背景:肺炎是儿童发病和死亡的主要原因。重新入院可能意味着错过了护理机会或未诊断的合并症。
方法:我们进行了一项回顾性队列研究,包括2013年至2021年间在肯尼亚20家主要转诊医院网络中住院的2个月至14岁以上重症肺炎儿童。使用2013年世界卫生组织标准定义重症肺炎,再次入院的依据是个别患者病例记录的临床记录.我们估计了再入院的患病率,描述了临床管理实践,并对再入院和住院死亡率的危险因素进行建模。
结果:在20,603名被诊断为严重肺炎的儿童中,2,274(11.0%,95%CI10.6-11.5)再次入院。再次入院与年龄独立相关(12-59个月vs.2-11个月:调整后赔率比(aOR)1.70,1.54-1.87;>5年与2-11个月:aOR1.85,1.55-2.22),营养不良(体重-年龄-z-评分(WAZ)<-3SDvs.WAZ>-2SD:aOR2.05,1.84-2.29);WAZ-2至-3SD与WAZ>-2SD:aOR1.37,1.20-1.57),喘息(aOR1.17,1.03-1.33)和并发神经系统疾病的存在(aOR4.42,1.70-11.48)。在重新入院的人群中,胸部X线摄影的订购频率更高(540/2,274[23.7%]vs.3,102/18,329[16.9%],p<0.001)。再次入院的患者更频繁地接受二线抗生素(808/2,256[35.8%]vs.5,538/18,173[30.5%],p<0.001),结核病药物(69/2,256[3.1%]vs.298/18,173[1.6%],p<0.001),沙丁胺醇(530/2,256[23.5%]vs.3,707/18,173[20.4%],p=0.003),和泼尼松龙(157/2,256[7.0%]vs.764/18,173[4.2%],p<0.001)。首次重症肺炎患儿的住院死亡率为2,354/18,329(12.8%),再次入院患儿的住院死亡率为269/2,274(11.8%)(调整后风险比(aHR)0.93,95%CI0.82-1.07)。年龄(12-59个月vs.2-11个月:aHR0.62,0.57-0.67),男性(AHR0.81,0.75-0.88),营养不良(WAZ<-3SDvs.WAZ>-2SD:aHR1.87,1.71-2.05);WAZ-2至-3SD与WAZ>-2SD:AHR1.46,1.31-1.63),完成疫苗接种(AHR0.74,0.60-0.91),喘息(aHR0.87,0.78-0.98)和贫血(aHR2.14,1.89-2.43)与死亡率独立相关.
结论:重症肺炎患儿再次入院占肺炎住院和死亡的很大比例。需要进一步的研究来开发基于证据的筛查方法,案件管理,以及重症肺炎患儿的随访,优先考虑那些具有再入院和死亡率潜在风险因素的人。
BACKGROUND: Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities.
METHODS: We conducted a retrospective cohort study including children aged ≥ 2 months-14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 20 primary referral hospitals in Kenya. Severe pneumonia was defined using the 2013 World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality.
RESULTS: Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% CI 10.6-11.5) were readmitted. Re-admission was independently associated with age (12-59 months vs. 2-11 months: adjusted odds ratio (aOR) 1.70, 1.54-1.87; >5 years vs. 2-11 months: aOR 1.85, 1.55-2.22), malnutrition (weight-for-age-z-score (WAZ) <-3SD vs. WAZ> -2SD: aOR 2.05, 1.84-2.29); WAZ - 2 to -3 SD vs. WAZ> -2SD: aOR 1.37, 1.20-1.57), wheeze (aOR 1.17, 1.03-1.33) and presence of a concurrent neurological disorder (aOR 4.42, 1.70-11.48). Chest radiography was ordered more frequently among those readmitted (540/2,274 [23.7%] vs. 3,102/18,329 [16.9%], p < 0.001). Readmitted patients more frequently received second-line antibiotics (808/2,256 [35.8%] vs. 5,538/18,173 [30.5%], p < 0.001), TB medication (69/2,256 [3.1%] vs. 298/18,173 [1.6%], p < 0.001), salbutamol (530/2,256 [23.5%] vs. 3,707/18,173 [20.4%], p = 0.003), and prednisolone (157/2,256 [7.0%] vs. 764/18,173 [4.2%], p < 0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.93, 95% CI 0.82-1.07). Age (12-59 months vs. 2-11 months: aHR 0.62, 0.57-0.67), male sex (aHR 0.81, 0.75-0.88), malnutrition (WAZ <-3SD vs. WAZ >-2SD: aHR 1.87, 1.71-2.05); WAZ - 2 to -3 SD vs. WAZ >-2SD: aHR 1.46, 1.31-1.63), complete vaccination (aHR 0.74, 0.60-0.91), wheeze (aHR 0.87, 0.78-0.98) and anaemia (aHR 2.14, 1.89-2.43) were independently associated with mortality.
CONCLUSIONS: Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality.