Pediatric necrotizing pneumonia: Clinical features, microbiology, management, and outcomes in the tertiary center

Pediatric necrotizing pneumonia (PNP) is a rare but life-threatening complication of pneumonia. This study aimed to describe the clinical characteristics, paraclinical features, interventional treatments, and outcomes of PNP.

This was a retrospective study of PNP identified from hospitalized pneumonia cases at a tertiary center. Diagnosis was based on clinical presentation and imaging findings (CXR, ultrasound, or CT). Demographic, clinical, microbiological, laboratory, treatment, and outcome data were analyzed. Associations between clinical variables and outcomes were analyzed, with statistical significance set at p < 0.05.

Among 963 pediatric pneumonia hospitalizations, 15 patients (1.6%) were diagnosed with PNP, with a median age of 3 years. At admission, respiratory failure (SpO₂ < 94%) was present in 73.3% of patients. Respiratory support was administered to all patients and categorized according to the highest level of support received: invasive mechanical ventilation (40.0%), nasal continuous positive airway pressure (NCPAP) (33.3%), and low-flow oxygen via nasal cannula (26.7%); no patients received high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). No patients received corticosteroids or nebulized therapy before admission, whereas corticosteroids and nebulized therapy were administered during hospitalization in 13.3% and 20.0% of patients, respectively. Streptococcus pneumoniae was the predominant pathogen (53.3%), followed by Staphylococcus aureus (13.3%), and polymicrobial infections were identified in 46.7% of cases. PCR showed a higher pathogen detection rate than conventional culture (64.7% vs. 20.3%), particularly in respiratory and pleural specimens. Pleural effusion or empyema was identified in 73.3% of patients, and surgical intervention was required in 53.3%, primarily involving video-assisted thoracoscopic surgery (VATS) with pleural drainage. Initial antimicrobial therapy mainly consisted of β-lactams combined with vancomycin (60 mg/kg/day), with dose escalation to 80 mg/kg/day required in 60.0% of patients. Median durations of hospitalization and antibiotic therapy were 25 and 28 days, respectively. Overall survival was 93.3%, with one death attributed to septic shock and multi-organ failure. Elevated C-reactive protein was the only factor significantly associated with treatment outcome (p = 0.011).

Persistent fever, respiratory failure, or prolonged pneumonia after 72 h of antibiotics warrants evaluation for complications. Diagnosis relies on chest imaging (CXR, ultrasound, or CT), with prolonged intravenous antibiotics targeting Streptococcus pneumoniae and Staphylococcus aureus. Therapeutic drug monitoring is essential for vancomycin. Surgical intervention (debridement, pleural drainage) is indicated for persistent infection, significant pleural effusion, or extensive necrosis leading to uncontrolled sepsis or respiratory failure.