COMMENTARY

Do All Children Hospitalized With

Community-Acquired Pneumonia
Require Blood Cultures?

The 2011 pediatric community-acquired pneumonia (CAP) management guideline AUTHOR

Derek J. Williams, MD, MPH
released jointly by the Infectious Diseases Society of America and the Pediatric
Division of Hospital Medicine, Department of
Infectious Diseases Society recommends blood cultures for children with moderate Pediatrics, Vanderbilt University School of Medi-
to severe CAP requiring hospitalization.1 However, the study featured in this issue cine and the Monroe Carell Jr. Children’s Hospi-
of Hospital Pediatrics by Heine et al concludes otherwise, suggesting that a more tal at Vanderbilt, Nashville, Tennessee
www.hospitalpediatrics.org
restricted approach may be best.
doi:10.1542/hpeds.2013-0005
Address correspondence to Derek J. Williams,
The authors examined >300 children from a single institution with a primary diag-
MD, MPH, 1161 21st Ave South, CCC 5311 MCN,
nosis of pneumonia; 60% required hospitalization. Among all children with a blood Nashville, TN 37232. E-mail: Derek.williams@
culture obtained (n = 155 [47%]), the prevalence of true bacteremia was only 3% vanderbilt.edu

(n = 5 [3 Streptococcus pneumoniae, 1 each of Escherichia coli and Streptococcus HOSPITAL PEDIATRICS (ISSN Numbers: Print,
2154 - 1663; Online, 2154 - 1671).
pyogenes]), although just as many positive culture results were attributed to non-
Copyright © 2013 by the American Academy of
causative organisms (ie, contaminants). All 5 children with true bacteremia had Pediatrics
severe illness on presentation; all were hospitalized with radiographic evidence FINANCIAL DISCLOSURE: The author has
of parapneumonic effusion, and 4 required critical care admission. Given the low indicated he has no financial relationships
relevant to this article to disclose.
prevalence of documented bacteremia and the obvious illness severity among
those with bacteremia detected, the authors concluded a relative lack of clinical FUNDING: No external funding.

utility for routine blood cultures in children with CAP. Retrospectively comparing
clinical management against a local practice guideline that recommends more
restricted use of blood cultures (based on age, comorbid conditions, immuniza-
tion status, and illness severity), the authors noted that 45% of those with cultures
obtained were considered “low risk” for bacteremia; none of these children had
true bacteremia detected. Of course, it is difficult to estimate the true prevalence
of bacteremia because only one-half of children had cultures obtained, a limi-
tation acknowledged by the authors. Although the prevalence may be lower, it
almost certainly is not zero. It is possible that some children in the low-risk group
could have had detectable levels of bacteremia had cultures been performed.

The Infectious Diseases Society of America/Pediatric Infectious Diseases Society

guideline committee’s recommendation to obtain blood cultures among children
hospitalized with moderate to severe pneumonia was rated as a “strong recom-
mendation” but based on “low quality evidence.” One assumes this means that
although the committee was generally in support of the recommendation (due to
strong potential benefits with little perceived risks), it was supported by a paucity
of evidence. The major benefit of obtaining blood cultures in children with pneumonia
centers on the potential to identify a causative organism. Isolating a pathogen
allows the clinician to provide targeted antimicrobial therapy while minimizing the
use of unnecessary broad-spectrum agents. For instance, a child presenting to our
institution with pneumonia complicated by a sizeable parapneumonic effusion is

