Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Complementary and Alternative Medicine

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

A cross-sectional study of the clinical characteristics of hospitalized children with community-acquired pneumonia in eight eastern cities in China

  • Xue-Feng Wang1Email author,
  • Jian-Ping Liu2Email author,
  • Kun-Ling Shen3,
  • Rong Ma4,
  • Zhen-Ze Cui5,
  • Li Deng6,
  • Yun-Xiao Shang7,
  • De-Yu Zhao8,
  • Li-Bo Wang9,
  • Li-Ya Wan10,
  • Yi-Qiu Sun11,
  • Yan-Ning Li12,
  • Zhi-Yan Jiang13,
  • Hua Xu14,
  • Xin-Min Li4,
  • Zhen-Qi Wu1,
  • Zhao-Lan Liu2,
  • Ying-Hui Hu3,
  • Yan Huang5,
  • Chun-Hui He6,
  • Han Zhang7,
  • Yong-Hong Jiang13,
  • Hua Liu14 and
  • Zi Wang1
Contributed equally
BMC Complementary and Alternative MedicineThe official journal of the International Society for Complementary Medicine Research (ISCMR)201313:367

https://doi.org/10.1186/1472-6882-13-367

Received: 28 May 2013

Accepted: 16 December 2013

Published: 23 December 2013

Abstract

Background

Community-acquired pneumonia in children is common in China. To understand current clinical characteristics and practice, we conducted a cross-sectional study to analyze quality of care on childhood pneumonia in eight eastern cities in China.

Methods

Consecutive hospital records between January 1, 2010 and December 31, 2010 were collected from 13 traditional Chinese medicine (TCM) and western medicine (WM) hospitals in February, May, August, and November (25 cases per season, 100 cases over the year), respectively. A predesigned case report form was used to extract data from the hospital medical records.

Results

A total of 1298 cases were collected and analyzed. Symptoms and signs upon admission at TCM and WM hospitals were cough (99.3% vs. 98.6%), rales (84.8% vs. 75.0%), phlegm (83.3% vs. 49.1%), and fever (74.9% vs. 84.0%) in frequency. Patients admitted to WM hospitals had symptoms and signs for a longer period prior to admission than patients admitted to TCM hospitals. Testing to identify etiologic agents was performed in 1140 cases (88.4%). Intravenous antibiotics were administered in 99.3% (595/598) of cases in TCM hospitals and in 98.6% (699/700) of cases in WM hospitals. Besides, Chinese herbal extract injection was used more frequently in TCM hospitals (491 cases, 82.1%) than in WM hospitals (212 cases, 30.3%) (p < 0.01). At discharge, 818 cases (63.0%) were clinically cured, with a significant difference between the cure rates in TCM (87.6%) and WM hospitals (42.0%) (OR = 9.8, 95% confidence interval (CI): 7.3 ~ 12.9, p < 0.01). Pathogen and previous medical history were more likely associated with the disappearance of rales (OR = 7.2, 95% CI: 4.8 ~ 10.9). Adverse effects were not reported from the medical records.

Conclusions

Intravenous use of antibiotics is highly prevalent in children with community-acquired pneumonia regardless of aetiology. There was difference between TCM and WM hospitals with regard to symptom profile and the use of antibiotics. Intravenous use of herbal injection was higher in TCM hospitals than in WM hospitals. Most of the cases were diagnosed based on clinical signs and symptoms without sufficient confirmation of aetiology. Audit of current practice is urgently needed to improve care.

Keywords

Childhood pneumoniaCommunity-acquiredClinical characteristicsTreatmentCross-sectional studyChinese population

Background

Pneumonia is an inflammatory condition of the lung, caused by different pathogens or other etiologic factors [1]. Worldwide it is the leading cause of death in children under five years old [24], with nearly 2 million deaths, or almost 19.0% of total deaths in children [5]. In China, it is estimated that there are an annual 21.1 million new cases of pneumonia in children younger than 5 years of age. This is a disease burden second only to India, which has 43 million annual new cases in the same age group [6, 7]. In China, pneumonia accounts for most pediatric hospitalizations [8].

Addressing childhood pneumonia remains a difficult public health task in China. In terms of surveillance, pneumonia is not even listed as a national notifiable infectious disease [9], though in 2003 after the outbreak of severe acute respiratory syndrome (SARS), “pneumonia of unknown cause” was required to be reported because airborne etiologic agents such as the SARS coronavirus and human avian influenza virus (H5N1) are extremely pathogenic and capable of quickly causing an epidemic [10]. Moreover, China’s current health policy of “integration of TCM and Western medicine” need large-scale surveys comparing cases of childhood pneumonia at TCM and WM hospitals. Whether for guiding healthcare policy or for improving disease management and prevention, evaluating quality of care in paediatric pneumonia is of paramount importance. Through the ages, WM hospitals hold a principle status in public health. TCM hospitals are gradually into mass vision, although at most time as a complementary role. The two types of hospitals have advantages and disadvantages. Commonly, WM hospitals prefer to acute severe disease, and TCM hospitals prefer to chronic mild disease. To exploring specific difference on pneumonia therapy between two types of hospitals, this cross-sectional study was designed to investigate the distribution, diagnosis, treatment, and clinical outcome of childhood community-acquired pneumonia in China.

Methods

Study subjects

Data were drawn from 13 traditional Chinese medicine (TCM) and western medicine (WM) hospitals in eight eastern cities of China: Beijing, Dalian, Guangzhou, Jinan, Nanjing, Shanghai, Shenyang, and Tianjin. Hospitals selection refers to region representation as provincial capitals or coast cities, which reflects a better status of economic and health in China. The hospitals are either affiliated with universities or are provincial/municipal children’s hospitals. Our protocol of study was approved by institutional review board (IRB) of the affiliated hospital of Liaoning University of Traditional Chinese Medicine (principle investigator) which covered each hospital’s IRB.

Children between 1 and 14 years of age presenting to the pediatric ward with clinical diagnosis of community-acquired pneumonia were eligible for the study. Our previous study [1114] found that admission rates and numbers of severe pneumonia cases, especially in children <1 year of age, between TCM and WM hospitals were highly incongruent. Therefore, to avoid bias in the current study, we excluded children younger than one year old and children with severe pneumonia. Indications for severe pneumonia in patient age 0–3 years were temperature >38.5°C, respiratory rate (RR) >70 breaths/min, chest retractions, nasal flaring, cyanosis, intermittent apnea, grunting, not feeding. Indications for severe pneumonia in patient age 4–14 years were temperature >38.5°C, RR >50 breaths/min, nasal flaring, cyanosis, grunting, and signs of dehydration.

Criteria of diagnosis were based on nationally-recognized guidelines from either the Chinese Medical Association [10] or Zhu Futang Textbook of Pediatrics[1], with symptoms of fever, cough and dyspnea, fixed fine moist rales, and patchy infiltrates on chest radiography. Criteria for clinical therapeutic effectivness were also based on national guidelines [15, 16]. Clinical cure was defined as temperature ≤37.2°C, disappearance of all symptoms except occasional cough, and disappearance of rales. Clinical improvement was defined as ≤37.2°C, all symptoms and rales reduced. Failure was defined as no improvement in presenting symptoms.

Data sampling was from January 1, 2010 to December 31, 2010. Total study sample was 1300. Consecutive hospitalised records of children with paediatric pneumonia were collected from each hospital in February, May, August, and November, respectively, that is, first consecutive 25 cases each month, or 100 cases per hospital over the 1-year study period.

Data collection

A predesigned case report form was applied by trained investigators with clinical medicine backgrounds. Information extracted were demographic data including name, gender, age, hospital case number, birth history (route of delivery, birth weight), past medical history (recurrent respiratory tract diseases, eczema, asthma, allergic rhinitis, and other allergies), duration of hospital stay, symptoms and signs up to admission, diagnosis on admission and at discharge, therapy modalities, and clinical outcome at discharge. All records were input into an electronic database based on EpiData software version 3.1.

Statistical analysis

EpiData software version 3.1 and IBM SPSS software version 17.0 were used for record and data analyses. All p values were applied with two-tailed tests and were not adjusted for multiple testing. Logistic regression model was used to explore the relationship between different types of hospitals and the improvement of symptoms.

Results

Clinical characteristics

A total of 1298 cases were collected from six TCM hospitals and seven WM hospitals (Table 1). Data of two cases were missing from one hospital. Male to female ratio was 1.41:1. Previous medical history included recurrent pneumonia, recurrent bronchitis, and recurrent upper respiratory tract infection (RURTI) in 349/1298 (26.9%) children; eczema in 130 (10.0%) children; asthma in 53 (4.1%) children; and allergic rhinitis in 56 (4.3%) children. There was significant difference on previous medical history in sampled patients between two types of hospitals.
Table 1

Characteristics of children hospitalised with pneumonia in the sampled hospitals

Characteristics

TCM hospitals

WM hospitals

χ2

P value

 

Number (n = 598)

%

Number (n = 700)

%

  

Gender

    

3.75

0.05

  Male

333

55.7

427

61.0

  

  Female

265

44.3

273

39.0

  

Age, y

    

4.74

0.09

  1-3

163

27.3

228

32.6

  

  4-7

327

54.7

346

49.4

  

  8-14

108

18.0

126

18.0

  

Previous medical history

      

  Recurrent pneumoniaa

116

19.4

45

6.4

38.60

<0.01

  Recurrent bronchitisb

43

7.2

13

1.9

5.59

0.02

  RURTIc

78

13.0

54

7.7

17.33

<0.01

  Eczema

73

12.2

57

8.1

2.42

0.12

  Asthmad

42

7.0

11

1.6

19.52

<0.01

  Allergic rhinitis

48

8.0

8

1.1

30.75

<0.01

Abbreviations: TCM traditional Chinese medicine, WM Western medicine, RURTI recurrent upper respiratory tract infection, URTI upper respiratory tract infection.

aRecurrent pneumonia is defined as at least two pneumonia episodes in a 1-year period or at least three episodes over a lifetime, with normal chest radiography between each episode [17].

bRecurrent bronchitis is defined as in patients age 0–2 years, three or more bronchitis episodes in 1 year; age 3–14 years, two or more episodes in 1 year [17].

cRURTI is defined as in patients age 0–2 years, seven or more episodes of URTI in 1 year; age 3–5 years, six or more episodes in 1 year; 6–14 years, five or more episodes of URTI in 1 year [10, 17].

dIncludes cough-variant asthma.

Clinical manifestations on admission

Presentation of symptoms and signs on admission in TCM hospitals were, from most to less frequent: cough (99.3%), rales (84.8%), phlegm (83.3%), and fever (74.9%). These percentages were nearly the same as those in WM hospitals: cough (98.6%), fever (84%), rales (75.0%), and phlegm (49.1%). Except for cough (p = 0.19), the frequencies of rales, phlegm, and fever were significantly higher in WM hospitals than in TCM hospitals (p < 0.01). Average duration of illness from onset of symptoms and signs to admission was markedly higher in WM hospitals than in TCM hospitals (Table 2).
Table 2

Symptoms and signs of children with pneumonia on admission to hospital in the sampled hospitals

 

Frequency

χ2

P

Time from onset of symptoms up to admission (days)

Z

P

Symptoms

TCM hospitals (n = 598)

WM hospitals (n = 700)

TCM hospitals

WM hospitals

Cough

594

690

1.74

0.19

7.4 ± 6.6

8.8 ± 7.5

−6.11

<0.01

Rales

507

525

18.94

<0.01

1.2 ± 0.7

1.6 ± 1.7

−4.59

<0.01

Phlegma

498

344

164.89

<0.01

5.8 ± 9.7

4.0 ± 6.7

−5.87

<0.01

Feverb

448

588

16.52

<0.01

93.6 ± 64.2

147.1 ± 120.7

−8.91

<0.01

Tachypnea

196

87

78.31

<0.01

2.6 ± 2.9

4.9 ± 5.0

−4.72

<0.01

Dyspnea

24

70

17.21

<0.01

2.2 ± 2.3

7.0 ± 15.0

−3.47

<0.01

Abbreviations: TCM traditional Chinese medicine, WM Western medicine.

aIncludes white sputum, yellow sputum, or difficult to expectorate sputum.

bTime of onset of fever up to admission recorded in hours.

Aetiology diagnosis

Specific pathogens (one pathogen or more) were identified in 624 (48.1%) cases (Table 3). Negative pathogen findings were identified in 524 (40.4%) cases. Eighty-five (6.5%) cases were not tested for pathogens. Data were missing in 65 (5.0%) cases. TCM hospitals performed significantly fewer pathogen tests as compared to WM hospitals (30.3% versus 69.7%, p < 0.01). In terms of pathogenic agent, Mycoplasma pneumoniae (M pneumoniae) was identified more frequently, followed by mixed pathogens.
Table 3

Etiologic agents identified in children hospitalised with pneumonia in the sampled hospitals

Pathogen

1-3 years (N = 391)

4-7 years (N = 673)

8-14 years (N = 234)

Total

TCM hospitals

WM hospitals

TCM hospitals

WM hospitals

TCM hospitals

WM hospitals

n

%

n

%

n

%

n

%

n

%

n

%

Bacteriaa

1

0.7

32

15.6

4

1.2

37

11.6

1

0.9

7

6.2

82

M pneumoniae b

37

22.8

36

17.6

89

27.2

59

18.6

39

36.1

39

34.5

299

Virusc

0

0.0

25

12.2

4

1.2

23

7.2

0

0.0

4

3.6

56

Mixedd

0

0.0

41

20.0

5

1.5

101

31.8

1

0.9

39

34.5

187

Negative findinge

95

58.6

68

33.2

183

56.0

96

30.2

58

53.7

24

21.2

524

Not testedf

29

17.9

3

1.4

42

12.8

2

0.6

9

8.4

0

0.0

85

Total

162

 

205

 

327

 

318

 

108

 

113

 

1233g

Abbreviations: TCM traditional Chinese medicine, WM Western medicine.

aIdentified through sputum or blood culture.

bIdentified through serum antibody or antigen test.

cIdentified through nasopharyngeal secretion antibody test or serum antibody test.

dInfection of two or more pathogens.

eNone identified through above tests.

fNot go through any etiological tests.

gMissing 65 cases of etiological tests results.

Treatment

Prevalence of intravenous antibiotic use in TCM and WM hospitals were 595 (99.3%) and 699 (98.6%), respectively, in records of children with pneumonia, with no significant difference (p = 0.34) (Table 4). However, the patterns of antibiotic use in TCM and WM hospitals were different. In TCM hospitals, antibiotics used were by frequency, macrolides, third generation cephalosporins, second generation cephalosporins, first generation cephalosporins, and β-lactamases. In WM hospitals, antibiotics used were by frequency, third generation cephalosporins, macrolides, second generation cephalosporins, β-lactamases, and first generation cephalosporins. Oral antibiotic use was significantly higher in WM hospitals (243 cases) than in TCM hospitals (65 cases) (p < 0.01). Chinese herbal injections were applied more frequently in TCM hospitals (491 cases, 82.1%) than in WM hospitals (212 cases, 30.3%) (p < 0.01). Use of Chinese proprietary medicines was similar across both types of hospitals (40.0% in TCM hospitals versus 42.2% in WM hospitals) (p = 0.37). The most frequently used herbal injections in TCM hospitals were Tanreqing, Danshen, Shengmai, and Xiyanping. While in WM hospitals they were Xiyanping and Xixinnao. In addition, 312 (52.2%) children were treated with herbal decoctions consisting of several herbs and 320 (53.5%) underwent external application of herbs.
Table 4

Treatment modalities in children hospitalised with pneumonia in the sampled hospitals

Medications

TCM hospitals

WM hospitals

χ2

P value

Number (n = 598)

%

Number (n = 700)

%

Antibiotics

      

  IV

595

99.5

699

99.9

-

0.34

  Macrolide

383

64.0

357

51.0

22.40

<0.01

  Third generation cephalosporin

186

31.1

390

55.7

79.13

<0.01

  Second generation cephalosporin

114

19.1

186

26.6

10.23

0.01

  First generation cephalosporin

98

16.4

89

12.7

3.53

0.06

  β-lactamase inhibitor

73

12.2

101

14.4

1.37

0.24

  Oral

65

10.9

243

34.7

101.32

<0.01

  Inhalationa

8a

1.3

0

0.0

-

<0.01

Antiviral drugs

      

  IV

10

1.7

77

11.0

44.87

<0.01

  Inhalation

41

6.9

43

6.1

0.27

0.60

β2 agonist

      

  Oral

205

34.3

216

30.9

1.73

0.19

  Inhalation

342

57.2

205

29.3

102.99

<0.01

Steroids

      

  IV

61

10.2

39

5.6

9.72

0.02

  Inhalation

188

31.4

129

18.4

29.57

<0.01

TCM treatment

      

  Chinese herbal extract injection

491

82.1

212

30.3

348.83

<0.01

  Chinese patent drugs

239

40.0

297

42.2

0.81

0.37

  Decoction

312

52.2

16

2.3

425.03

<0.01

  External methods

320

53.5

179

25.6

106.39

<0.01

Abbreviations: TCM traditional Chinese medicine, WM Western medicine.

a7 cases of gentamicin and 1case of erythrocin.

