{"doi":"10.1002/ppul.26943","title":"Radiographic uncertainty and outcomes of children with lower respiratory tract infections","abstract":"Community-acquired pneumonia (CAP) is a common and significant infection among children, leading to a substantial number of emergency department (ED) encounters and hospitalizations. More than two-thirds of children with CAP or lower respiratory tract infections (LRTI) concerning for CAP have mild disease, defined as being well enough to be managed as an outpatient.1 Distinguishing between presumed bacterial and viral etiologies of LRTI, including bronchiolitis, is challenging because of overlapping symptoms and signs. The determination of whether a patient has a bacterial or viral LRTI influences antibiotic decision-making. The degree of diagnostic uncertainty may impact outcomes such as return visit and quality of life. National guidelines for pediatric CAP advises against the regular use antimicrobial therapy for preschool-aged children with CAP managed as outpatients.2 Nevertheless, approximately 80% of children diagnosed with CAP in the ED are provided with antibiotics.3 Among children with radiographic pneumonia, only a minority (15%) are proven to have a bacterial etiology.4 Chest radiography (CXR) is frequently obtained to gauge the likelihood of CAP among children with LRTI. Diagnostic uncertainty can be measured by the level of confidence in a CAP diagnosis from the radiologist's interpretation. While prior work demonstrates the limited ability of CXRs to diagnose CAP and distinguish viral vs bacterial CAP,4 CXRs are commonly obtained in children with LRTIs to diagnose CAP. It remains unknown if radiographic uncertainty, and its associated antibiotic use, impacts postdischarge outcomes for children with LRTI who present to the ED. We sought to (1) evaluate the association of CXR interpretations (e.g., atelectasis, atelectasis vs. pneumonia, pneumonia) with antibiotic prescribing among children with LRTI and postdischarge outcomes, (2) evaluate the association of antibiotic prescription with postdischarge outcomes, and (3) evaluate the association of antibiotic prescription with subsequent care utilization and quality of life. We performed a secondary analysis of data from Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine (CARPE DIEM), a prospective cohort study of children with suspected pneumonia.1 This study was approved by our local Institutional Review Board. The CARPE DIEM study included a sample of children (3 months to 18 years) with signs and symptoms of a LRTI who presented to the Cincinnati Children's Hospital Medical Center ED and had a CXR obtained for clinically suspected CAP between July 2013 to December 2017. The sample excluded children with medical complexity or who had a recent hospitalization (≤14 days before the index ED visit) for pneumonia. Parents were contacted by telephone within 7–12 days of their ED discharge by a trained research coordinator to evaluate postdischarge outcomes including their child's clinical course, impact of the disease on caregivers, and additional medical care obtained. We limited our sample to children who did not have another concomitant condition that would typically require antibiotic use (e.g., urinary tract infections, otitis media, skin/soft tissue infections), who were discharged from the ED (i.e., mild pneumonia), and who had postdischarge outcome data available. All CXRs were evaluated by a clinical radiologist as a part of routine care. These interpretations were classified into one of four categories by the CARPE DIEM study PI (TAF): normal/no atelectasis or pneumonia, definite/probable atelectasis, atelectasis versus pneumonia, and definite/probable pneumonia. Postdischarge follow-up outcomes included impact of the child's diagnosis on child and parental quality of life, patient symptoms, new or changes to diagnoses, and changes to antibiotic utilization. Descriptive results were stratified by radiologist interpretation. We evaluated our postdischarge outcomes stratified by the provision of antibiotics amo","journal":"Pediatric Pulmonology","year":2024,"id":476403,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":2,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9616,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2024-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":922920,"name":"Jillian M. Cotter","orcid":"0000-0002-7978-9045","position":1,"is_corresponding":false},{"id":317044,"name":"Nidhya Navanandan","orcid":"0000-0002-5058-058X","position":2,"is_corresponding":false},{"id":465181,"name":"Lilliam Ambroggio","orcid":"0000-0002-6242-607X","position":3,"is_corresponding":false},{"id":747412,"name":"Kenneth A. Michelson","orcid":"0000-0003-1763-7262","position":4,"is_corresponding":false},{"id":465180,"name":"Todd A. Florin","orcid":"0000-0002-4387-2605","position":5,"is_corresponding":false},{"id":283190,"name":"Sriram Ramgopal","orcid":"0000-0002-1389-5726","position":0,"is_corresponding":true}],"reference_count":8,"raw_metadata":null,"created_at":"2026-07-19T02:06:25.428435Z","pmid":"38415980","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}