Novel Pneumonia Risk Score (PRS)
Apply this calculator to children 3 months to 18 years of age in whom pneumonia is suspected.
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From the Creator
What led to the development of the pediatric Pneumonia Risk Score? Was there a particular clinical experience or patient encounter that inspired your research?
Respiratory illnesses account for a large number of outpatient and emergency department visits in children. Although many of these children have features commonly associated with pneumonia (fever, cough, crackles on auscultation), most will not have radiographic pneumonia. Ideally, we would prescribe antibiotics to the children who need them while avoiding overuse of antibiotics and chest radiography in the vast majority of children with viral illness. We wanted to derive a rule that would help clinicians avoid radiography and antibiotics in children at low risk of pneumonia.
How does this tool change clinical care for patients?
Currently, clinicians construct a mental model of a child’s risk of pneumonia based on their own gestalt and clinical experience. The pneumonia risk score (PRS) is superior to clinician gestalt in predicting radiographic pneumonia. It is straightforward to use and based on easy-to-obtain clinical information. The PRS will help clinicians make more informed decisions about which children warrant chest radiography or antibiotics.
What pearls, pitfalls and/or tips do you have for users of the Pneumonia Risk Score?
The Pneumonia Risk Score was derived and validated in children in whom the treating physician ordered a chest radiograph for suspicion of pneumonia. Applying the rule more broadly to all children with respiratory illness may result in increased use of chest radiography. Until we have more information about the rule’s performance, particularly among low-risk children in the outpatient setting, we would encourage clinicians to use the score only when pneumonia is already suspected.
It is also important to consider that while the PRS accurately predicts the presence or absence of radiographic pneumonia, many children with pneumonia have viral rather than bacterial infections. Thus, not all children with radiographic pneumonia require antibiotic therapy. However, chest radiography is a reasonable reference standard, so use of the PRS to identify children at low risk of radiographic pneumonia may reduce overall antibiotic use among children with respiratory illness.
What recommendations do you have for doctors and clinical staff once they have applied the Pneumonia Risk Score?
If the PRS recommends chest radiography and the radiograph is negative, clinicians should remember that a negative chest radiograph in children is excellent at ruling out pneumonia:
Lipsett SC, Monuteaux MC, Bachur RG, Finn N, Neuman MI. Negative chest radiography and risk of pneumonia. Pediatrics. 2018 Sep;142(3):e20180236.
Thus, well-appearing children whose chest radiographs do not show pneumonia should not generally be treated with antibiotics unless another bacterial source of infection is identified.
Are there any adjustments or updates you would make to the score based on new data or practice changes?
The next step is to validate the rule more broadly in both the emergency department and outpatient settings. We observed that the PRS performed equally well both with and without the inclusion of rales as a predictor. If this holds true when further externally validated, we may simplify the PRS by including only age, oxygen saturation, fever, and wheeze.
Any other research in the pipeline that you’re particularly excited about?
We plan to study how real-time use of the PRS impacts the use of chest radiography and antibiotic prescribing. We are also considering ways to incorporate ultrasound and viral testing into risk stratification models for predicting pediatric pneumonia.
About the Creator
Susan Lipsett, MD is an assistant professor of pediatrics and emergency medicine at Harvard Medical School. She also works in the emergency department at Boston Children’s Hospital. Dr. Lipsett’s primary research is focused on identifying the optimal diagnostic strategy for the identification of pediatric pneumonia, with the goal of reducing radiography and targeted antibiotic treatment for children with bacterial pneumonia.
About the Creator
Mark Neuman, MD, MPH is an associate professor of pediatrics and emergency medicine at Harvard Medical School. He also works in the emergency department at Boston Children’s Hospital. Dr. Neuman’s primary research is focused on identifying the optimal diagnostic strategy for the identification of pediatric pneumonia, with the goal of reducing radiography and targeted antibiotic treatment for children with bacterial pneumonia.