Clinical outcome at discharge

Eight hundred and eighteen cases were identified as clinically cured when discharged, a cure rate of 63.0% (Tables 5 and 6). Relief rates of fever, though, were significantly higher in TCM hospitals than in WM hospitals (OR = 3.5, 95% CI: 2.0 ~ 6.3, p < 0.01), but the time from onset of fever to complete resolution was similar in two types of hospitals (p = 0.013). Relief rates of cough and rales were significantly higher in TCM hospitals than in WM hospitals (OR = 2.6, 95% CI 2.6 ~ 3.2, OR = 4.1, 95% CI: 3.0 ~ 5.7, p < 0.01), but duration from onset to complete relief of cough and rales was longer in TCM than in WM hospitals (p < 0.01). Relief rates of phlegm were significantly higher in WM hospitals than in TCM hospitals (OR = 0.6, 95% CI 0.4 ~ 0.8, p < 0.01), and the time from onset of phlegm to complete resolution was longer in TCM than in WM hospitals (p < 0.01). There was no difference in relief rates of tachypnea (OR = 1.2, 95%CI: 0.5 ~ 2.8, p = 0.66) between two types of hospitals. The data of dyspnea did not match criteria of logistic regression. The results were adjusted for gender, age, pathogen and previous medical history listed in Table 1 and Table 3. Relief rates of rales were significantly higher (OR = 7.2, 95% CI 4.8 ~ 10.9) after adjustification. Duration of hospitalization was significantly longer in WM hospitals than in TCM hospitals (p < 0.01). There was marked difference in treatment efficacy between TCM hospitals and WM hospitals (OR = 9.8, 95% CI 7.3 ~ 12.9, p < 0.01).
Table 5

Symptom outcomes of children hospitalised with pneumonia in the sampled hospitals

 

TCM hospitals

WM hospitals

ORb

95% CIc

Pd

AORe

95% CIf

APg

Fever

        

  Cured

433

524

      

  Failed

15

64

3.5

2.0 ~ 6.3

<0.01

3.7

2.0 ~ 6.8

<0.01

Cough

        

  Cured

325

220

      

  Failed

269

470

2.6

2.6 ~ 3.2

<0.01

2.5

2.0 ~ 3.1

<0.01

Phlegm

        

  Cured

291

247

      

  Failed

209

104

0.6

0.4 ~ 0.8

<0.01

0.4

0.2 ~ 0.6

<0.01

Tachypnea

        

  Cured

179

78

      

  Failed

17

9

1.2

0.5 ~ 2.8

0.7

1.7

0.5 ~ 6.0

0.4

Rales

        

  Cured

446

335

      

  Failed

61

190

4.1

3.0 ~ 5.7

<0.01

7.2

4.8 ~ 10.9

<0.01

Symptoms

        

  Cured

524

294

      

  Improved

72

403

      

  Faileda

2

3

9.8

7.3 ~ 12.9

<0.01

9.7

7.3 ~ 13.1

<0.01

a5 cases experienced no improvement of symptoms and were voluntarily discharged.

bodds ratio.

codds ratio confidence interval.

dP value.

eThe odds ratio of adjusted gender, age, pathogen, previous medical history.

fThe odds ratio confidence interval of adjusted gender, age, pathogen, previous medical history.

gThe P value of adjusted gender, age, pathogen, previous medical history.

Table 6

Overall clinical outcome of children hospitalised with pneumonia in the sampled hospitals

Symptoms

Outcome at dischargea

χ2x

P

Time from admission to recovery from symptoms (days)

Z

P

TCM hospitals (n/N)

WM hospitals (n/N)

TCM hospitals

WM hospitals

Feverb

433/448

565/588

0.23

0.63

53.2 ± 51.5

63.5 ± 63.0

−2.49

0.01

Cough

325/594

220/690

68.10

<0.01

9.5 ± 4.9

8.2 ± 3.5

−3.01

<0.01

Phlegmc

292/498

244/344

13.30

<0.01

6.5 ± 9.1

3.1 ± 5.4

−7.55

<0.01

Tachypnea

179/196

78/87

0.20

0.65

2.4 ± 2.0

3.4 ± 2.3

−4.67

<0.01

Dyspnea

24/24

69/70

-

1.00

3.3 ± 2.2

3.8 ± 2.5

−0.68

0.50

Rales

37/507

174/525

105.92

<0.01

1.4 ± 1.6

1.7 ± 1.9

−9.07

<0.01

Duration of hospital stay

-

-

-

-

8.7 ± 5.8

9.0 ± 3.8

−3.44

<0.01

Abbreviations: TCM traditional Chinese medicine, WM Western medicine.

aSymptom almost disappeared.

bTime of onset of fever up to admission recorded in hours.

cIncludes white sputum, yellow sputum, or difficult to expectorate sputum.

Discussion

This cross-sectional study is the first of its kind investigating the clinical profile of children hospitalized with community-acquired pneumonia in China. Our sample was drawn from children of different ages admitted with pneumonia to 13 hospitals across eight eastern cities in China. The consecutive hospital charts covered four seasons. We believe the information gathered reflects current clinical characteristics of childhood CAP in China.

Children with histories of respiratory disease or allergy accounted for 41.0% of the 1298 cases. The percentage (12.4%) of childhood pneumonia cases with histories of recurrent pneumonia was high, similar to study findings elsewhere [18, 19]. Ozdemir and colleagues [20] in their sample of 595 hospitalized children found that 62 (10.4%) patients had histories of recurrent pneumonia. In our study, 10.2% of admitted children had recurrent upper respiratory tract infection (RURTI). Risk factors for RURTI are known to be atopy (allergy), daycare attendance, tobacco smoke or air pollution exposure, among others [21]. Such correlations for our sample need further corroboration.

In our study, pneumonia patients with atopic condition were common. Percentages of children with histories of eczema, asthma, or allergic rhinitis were 10.0%, 4.1%, and 4.3%, respectively. Bronchial pneumonia was a complication of all asthma cases. There were also cases of undiagnosed asthma among patients with recurrent pneumonia. This seems to concur with other authors’ findings. For example, Ozdemir and colleagues [20] reported that 30.6% of pneumonia inpatients had histories of asthma. Youn and Lee [22] found that history of asthma might increase the risk of pneumonia caused by Mycoplasma pneumoniae. Our study found that onset of childhood pneumonia is closely associated with medical history, in particular with respiratory or atopic conditions. Therefore, attention should be focused on such children and preventive measures applied such as immunization [23, 24] and educating families about avoiding contact with allergens and other triggers.