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 HOSPITAL Pediatrics ® AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
likely to receive broad-spectrum anti-
microbial agents targeting resistant
pneumococci (eg, third-generation
cephalosporin) as well as methicillin-
resistant Staphylococcus aureus (eg,
clindamycin or vancomycin). Without an
isolated pathogen, this empirical regi-
men is typically continued for the dura-
tion of the treatment course. However,
identifying the causative pathogen often
results in narrowing of therapy to a single
agent. This strategy is important not only
for providing the most effective treat-
ment of that child but also for helping to
slow the spread of antimicrobial resis-
tance so that effective therapies remain
for other children. Culture data are also
used for national disease surveillance,
such as the Centers for Disease Control
and Prevention’s Active Bacterial Core
surveillance program. This program
uses culture data collected from clinical
laboratories to provide epidemiologic
information (eg, trends in disease inci-
dence and antimicrobial resistance pat-
terns) for selected bacterial pathogens.2
Thus, culture data have the potential to
be enormously beneficial.
Unfortunately, 1 fact has prevented us
from realizing the enormity of the per-
ceived benefi ts outlined here: blood
culture results are rarely positive among
children with pneumonia. With the
notable exception of complicated pneu-
monia, most studies, including that of
Heine et al, report positivity rates of
<5% for blood cultures obtained among
children with pneumonia.3–8 Even when
culture results reveal a potential patho-
gen, the proportion identified as con-
taminants often approaches or even
exceeds that of true pathogens. Con-
taminated cultures may lead to unnec-
essary switching of antibiotics (often
to broader-spectrum therapy), may
prolong hospitalization, and certainly
contribute to increased costs. 9 As a
178 | VOLUME 3 • ISSUE 2 www.hospitalpediatrics.org
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result, as long as the potential of cul-
ture contamination remains a signifi-
cant threat, obtaining blood cultures
is not without “risk.” Results are also
mixed as to whether positive culture
results for true pathogens lead to sub-
stantive changes in management. 5,8
Empirical use of narrow-spectrum anti-
microbial therapy (eg, ampicillin) as
outlined in the Infectious Diseases
Society of America/Pediatric Infectious
Diseases Society guideline provides
effective therapy for the vast majority
of cases of uncomplicated bacterial
CAP. Consequently, adherence to the
guideline further reduces the prospect
that culture data will influence man-
agement in the absence of severe or
complicated disease.
Pros and cons notwithstanding, blood
cultures remain our best and often only
practical hope of identifying a bacterial
pathogen in children with pneumonia.
Sputum cultures are often helpful in
adults and even older children (and
should be performed), although the
majority of children presenting with
pneumonia are <5 years of age and
cannot reliably produce an adequate
sample. A number of novel diagnostic
techniques that are under development,
including polymerase chain reaction
and rapid antigen detection tests,10
hopefully will improve detection of
bacterial pathogens from blood and
other sterile sites; however, these tests
are currently not widely available.
So, what’s a hospitalist to do? Is it
possible to improve the clinical utility
of blood cultures? The work by Heine
et al highlights 1 example of how we
might do that: target a population of
children at higher risk for bacteremia
and other complications (ie, those at
risk for more severe disease). Unfor tu-
nately, few data are available to guide
clinicians on how to define moderate
or even severe disease. Although it
seems reasonable to presume that
disease severity among children hos-
pitalized with pneumonia should never
be categorized as mild, clinical expe-
rience tells us otherwise. Thus, per-
haps hospitalization alone is not the
best predictor of disease severity.
Studies also suggest that clinical judg-
ment alone is often a poor predictor
of future outcomes.11 Objective mea-
sures of severity have proven useful
in adults with pneumonia. A number
of prognostic scoring systems have
been developed that predict mortality
among adults with pneumonia based
on a varying number of demographic
and clinical factors. Two well-known
examples include the Pneumonia
Severity Index and the CURB-65
score.12,13 Both have been extensively
validated and demonstrate clinical util-
ity, including assisting clinicians with
site-of-care decisions and antimicro-
bial selection.14,15 Regrettably, disease-
specific severity measures have yet to
be developed for pediatric pneumonia,
a critical research need highlighted by
the guideline committee. Similar to adult
pneumonia, such measures could prove
useful for clinicians caring for children
by improving risk assessments and
outcome prediction, and in the case of
blood cultures, improving their clinical
utility.
Although few single studies are suf-
ficient to change clinical practice or
guideline recommendations, the cur-
rent study is a good example of the type
of research needed to inform the next
iteration of the guideline. The forth-
coming Etiology of Pneumonia in the
Community (EPIC) Study,16 a population-
based surveillance of pneumonia
hospitalizations among children in 3 US
cities, should also provide much-needed
 HOSPITAL Pediatrics ®
data on pneumonia epidemiology in
the conjugate vaccine era, including
microbiologic etiology, as well as the
prevalence and risk factors for severe
outcomes, including bacteremia. In
addition, strategies to standardize clini-
cal management, through local practice
guidelines as suggested by Heine et al
as well as quality improvement efforts
(eg, initiatives to reduce blood culture
contaminants) are also critically impor-
tant for optimizing care and outcomes.
These are all areas in which hospitalists
can and should lead.
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Do All Children Hospitalized With Community-Acquired Pneumonia Require
Blood Cultures?
Derek J. Williams
Hospital Pediatrics 2013;3;177
DOI: 10.1542/hpeds.2013-0005

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Do All Children Hospitalized With Community-Acquired Pneumonia Require
Blood Cultures?
Derek J. Williams
Hospital Pediatrics 2013;3;177
DOI: 10.1542/hpeds.2013-0005

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://hosppeds.aappublications.org/content/3/2/177

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