Impact of HIV-1 status on the radiological presentation and clinical outcome of children with WHO defined community-acquired severe pneumonia

Aims

We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa.

Methods

Of 425 children aged between 3 and 59?months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48?h after enrolment or deterioration within 14?days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status.

Results

82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12?months of age was significantly worse in HIV‐1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p?=?0.002), while HIV‐1 infected and uninfected children aged ?12?months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher “other consolidates/infiltrates” than “endpoints for consolidation” in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<0.036).

Conclusions

The WHO standard treatment guideline for severe pneumonia is inadequate for HIV‐1 infected infants. The increased prevalence of “other consolidates/infiltrates” among HIV‐1 infected children who failed standard treatment supports the addition of co‐trimoxazole to WHO standard treatment.The global incidence of acute lower respiratory infections (ALRI) is 154 million new episodes per annum with 7–13% of patients requiring hospitalisation.¹ ALRI causes 1.9 million deaths among children annually, accounting for over a fifth of all deaths in Africa.² The World Health Organization (WHO) response to this burden of disease has been the introduction of standard case management guidelines. The benefit of this intervention in HIV non‐endemic areas was recently shown in a meta‐analysis where pneumonia related mortality among neonates, infants and children between 0 and 4?years of age was reduced by 27%, 27% and 20%, respectively.³ The HIV‐1 epidemic has altered the prevalence, presentation and outcome of ALRI.The role of chest radiographs in the management of children with ALRI has had mixed reviews. Some studies suggest that radiographs help confirm the diagnosis of pneumonia in only 36% of episodes, help change the diagnosis in approximately 20% of cases and result in a change in treatment plan in 34%.^4,5 The chest radiographic features of HIV associated pneumonia in childhood have scarcely been reported. Sivit et al described the radiological features of Pneumocystis jiroveci (carinii) pneumonia in infancy (PCP) and found that a ground glass interstitial appearance with pulmonary air cysts and thoracic air leak syndromes were common.⁶ The WHO has defined radiological criteria to assist in the determination of bacterial pneumonia in their vaccine trials on streptococcal pneumonia.⁷ While several studies have described the aetiology of HIV related pneumonia in children, none have evaluated the differences in radiology and response rates to standard WHO therapy.We therefore performed a prospective nested substudy of a larger international pneumonia study⁸ to define the radiological features on admission and clinical response at day 14 of HIV‐1 infected and exposed children with WHO defined severe pneumonia treated with either oral amoxicillin or injectable penicillin.