Chest X-ray prevents excess antibiotic use in childhood pneumonia

By Helen Albert

Use of a chest X-ray as well as traditional clinical parameters to diagnose childhood pneumonia can prevent overdiagnosis and unnecessary use of antibiotics, say researchers.

"Despite the prevalence of pneumonia in children, there is still significant debate regarding the optimal method for diagnosing this condition," write Deena Rachel Zimmerman (Terem Emergency Medical Services, Jerusalem, Israel) and colleagues.

Guidelines from many developing countries do not recommend routine X-ray for diagnosis of pediatric pneumonia, due to a common lack of resources, and instead suggest use of clinical symptoms such as hypoxia, tachypnea, rales, wheeze, and dyspnea for diagnosis.

Despite having access to X-ray equipment, similar guidelines are in place in many developed countries, suggesting use of radiologic examination only in atypical circumstances.

Based on the hypothesis that these guidelines may lead to significant overdiagnosis of the condition as well as overprescription of antibiotics, Zimmerman and team followed up 278 children aged 2.5 years on average who were admitted to five urgent care clinics in Jerusalem during 2007 to 2008 with symptoms of pneumonia. All the children had chest X-rays carried out to check the suspected diagnosis and 90 had radiologic signs of pneumonia.

For all combinations of symptoms except fever and wheeze, which increased the risk for pneumonia diagnosis on X-ray a significant 2.52-fold, less than half the children had radiologically confirmed pneumonia.

On multivariate analysis only fever was positively predictive of pneumonia, increasing the odds by over 13-fold, whereas wheezing was negatively predictive. No other symptoms, alone or in combination, predicted pneumonia diagnosis on X-ray.

"Clinical assessment alone leads to many children being treated in the absence of radiologically confirmed pneumonia," write the authors in Pediatric Emergency Care.

"In an era when the emphasis is on the more judicious use of antibiotics to reduce antibiotic resistance, we must reconsider the need to obtain radiological confirmation of pneumonia, at least where X-ray services are readily available," they conclude.

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