Significant difference existed between TCM and WM hospitals in the presenting symptoms and signs at admission. The World Health Organization’s (WHO) guideline on the management of childhood pneumonia [25] has been widely adopted in developing countries. The guideline suggests that cough and dyspnea present high sensitivity and specificity as main indicators for pediatric pneumonia diagnosis. However, in China dyspnea is rarely applied to diagnose mild pediatric pneumonia because though respiratory rate is increased, it is still within normal range, especially in very young children. Instead, cough and auscultatory findings are more commonly used. In our study, the prevalence of cough at admission was similar between TCM hospitals and WM hospitals. These data are concordant with WHO data [25]. Although there was significant difference between the two types of hospitals regarding other symptoms and signs, a large proportion of children presented with fever and rales.

Duration of symptoms and signs in children before admission in WM hospitals was markedly longer than in children in TCM hospitals. We suspect that the two types of hospitals differ in regard to criteria for admission (such as severity of disease), ability of the family to afford hospitalization, or bed availability. Further studies are required to explore relevant factors that influence hospital intake.

With the growing use of antibiotics in China, incidence of childhood bacterial pneumonia stabilized and declined between 1985 and 2008 [8]. But pneumonia caused by other pathogens increased, especially respiratory syncytial virus and mixed bacterial and viral infections. As elsewhere in the world, China has seen a rise in pneumonia caused by M pneumoniae in school-age children [26, 27]. Our study showed that M pneumoniae accounted for 23.0% of all cases and was highest in preschool children, who comprised 30.8% of all M pneumoniae cases. Our previous randomised controlled trial [11] found that M pneumoniae pneumonia showed highest prevalence in preschool children, accounting for 43.6% of all cases. Studies in some countries, such as Korea, also found that M pneumoniae pneumonia was prevalent in 4 to 6 year-old children, reaching almost 60% [22, 27, 28]. Current evidence indicates that M pneumoniae pneumonia is appearing in increasingly younger children.

In our study, mixed pathogen infection was found in 14.4% of cases and was highest in preschool children at 22.0%. Some authors report that age is related closely to pathogen type in mixed infections, with M pneumoniae as one of the most common pathogens in such infections [2931]. Our study found mixed infections with M pneumoniae accounting for the highest proportion of such infections of which the majority of cases were preschool children.

Pediatric pneumonia can be considered a syndrome [32], thus comprehensive treatment and management are needed [10, 23]. In China, treatment of childhood pneumonia involves myriad WM and TCM methods. In both types of hospitals, common modalities include intravenous injection of antibiotics and intravenous injection of Chinese herbal preparations. External therapy is also widely applied, mainly inhalation therapy in WM hospitals and external application of herbal medicine and cupping therapy in TCM hospitals.

Antibiotics were the mainstay of childhood pneumonia treatment in the 13 hospitals included in our study. Other authors [3335] have reported that macrolides are more effective in shortening disease duration and reducing severity of M pneumoniae pneumonia compared with other antibiotics. Macrolides are also more effective for a wide range of bacterial pathogens [33, 35], which might be one of the reasons that in our study this class of antibiotics was widely used. However, macrolide resistance is a serious worldwide problem [3638]. Suzuki and colleagues [35] reported that of 96 cases of M pneumoniae pneumonia in Yamagata, Japan, 83.0% were identified as macrolide-resistant. Cephalosporins are widely used for treating childhood pneumonia in China. In fact, there has been inappropriate use and abuse of cephalosporins in China [39, 40], where cephalosporins use was higher than Northern England (36% in 542 children [41]). In cases of pneumonia caused by M pneumoniae, cephalosporins are ineffective. In our study, among 1298 cases, 576 patients (44.4%) received third generation cephalosporins and 300 patients (23.1%) received second generation cephalosporins. In general, selection of antibiotics in China has not been based on drug sensitivity testing but on clinician experience or medical insurance policy. With the promulgation by the Chinese Ministry of Health in August 2012 of regulations on the rational use of antibiotics [42], it is hoped that arbitrary administration of antibiotics, especially for childhood pneumonia, will be curbed.

In the modernization drive, TCM injection in China was popularly used in both types of hospitals. There was a lot of literatures [4350] reported that the effect of combined therapy with these injections plus conventional treatment for pediatric pneumonia was better than conventional treatment alone. Therefore, this could be explained as the reasons for their use. However, the adverse reaction must not to be overlooked as herb-drug interaction might exist. According to literature review, most common adverse reactions of Chinese herbal injections were rash and pruritus, diarrhea, or vomiting [51]. The high incidence of adverse reaction may be related to physiological characteristics of children or irrational use and preparing technology. Thus, appropriate measures should be taken to reduce the occurrence of such events.

Length of hospitalization in our study was found to be shorter in TCM hospitals than that in WM hospitals. This may be related to the mildness of disease or turnover in ward beds as required by local health policy. Another possible reason for shorter hospital stay in TCM hospitals is that treatment that combines TCM and WM based on syndrome differentiation is more effective than WM alone in resolving symptoms, thus reducing disease duration. In our study, fewer patients in TCM hospitals than in WM hospitals were reported as having symptoms, such as cough and sputum, at discharge. Shorter hospital stay in TCM hospitals may also be attributed to lower emphasis on strict adherence to discharge guidelines. For example, patients deemed “cured” and who are therefore discharged in TCM hospitals would in WM hospitals be considered only “improved” and have a longer length of stay.

Treatment approach differs between TCM and WM. TCM treatment is based on syndrome differentiation in which individual signs and symptoms are evaluated and treated together holistically instead of the solitary symptom approach of WM. With pneumonia, TCM considers sputum an essential sign as part of the overall syndrome. Therefore, TCM clinicians focus on the presence of sputum by observation of signs or airway suctioning. Treatment is rendered based on the quantity, quality, and color of sputum. WM clinicians, on the other hand, view these finer points of sputum as less important, and assess and treat based simply on whether or not sputum is present. Indeed in our study, description of sputum was lacking in most of the cases in WM hospitals. TCM hospitals showed an advantage in relieving rales. This may be because more external therapy, such as herbal medicine application and cupping, was used in TCM hospitals.

