Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

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

BMC Complementary and Alternative Medicine volume 13, Article number: 367 (2013) Cite this article

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.

Peer Review reports

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 [2–4], 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 [11–14] 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
Full size table

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
Full size table

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
Full size table

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
Full size table

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
Full size table
Table 6 Overall clinical outcome of children hospitalised with pneumonia in the sampled hospitals
Full size table

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 [29–31]. 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 [33–35] 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 [36–38]. 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 [43–50] 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.

References

  1. Hu YM, Jiang ZF: Zhu Futang Textbook of Pediatrics. 2002, Beijing: People’s Medical Publishing House, 1199-1200. 7

    Google 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.

    Article  PubMed  PubMed Central  Google 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.

    PubMed  Google 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.

    Article  Google 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.

    Article  PubMed  Google 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.0011721

    Article  PubMed  PubMed Central  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  Google 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. 7

    Google 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.

    Article  CAS  PubMed  PubMed Central  Google 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.

    Article  PubMed  Google 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.i1

    Article  Google 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 Organization

    Google 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:10.1186/1471-2431-10-48

    Article  PubMed  PubMed Central  Google 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.

    Article  PubMed  Google 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.

    PubMed  Google 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.

    Article  CAS  PubMed  Google Scholar 

  32. Langley JM, Bradley JS: Defining pneumonia in critically ill infants and children. Pediatr Crit Care Med. 2005, 6 (Supp 3): 9-13.

    Article  Google 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.

    Article  CAS  PubMed  Google Scholar 

  34. Kabra SK, Lodha R, Pandey RM: Antibiotics for community acquired pneumonia in children. Cochrane Database Syst Rev. 2006, 3: CD004874

    Google 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.

    Article  Google Scholar 

  37. Xin DL, Han X, Mi ZH: Macrolide resistance and molecular mechanisms in Mycoplasma pneumoniae. Chin J Lab Med. 2008, 31: 543-546.

    CAS  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.

    PubMed  Google 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.

    Article  CAS  PubMed  Google 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.

    Article  Google 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.

    CAS  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.

    CAS  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:10.1155/2013/203845

    Google 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 

Pre-publication history

Download references

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.

Author information

Author notes

    Authors and Affiliations

    1. Department of Pediatrics, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, 33 Beiling Street, Huanggu District, Shenyang, Liaoning, 110032, China

      Xue-Feng Wang, Zhen-Qi Wu & Zi Wang

    2. Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, 11 Beisanhuan Dong Road, Chaoyang District, Beijing, 100029, China

      Jian-Ping Liu & Zhao-Lan Liu

    3. Department of Respiratory Medicine, Beijing Children’s Hospital, 56 Nanlishi Road, Xicheng District, Beijing, 100045, China

      Kun-Ling Shen & Ying-Hui Hu

    4. First Teaching Hospital of Tianjin University of TCM, 314 Anshan Xi Road, Nankai District, Tianjin, 300193, China

      Rong Ma & Xin-Min Li

    5. Department of Respiratory Medicine, Dalian Children’s Hospital, 154 Zhongshan Road, Xigang District, Dalian, Liaoning, 116012, China

      Zhen-Ze Cui & Yan Huang

    6. Department of Respiratory Medicine, Guangzhou Women and Children’s Medical Center, 318 Renminzhong Road, Yuexiu District, Guangzhou, Guangdong, 510623, China

      Li Deng & Chun-Hui He

    7. Department of Pediatric Respiratory Medicine, Shengjing Hospital of China Medical University, 36 Sanhao Street, Heping District, Shenyang, Liaoning, 110004, China

      Yun-Xiao Shang & Han Zhang

    8. Department of Pediatric Respiratory Medicine, Nanjing Children’ Hospital, 72 Guangzhou Road, Nanjing, Jiangsu, 210008, China

      De-Yu Zhao

    9. Department of Pediatric Respiratory Medicine, Children’s Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China

      Li-Bo Wang

    10. Department of Pediatric Respiratory Medicine, Tianjin Children’s Hospital, 225 Machang Road, Hexi District, Tianjin, 300074, China

