39 - Pneumonia Diagnosis Following Emergency Department Evaluation Among Children with Infectious Respiratory Symptoms

Community-acquired pneumonia (CAP) is often included in the differential diagnosis for children presenting to the emergency department (ED) with fever or respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED discharge for fever or respiratory illness.

Objective:

Among children discharged from the ED with a respiratory illness other than CAP, we sought to assess the incidence of CAP within 7 days and to describe the characteristics of these children.

Design/Methods: This is a retrospective cohort study of children 3 months to 18 years who were discharged from a pediatric ED with fever and/or respiratory illness between January 2011 and December 2021. To maximize the capture of all eligible visits, we included children who were seen at one of four hospital-affiliated primary care clinics and likely to use the study ED and included clinics for all study-relevant care. We excluded children who had a complex chronic condition, diagnosis of CAP, aspiration, or complicated pneumonia at the index visit, or a prior ED visit within the preceding 7 days. The primary outcome was the proportion of children diagnosed with CAP within 7 days of ED discharge, either in the ED or primary care setting. We also evaluated the location of diagnosis, use of CXR, antibiotic selection, and need for hospitalization.

Results: Of the 10,343 children discharged from the ED with fever and/or respiratory illness, 74 (0.7%, 95% CI: 0.6%, 0.9%) were diagnosed with CAP within 7 days. At the index ED visit, most (67.6%) had a history of asthma, and the most frequent presenting symptoms were cough (100%) and fever (45.9%) (Table 1). Wheezing (33.8%) and decreased breath sounds (14.9%) were common, and asthma-directed therapies were frequently (67.5%) administered. CXR was obtained in 13 (17.5%) patients at the index visit. The most common diagnoses coded at discharge were asthma (67.5%) and viral upper respiratory infection (60.8%), followed by bronchiolitis (16.2%), croup (2.7%), and gastroenteritis (1.4%). The median time to CAP diagnosis was 3 days (IQR 2-4 days). At revisit, CAP was diagnosed radiographically in 71.6% of cases and clinically in 28.4% (Table 2). At revisit, 16.2% and 4.1% of patients were admitted to the floor and intensive care unit respectively. 

Conclusion(s): CAP diagnosis after discharge from the ED with respiratory illness is rare. Future studies are needed to assess whether the characteristics of children with potentially delayed diagnosis of pneumonia differ from children with other respiratory conditions.