The disappearance of rales may be associated with pathogen and previous medical history. Some pathogen induced pneumonia such as M pneumoniae pneumonia need more time to absorb inflammation, so rales usually lasted longer than the others. Children with recurrent respiratory disease were more susceptible to illness. Once they got pneumonia, they need more time to recovery than health children. Thus, we should pay more attention to such children and prevent them from pneumonia.

Another difference between TCM and WM hospitals in terms of treatment approach is aetiology diagnosis. As mentioned, TCM practitioners render treatment based on syndrome differentiation. As such, we suspect pathogen testing plays a less important role in guiding treatment than for WM practitioners. This may be the reason that in our study, pathogen testing was ordered less frequently in TCM hospitals than in WM hospitals. (National guidelines in China recommend pathogen testing for CAP [1, 10]).

Criteria for evaluating therapeutic effectiveness in childhood pneumonia between TCM and WM hospitals were about the same. But weighting of individual parameters was different. For example, based on guidelines [1, 10], fever normalization is foremost for assessing whether pneumonia is only improved or cured. Improvement of symptoms, such as cough, is used to evaluate the status of disease (cured, clinical improvement, or failed). Clinical cure of disease is based on the disappearance of rales (moist rales) through auscultation.

A limitation of our study is that this was a cross-sectional study. Our data was extracted from medical records at 13 hospitals. Although we exercised quality control to the best of our ability during the extraction process, still the quality and scope of the study were dependent on these records.

Another limitation is that patients in this study were drawn from eight cities in China. The data are not representative of childhood CAP elsewhere in China, especially non-urban areas where healthcare seeking behavior and delivery practices vary widely from those in metropolitan locales.

Conclusions

Our study presents the clinical characteristics of hospitalized children with pneumonia in eight eastern cities in China. Intravenous use of antibiotics was highly prevalent regardless of causative organism. As expected, intravenous use of herbal injections was more prevalent in TCM hospitals than in WM hospitals. This study finds that the basic characteristics of children with pneumonia admitted to the included TCM and WM hospitals are similar. Universal issues, such as inconsistent application of diagnostic criteria and treatment based on clinical experience instead of current guidelines, exist in both types of hospitals. Awareness of these and other shortcomings and taking necessary measures to overcome will help clinicians in China improve their care practice for children with pneumonia.

Notes

Declarations

Acknowledgements

This study was supported by the project grant of the national TCM clinical research base key diseases-pediatric pneumonia (JDZX2012098). JP Liu and ZL Liu were partially supported by the grants of the 111 Project (No.B08006), the National Technological Platform of Clinical Evaluation and Research for New Herbal Medicinal Products (2011ZX09302-006-01-03(5)).

The authors gratefully acknowledge the assistance of Nissi S. Wang, MSc, in editing the manuscript and Liqiong Wang, MSc, in statistical analysis.

Authors’ Affiliations

(1)
Department of Pediatrics, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine
(2)
Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
(3)
Department of Respiratory Medicine, Beijing Children’s Hospital
(4)
First Teaching Hospital of Tianjin University of TCM
(5)
Department of Respiratory Medicine, Dalian Children’s Hospital
(6)
Department of Respiratory Medicine, Guangzhou Women and Children’s Medical Center
(7)
Department of Pediatric Respiratory Medicine, Shengjing Hospital of China Medical University
(8)
Department of Pediatric Respiratory Medicine, Nanjing Children’ Hospital
(9)
Department of Pediatric Respiratory Medicine, Children’s Hospital of Fudan University
(10)
Department of Pediatric Respiratory Medicine, Tianjin Children’s Hospital
(11)
Department of Pediatrics, Jiangsu Provincial Hospital of TCM
(12)
Department of Pediatrics, Affiliated Hospital of Shandong University of TCM
(13)
Department of Pediatrics, Longhua Hospital of Shanghai University of TCM
(14)
Department of Pediatrics, Affiliated Hospital of Guangzhou University of TCM

