to October 2017, 230 pneumonia cases were enrolled: 30 with definite bacterial pneumonia, 118 with presumed viral pneumonia and 82 other pneumonia cases. Differences in clinical signs and symptoms across the groups were noted; more definite bacterial pneumonia cases required intravenous fluid and oxygen supplementation than presumed viral or other pneumonia cases. CRP, WCC and ANC were substantially higher in definite bacterial cases. For a CRP threshold of 72 mg/L, the AUC of ROC was 0.82 for discriminating definite bacterial pneumonia from presumed viral pneumonia. Combining the CRP with either the presence of fever (≥38οC) or the absence of rhinorrhea improved the discrimination.

Conclusions: Combining elevated CRP with the presence or absence of clinical signs/ symptoms differentiates definite bacterial from presumed viral pneumonia better than CRP alone. Further studies are required to explore combination of biomarkers and symptoms for use as definitive diagnostic tool.

Keywords: Bacteria; Blood biomarker; C-reactive protein; Children; Pneumonia; Virus.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

Written informed consent was obtained for participation and specimen collection from the parent/guardian of each case and assent was obtained from cases aged ≥ 7 years. The study protocol was approved by Human Research Ethics Committee of the Princess Margaret Hospital for Children (PMH HREC REF 2014117EP).

Consent for publication

This manuscript does not contain identifiable individual person’s details.

Competing interests

Prof. Richmond receives grants from GlaxoSmithKline, Novavax, Medimmune, and Janssen outside the submitted work; Dr. Kirkham has a patent WO2005108580A1 licensed to Pfizer. All other authors have no potential conflicts of interest to declare.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
a: ROC curve for CRP for differentiating definite bacterial pneumonia against presumed viral pneumonia in radiologically confirmed CAP cases. b: ROC curve for CRP for differentiating definite bacterial pneumonia against presumed viral plus other pneumonias in radiologically confirmed CAP cases
See this image and copyright information in PMC

References

    1. Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405–1416. doi: 10.1016/S0140-6736(13)60222-6. - DOI - PMC - PubMed
    1. Burgner D, Richmond P. The burden of pneumonia in children: an Australian perspective. Paediatr Respir Rev. 2005;6(2):94–100. doi: 10.1016/j.prrv.2005.03.004. - DOI - PMC - PubMed
    1. Moore H, Burgner D, Carville K, Jacoby P, Richmond P, Lehmann D. Diverging trends for lower respiratory infections in non-aboriginal and aboriginal children. J Paediatr Child Health. 2007;43(6):451–457. doi: 10.1111/j.1440-1754.2007.01110.x. - DOI - PubMed
    1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;346(6):429–437. doi: 10.1056/NEJMra011994. - DOI - PubMed
    1. Huijskens EG, Koopmans M, Palmen FM, van Erkel AJ, Mulder PG, Rossen JW. The value of signs and symptoms in differentiating between bacterial, viral and mixed aetiology in patients with community-acquired pneumonia. J Med Microbiol. 2014;63(Pt 3):441–452. doi: 10.1099/jmm.0.067108-0. - DOI - PubMed

MeSH terms