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Chest Radiographic Findings and Outcomes of Pneumonia Among Children in Botswana

Kelly, Matthew S. MD, MPH; Crotty, Eric J. MD; Rattan, Mantosh S. MD; Wirth, Kathleen E. ScD; Steenhoff, Andrew P. MB BCh, FCPaed; Cunningham, Coleen K. MD; Arscott-Mills, Tonya MD, MPH; Boiditswe, Sefelani BNSc; Chimfwembe, David MSc; David, Thuso MB BCh, FCPaed; Finalle, Rodney MD; Feemster, Kristen A. MD, MPH, MSHPR; Shah, Samir S. MD, MSCE

The Pediatric Infectious Disease Journal: March 2016 - Volume 35 - Issue 3 - p 257–262
doi: 10.1097/INF.0000000000000990
Original Studies

Background: Chest radiography is increasingly used to diagnose pneumonia in low-income and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings.

Methods: This is a hospital-based, prospective cohort study of children 1–23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by 2 pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes.

Results: From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months, and 58% were male. Chest radiograph classifications were primary endpoint pneumonia (35%), other infiltrate/abnormality (42%) or no significant pathology (22%). The prevalence of endpoint consolidation was higher in children with HIV infection (P = 0.0005), whereas endpoint pleural effusions were more frequent among children with moderate or severe malnutrition (P = 0.0003). Ninety-one (37%) children failed treatment, and 12 (4.8%) children died. Primary endpoint pneumonia was associated with an increased risk of treatment failure at 48 hours (P = 0.002), a requirement for more days of respiratory support (P = 0.002) and a longer length of stay (P = 0.0003) compared with no significant pathology. Primary endpoint pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P = 0.004).

Conclusions: Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.

From the *Botswana-UPenn Partnership, Gaborone, Botswana; Division of Global Health, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina; §Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Department of Epidemiology, Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; **Division of Infectious Diseases, The Children’s Hospital of Philadelphia; ††Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡‡Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana; §§Ministry of Health, Gaborone, Botswana; and ¶¶Division of Hospital Medicine and ‖‖Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Accepted for publication October 6, 2015.

This research was supported by an Early Career Award from the Thrasher Research Fund (to M.S.K.); by the Children’s Hospital of Philadelphia (to A.P.S. and K.A.F.) and Pincus Family Foundation and through core services and support from the Penn Center for AIDS Research, a National Institutes of Health (NIH)-funded program (P30-AI045008). Funding for this project was also made possible in part by a CIPHER grant from the International AIDS Society. The views expressed in this publication do not necessarily reflect the official policies of the International AIDS Society. C.K.C. received financial support from the NIH through the Duke Center for AIDS Research (P30-AI064518). M.S.K. received salary support from the NIH (T32-HD060558).

The other authors have no conflicts of interest to disclose.

Address for correspondence: Matthew S. Kelly, MD, MPH, Division of Pediatric Infectious Diseases, Duke University Medical Center, Box 3499, Durham, NC 27710. E-mail:

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