References

  1. Hu YM, Jiang ZF: Zhu Futang Textbook of Pediatrics. 2002, Beijing: People’s Medical Publishing House, 1199-1200. 7Google Scholar
  2. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H: Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008, 86: 408-416. 10.2471/BLT.07.048769.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H: Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ. 2004, 82: 895-903.PubMedGoogle Scholar
  4. Nair H, Simões EAF, Rudan I, Gessner BD, Azziz-Baumgartner E, Zhang JSF, Feikin DR, Mackenzie GA, Moïsi JC, Roca A, Baggett HC, Zaman SMA, Singleton RJ, Lucero MG, Chandran A, Gentile A, Cohen C, Krishnan A, Bhutta ZQA, Arguedas A, Clara AW, Andrade AL, Ope M, Ruvinsky RO, Hortal M, McCracken JP, Madhi SA, Bruce N, Qazi SA, Morris SS: Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis. Lancet. 2013, 9875: 1380-1390.View ArticleGoogle Scholar
  5. UNICEF/WHO: Pneumonia: the forgotten killer of children. Wkly Epidemiol Rec. 2008, 83: 1-16.Google Scholar
  6. Williams BG, Gouws E, Boschi-Pinto C, Bryce J, Dye C: Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis. 2002, 2: 25-32. 10.1016/S1473-3099(01)00170-0.View ArticlePubMedGoogle Scholar
  7. Yan FY, Feng SH, Li S: Analysis of 2581 hospitalised pediatric patients. Modern Prev Med. 2008, 35: 388-389.Google Scholar
  8. Guan XH, Silk BJ, Li W, Fleischauer AT, Xing X, Jiang X, Yu H, Olsen SJ, Cohen AL: Pneumonia incidence and mortality in mainland China: systematic review of Chinese and English literature, 1985–2008. PLoS One. 2010, 5 (7): e11721-10.1371/journal.pone.0011721. doi:10.1371/journal.pone.0011721View ArticlePubMedPubMed CentralGoogle Scholar
  9. Wang L, Wang Y, Jin S, Wu Z, Chin DP, Koplan JP, Wilson ME: Emergence and control of infectious diseases in China. Lancet. 2008, 372: 1598-1605. 10.1016/S0140-6736(08)61365-3.View ArticlePubMedGoogle Scholar
  10. Chinese Society of Pediatrics, Pediatric Respiratory Group: Guidelines for the management of community-acquired childhood pneumonia. Chin J Pediatr. 2007, 45: 83-90.Google Scholar
  11. Wang XF, Dong D, Liu F, Yu JE, Lü YX, Jiang ZY, Xu YJ, Xiao XT, Liu XD, Ma GX: Pneumonia in children:analysis of common etiology in 840 cases. Chin J Pract Pediatr. 2005, 20: 239-241.Google Scholar
  12. Wang LN, Wang XF, Yuan XF, Li YN, Gao SB, Jiang ZY, Hong LJ, Zhang W, Hu XY, Liu XF, Wang MQ, Li WW, Xu YJ, Li LX, Yang Y: Research of TCM clinical validation scheme on children’s pneumonia with “wind and heat blocking the lung syndrome” and “phlegm-heat obstructing the lung syndrome” by multi-center randomized controlled study. Chin Pediatr Integr Tradit West Med. 2010, 2: 386-391.Google Scholar
  13. Cui ZZ, Chen HX, Huang Y: A study of myoplasma infection in 366 cases of children’s community acquired pneumonia. Chin Med. 2010, 5: 71-72.Google Scholar
  14. Yao KH, Wang LB, Zhao GM, Zheng TJ, Deng L, Zhao RZ, Deng QL, Hu YH, Yu SJ, Shen XZ, Yang YH: Surveillance of serotype distribution of Streptococcus pneumonia isolated from children with pneumonia in children’s hospitals located in Beijing, Shanghai, Guangzhou and Shenzhen. Chin J Evid Based Pediatr. 2008, 3: 426-432.Google Scholar
  15. State Administration of Traditional Chinese Medicine of the People’s Republic of China: Criteria of diagnosis and therapeutic effect of diseases and syndromes in traditional Chinese medicine (ZY/T001.1 ~ 001.9-94). 1994, Nanjing: Nanjing University Press, 78-Google Scholar
  16. Ministry of Health of the People’s Republic of China: Criteria of diagnosis and therapeutic effect of pediatric disease. 1997, Shanghai: Shanghai Medical University Press, 12-127.Google Scholar
  17. Chinese Medical Association, Chinese Society of Pediatrics, Pediatric Respiratory Group: Clinical understanding and principles of management of recurrent respiratory tract infections. Chin J Pediatr. 2008, 46: 108-110.Google Scholar
  18. Li HM, Jiang ZF, Jiang QB, Zhao SY: Underlying illnesses and diagnosis of recurrent pneumonia in children. Chin J Pract Pediatr. 2004, 19: 153-155.Google Scholar
  19. Owayed AF, Campbell DM, Wang EEL: Underlying causes of recurrent pneumonia in children. Arch Pediatr Adolesc Med. 2000, 154: 190-194. 10.1001/archpedi.154.2.190.View ArticlePubMedGoogle Scholar
  20. Ozdemir O, Sari S, Bakirtas A, Zorlu P, Ertan U: Underlying diseases of recurrent pneumonia in Turkish children. Turk J Med Sci. 2010, 40: 25-30.Google Scholar
  21. Ballow M, Adkinson NFJ, Adkinson NFJ, Bochner BS: Approach to the patient with recurrent infections. Middleton’s Allergy: Principles and Practice. Edited by: Busse WW, Holgate ST, Lemanske RFJr, Simons FER. 2008, Philadelphia, PA: Elsevier Mosby, 1405-1421. 7Google Scholar
  22. Youn YS, Lee KY: Mycoplasma pneumoniae pneumonia in children. Korean J Pediatr. 2012, 55: 42-47. 10.3345/kjp.2012.55.2.42.View ArticlePubMedPubMed CentralGoogle Scholar
  23. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH, Moore MR, St Peter SD, Stockwell JA, Swanson JT: The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of America. Clin Infect Dis. 2011, 53: e25-e76. 10.1093/cid/cir531.View ArticlePubMedGoogle Scholar
  24. British Thoracic Society of Standards of Care Committee: BTS guidelines for the management of community acquired pneumonia in childhood. Thorax. 2002, 57 (Suppl 1): i1-i24. doi:10.1136/thx.57.suppl_1.i1View ArticleGoogle Scholar
  25. World Health Organization: Technical bases for the WHO recommendations on the management of pneumonia in children at first level health facilities. 1991, Geneva, Switzerland: World Health OrganizationGoogle Scholar
