Necrotizing Pneumonia in Critically Ill Infants and Children: Predictive Factors for Critical Care Requirement

Abstract

Background: Necrotizing pneumonia (NP) represents a severe and potentially life-threatening complication of community-acquired pneumonia in children, characterized by progressive lung parenchymal necrosis, cavity formation and significant respiratory compromise. Despite advances in pediatric critical care, NP continue to pose substantial challenges in terms of early recognition, optimal management strategies and prediction of intensive care requirements.

Objectives: This multicenter observational study aimed to comprehensively analyze the clinical characteristics, microbiological patterns, radiological features and management strategies of pediatric NP requiring intensive care admission, with particular focus on identifying predictive factors for disease severity and resource utilization.

Methods: We conducted a retrospective analysis of all children admitted with radiologically confirmed NP to Italian pediatric intensive care units (PICUs) between January 2018 and December 2022. Comprehensive data collection included demographics, clinical presentation, laboratory findings, microbiological results, radiological patterns, therapeutic interventions, complications and outcomes. Statistical analysis was performed to identify associations between clinical variables and outcomes.

Results: Among 76 children (median age 45 months, interquartile range: 19-84), Streptococcus pneumoniae was identified in 38 patients (52.8%), followed by Staphylococcus aureus in 18 (23.7%), including 12 Panton-Valentine leukocidin-positive strains (16.7%). Mechanical ventilation was required in 44 patients (57.9%), chest drainage in 58 (76.3%) and video-assisted thoracoscopic surgery in 11 (14.5%). Comorbidities were present in 23 patients (30.3%). Mean PICU stay was 8.9 ± 8.8 days with zero mortality. Independent predictors of prolonged PICU stay included age <24 months [odds ratio (OR) 2.8, 95% confidence interval (CI): 1.2-6.5], comorbidities (OR 3.2, 95% CI: 1.4-7.3) and bilateral involvement (OR 3.8, 95% CI: 1.5-9.6).

Conclusions: Pediatric NP remains a challenging clinical entity requiring multidisciplinary management and significant intensive care resources. Early recognition of severity predictors, prompt microbiological diagnosis and individualized therapeutic approaches are essential for optimizing outcomes. Our findings support the need for standardized protocols and further prospective studies to refine management strategies for this severe condition.

Clinical trial registration: Not applicable (observational study).

Keywords: Necrotizing pneumonia; chest drainage; community-acquired pneumonia; mechanical ventilation; pediatric intensive care.