      Li-Ya Wan

    11. Department of Pediatrics, Jiangsu Provincial Hospital of TCM, 155 Hanzhong Road, Nanjing, Jiangsu, 210029, China

      Yi-Qiu Sun

    12. Department of Pediatrics, Affiliated Hospital of Shandong University of TCM, 42 Wenhua Xi Road, Jinan, Shandong, 250011, China

      Yan-Ning Li

    13. Department of Pediatrics, Longhua Hospital of Shanghai University of TCM, 725 South Wanping Road, Shanghai, 200032, China

      Zhi-Yan Jiang & Yong-Hong Jiang

    14. Department of Pediatrics, Affiliated Hospital of Guangzhou University of TCM, 16 Baiyun Jichang Road, Guangzhou, Guangdong, 510405, China

      Hua Xu & Hua Liu

    Authors
    1. Xue-Feng Wang
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Jian-Ping Liu
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Kun-Ling Shen
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Rong Ma
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Zhen-Ze Cui
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Li Deng
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Yun-Xiao Shang
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. De-Yu Zhao
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Li-Bo Wang
      View author publications

      You can also search for this author in PubMed Google Scholar

    10. Li-Ya Wan
      View author publications

      You can also search for this author in PubMed Google Scholar

    11. Yi-Qiu Sun
      View author publications

      You can also search for this author in PubMed Google Scholar

    12. Yan-Ning Li
      View author publications

      You can also search for this author in PubMed Google Scholar

    13. Zhi-Yan Jiang
      View author publications

      You can also search for this author in PubMed Google Scholar

    14. Hua Xu
      View author publications

      You can also search for this author in PubMed Google Scholar

    15. Xin-Min Li
      View author publications

      You can also search for this author in PubMed Google Scholar

    16. Zhen-Qi Wu
      View author publications

      You can also search for this author in PubMed Google Scholar

    17. Zhao-Lan Liu
      View author publications

      You can also search for this author in PubMed Google Scholar

    18. Ying-Hui Hu
      View author publications

      You can also search for this author in PubMed Google Scholar

    19. Yan Huang
      View author publications

      You can also search for this author in PubMed Google Scholar

    20. Chun-Hui He
      View author publications

      You can also search for this author in PubMed Google Scholar

    21. Han Zhang
      View author publications

      You can also search for this author in PubMed Google Scholar

    22. Yong-Hong Jiang
      View author publications

      You can also search for this author in PubMed Google Scholar

    23. Hua Liu
      View author publications

      You can also search for this author in PubMed Google Scholar

    24. Zi Wang
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding authors

    Correspondence to Xue-Feng Wang or Jian-Ping Liu.

    Additional information

    Competing interests

    The authors declare that they have no competing interests.

    Authors’ contributions

    WXF designed and revised the manuscript and organized the study. LJP designed, revised the manuscript and provided methodology perspectives. Other authors including SKL, MR, CZZ, DL, SYX, ZDY, WLB, WLY, SYQ, LYN, JZY, XH, LXM, WZQ, HYH, HY, HCH, ZH, JYH and LH contributed to implementation of the survey, LZL and WZ were responsible for data analyses. All authors read and approved the final manuscript.

    Xue-Feng Wang, Jian-Ping Liu contributed equally to this work.

    Authors’ original submitted files for images

    Rights and permissions

    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.

    Reprints and permissions

    About this article

    Cite this article

    Wang, XF., Liu, JP., Shen, KL. et al. A cross-sectional study of the clinical characteristics of hospitalized children with community-acquired pneumonia in eight eastern cities in China. BMC Complement Altern Med 13, 367 (2013). https://doi.org/10.1186/1472-6882-13-367

    Download citation

    • Received:

    • Accepted:

    • Published:

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

    Keywords

    BMC Complementary Medicine and Therapies

    ISSN: 2662-7671

    Contact us