  26. Chalker VJ, Stocki T, Litt D, Bermingham A, Watson J, Fleming DM, Harrison TG: Increased detection of Mycoplasma pneumoniae infection in children in England and Wales, October 2011 to January 2012. Euro Surveill. 2012, 17: i1-i5. pii = 20081. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20081.Google Scholar
  27. Youn YS, Lee KY, Hwang JY, Rhim JW, Kang JH, Lee JS, Kim JC: Difference of clinical features in childhood Mycoplasma pneumoniae pneumonia. BMC Pediatr. 2010, 10: 48-10.1186/1471-2431-10-48. doi:10.1186/1471-2431-10-48View ArticlePubMedPubMed CentralGoogle Scholar
  28. Eun BW, Kim NH, Choi EH, Lee HJ: Mycoplasma pneumoniae in Korean children: the epidemiology of pneumonia over an 18-year period. J Infect. 2008, 56: 326-331. 10.1016/j.jinf.2008.02.018.View ArticlePubMedGoogle Scholar
  29. Chen LL, Cheng YG, Chen ZM, Li SX, Li XJ, Wang YS: Mixed infections in children with Mycoplasma pneumoniae pneumonia. Chin J Pediatr. 2012, 50: 211-215.Google Scholar
  30. Numazaki K, Chiba S, Umetsu M, Tanaka T, Yoshimura H, Kuniya Y, Miura J, Adachi N, Ukae S, Mori T, Ueda D, Hotsubo T, Sato T: Etiological agents of lower respiratory tract infections in Japanese children. In Vivo. 2004, 18: 67-72.PubMedGoogle Scholar
  31. Tsolia MN, Psarras S, Bossios A, Audi H, Paldanius M, Gourgiotis D, Kallergi K, Kafetzis DA, Constantopoulos A, Papadopoulos NG: Etiology of community-acquired pneumonia in hospitalized school-age children: evidence for high prevalence of viral infections. Clin Infect Dis. 2004, 39: 681-686. 10.1086/422996.View ArticlePubMedGoogle Scholar
  32. Langley JM, Bradley JS: Defining pneumonia in critically ill infants and children. Pediatr Crit Care Med. 2005, 6 (Supp 3): 9-13.View ArticleGoogle Scholar
  33. Galova K, Sufliarska S, Kukova Z, Danisovicova A, Hrachova I, Grausova S, Marinova I, Krizan S, Stopkova K, Stahorska A, Durcanska K, Raskova J, Krupova I, Krcméry V: Multicenter randomized study of two once daily regimens in the initial management of community-acquired respiratory tract infections in 163 children: azithromycin versus ceftibuten. Chemotherapy. 1996, 42: 231-234. 10.1159/000239448.View ArticlePubMedGoogle Scholar
  34. Kabra SK, Lodha R, Pandey RM: Antibiotics for community acquired pneumonia in children. Cochrane Database Syst Rev. 2006, 3: CD004874Google Scholar
  35. Wang DM, Wang XH, Lu Q, Hong JG, Zhou YF: Clinical effectiveness and safety of azithromycin in the treatment of childhood pneumonia. Chin J Pract Pediatr. 2003, 18: 749-750.Google Scholar
  36. Bebear C: Editorial commentary: infections due to macrolide-resistant Mycoplasma pneumoniae: now what?. Clin Infect Dis. 2012, 39: 1650-1651.View ArticleGoogle Scholar
  37. Xin DL, Han X, Mi ZH: Macrolide resistance and molecular mechanisms in Mycoplasma pneumoniae. Chin J Lab Med. 2008, 31: 543-546.Google Scholar
  38. Suzuki Y, Itagaki T, Seto J, Kaneko A, Abiko C, Mizuta K, Matsuzaki Y: Community outbreak of macrolide-resistant Mycoplasma pneumoniae in Yamagata, Japan in 2009. Pediatr Infect Dis J. 2013, 32: 237-240.PubMedGoogle Scholar
  39. Ding H, Yang Y, Chen Y, Wang Y, Fan S, Shen X: Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr. 2008, 97: 100-104.View ArticlePubMedGoogle Scholar
  40. Huang FH, Lin Y, Zhou Y, Zhang CH, Xu X: Antibacterial use by line category in pediatric outpatient and emergency departments of a hospital: a survey. Chin J Nosocomiol. 2010, 20: 87-88.Google Scholar
  41. Elemraid MA, Rushton SP, Thomas MF, Spencer DA, Eastham KM, Gennery AR, Clark J, E. and North East of England Paediatric Respiratory Infection Study Group: Changing clinical practice: management of paediatric community-acquired pneumonia. J Eval Clin Pract. 2013, Available online: doi:10.1111/jep.12091.Google Scholar
  42. Xiao YH, Li LJ: Legislation of clinical antibiotic use in China. Lancet Infec Dis. 2013, 13: 189-191. 10.1016/S1473-3099(13)70011-2.View ArticleGoogle Scholar
  43. Wang XQ, Li H, Xiong NY, Zhu QH, Wang X, Zhang SL: Clinical and laboratory study on outcomes of Staphylococcus aureus pneumonia by three scenarios of treatment. Chin Rem Clin. 2010, 10: 741-743.Google Scholar
  44. Zhan HZ, Yan HX: Clinical observation of Tanreqing injection combined with azithromycin as sequential therapy for children with mycoplasma pneumonia. J Clin Pulm Med. 2013, 18: 1435-1436.Google Scholar
  45. Zhu ZW: The study of danshen injection in adjuvant treatment of infant bronchial pneumonia. Asia Pac Tradit Med. 2013, 9: 151-153.Google Scholar
  46. Zhang YL: Clinical observation of danshen injection combined with azithromycin in the treatment of children with mycoplasma pneumoniae pneumonia. Chin J Clin Ration Drug Use. 2013, 6: 24-25.Google Scholar
  47. Li XL, Huang BF: Efficacy observation on treating 68 cases of hold breath pneumonia by Xiyanping oxygen pump spray therapy. Clin J Chin Med. 2013, 5: 26-27.Google Scholar
  48. Wen JF, Wang ZX, Qu YH: Meta-analysis of xiyanping injection treatment for bronchial pneumonia. Pract Pharm Clin Rem. 2012, 15: 199-201.Google Scholar
  49. Jiao J: Observation on therapeutic effects of asarone with mechanical vibration sputum elimilations for brochopneumonia in children. J Paediatr Pharm. 2012, 18: 24-26.Google Scholar
  50. Yang QC, Wu DR, Mao W, Liu XS, Bao K, Lin QZ, Lu FH, Zou C, Li C: Chinese medical herbs for childhood pneumonia: a systematic review of effectiveness and safety. Evid Based Complement Alternat Med. 2013, Available online: doi:10.1155/2013/203845Google Scholar
  51. Zhang LX, Li M, Rong P, Ma R: Analysis and countermeasures of adverse drug reactions of traditional Chinese medicine injections in children. Chin J Chin Mater Med. 2012, 37: 2807-2809.Google Scholar
  52. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/13/367/prepub

Copyright

© Wang et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement