Paediatrica Indonesiana

November 

VOLUME 51

NUMBER 6

Original Article

Validity of bacterial pneumonia score for predicting

bacteremia in children with pneumonia
Rosalia Theodosia Daten Beyeng1, Putu Siadi Purniti1, Roni Naning2

Abstract
Background Bacteremia in children with pneumonia reflects
a severe condition, with longer duration of hospital care and
potentially lethal complications. Early detection of bacteremia
in patients with pneumonia may reduce serious complications.
Few bacteremia screening tools have been widely used in chidren
with pneumonia. One of those tools is the bacterial pneumonia
VFRUH%36
Objective To assess the validity of the bacterial pneumonia score
for predicting bacteremia in pediatric patients with pneumonia.
Methods A diagnostic test was conducted on children aged 1 to
PRQWKVKRVSLWDOL]HGZLWKSQHXPRQLDIURP'HFHPEHUWR
$XJXVW6XEMHFWVZHUHFROOHFWHGFRQVHFXWLYHO\3QHXPRQLD
ZDV GLDJQRVHG XVLQJ WKH :RUOG +HDOWK 2UJDQL]DWLRQ :+2
FULWHULD6XEMHFWVXQGHUZHQWFRPSOHWHEORRGFRXQWVDQGEORRG
culture examinations at admission. Statistical analyses included
VHQVLWLYLW\VSHFLILFLW\SRVLWLYHDQGQHJDWLYHSUHGLFWLYHYDOXH339
139 SRVLWLYH DQG QHJDWLYH OLNHOLKRRG UDWLR 3/51/5 DQG
SRVWWHVWSUREDELOLW\
Results 2XUVWXG\LQFOXGHGFKLOGUHQ%DVHGRQ%36ZLWKD
FXWRIIVFRUHRIWKHVHQVLWLYLW\ZDVVSHFLILFLW\
339  139  3/5  1/5  DQG SRVWWHVW
SUREDELOLW\IRUGHWHFWLQJEDFWHUHPLDLQSHGLDWULFSQHXPRQLD
patients.
Conclusion %36 FDQ QRW EH XVHG IRU SUHGLFWLQJ EDFWHUHPLD
in pediatric patients with pneumonia. [Paediatr Indones.
2011;51:322-6].
Keywords: bacteremia, pneumonia, bacterial
pneumonia score, children

FFRUGLQJWRDUHSRUWE\WKH:+2
SQHXPRQLDLVWKHOHDGLQJFDXVHRIXQGHU
five mortality worldwide. More than
two million children die annually from
SQHXPRQLD7KUHHIRXUWKVRIWKHFDVHVZHUHIRXQGLQ
15 countries, among which Indonesia ranked sixth.1
)URP  WR  LQ ,QGRQHVLD DFXWH UHVSLUDWRU\
LQIHFWLRQ$5,FRQWULEXWHGWRRIDOOFDVHV
DQG  RI SHGLDWULF PRUWDOLW\ ZDV UHSRUWHGO\
due to pneumonia. The Infectious Diseases Society
of America and the American Thoracic Society
recommend blood culture evaluation on every
KRVSLWDOL]HG SQHXPRQLD FDVH3 The frequency of
EDFWHUHPLDLQSQHXPRQLDYDULHVIURPWRRI
all cases.4
The consequences of severe pneumonia with
bacteremia are high mortality rate and increased
length of hospital stay. Cultures of lung parenchyma,
the gold standard of diagnosis, are rarely done because
it is an invasive procedure. Unfortunately, blood

From the Department of Child Health, Medical School, Udayana

University, Sanglah Hospital, Denpasar, Bali,1*DGMDK0DGD8QLYHUVLW\
6DUGMLWR+RVSLWDO<RJ\DNDUWD, Indonesia.
Reprint requests to: Rosalia Theodosia Daten Beyeng, M.D, Department
of Child Health, Medical School, Udayana University, Sanglah Hospital,
Jl. 3XODX 1LDV 'HQSDVDU %DOL ,QGRQHVLD 7HO  )D[
(PDLOossy_ped@yahoo.com

322Paediatr Indones, Vol. 51, No. 6, November 2011

Rosalia T.D. Beyeng et al: Bacterial pneumonia score for predicting bacteremia in pneumonia

culture examination as the predictor of bacteremia

in children is also both invasive and expensive. The
EDFWHULDO SQHXPRQLD VFRUH %36 ZDV GHYHORSHG WR
predict the presence of bacteremia in patients with
pneumonia. The total score ranges from 3 to 15.5 The
REMHFWLYHRIRXUVWXG\ZDVWRDVVHVVWKHXVHIXOQHVVRI
%36 IRU SUHGLFWLQJ EDFWHUHPLD LQ SHGLDWULF SDWLHQWV
with pneumonia.

Methods
:H FRQGXFWHG RXU VWXG\ IURP 'HFHPEHU  WR
$XJXVW  DW WKH 'HSDUWPHQW RI &KLOG +HDOWK
8GD\DQD8QLYHUVLW\0HGLFDO6FKRRO6DQJODK+RVSLWDO
Denpasar, with the approval of the Ethics Study
Committee. Written, proxy consent was obtained from
VXEMHFWV SDUHQWV  :H LQFOXGHG FKLOGUHQ DJHG 
PRQWKVZKRZHUHKRVSLWDOL]HGZLWKSQHXPRQLD:H
excluded patients with hematologic malignancy, such
as leukemia and lymphoma, or those with blood culture
contaminants. The diagnosis of bacteremia was based
RQEORRGFXOWXUHV7KHPLQLPXPQXPEHURIVXEMHFWV
UHTXLUHGLQWKLVVWXG\ZDVFDOFXODWHGWREHEDVHGRQ
DFRQILGHQFHLQWHUYDORIVWDQGDUGGHYLDWLRQUDQJH
RIVHQVLWLYLW\DQGVSHFLILFLW\UDWHRIDQGUHSRUWHG
SUHYDOHQFHRIEDFWHUHPLDLQSQHXPRQLDRI6
6XEMHFWVZHUHHQUROOHGFRQVHFXWLYHO\3QHXPRQLD
GLDJQRVHVZHUHPDGHEDVHGRQWKH:+2FULWHULD
Bacteremia was considered to be the presence of
positive blood cultures, indicating the growth of either
SDWKRJHQLFRUQRQSDWKRJHQLFEDFWHULDFRQWDPLQDQW
LQ WKH EORRG  8SRQ DGPLVVLRQ VXEMHFWV DEVROXWH
neutrophil count and band percentage were obtained
XVLQJ D &HOO '\Q  DQDO\]HU DORQJ ZLWK D FKHVW
;UD\ DQG EORRG FXOWXUH  7KH ODWWHU ZDV SHUIRUPHG
ZLWKWKH%DFWDOHUWV'DQDO\]HU$[LOODU\WHPSHUDWXUH
was measured with a mercury thermometer for 3
WRPLQXWHV&KHVW;UD\VZHUHLQWHUSUHWHGE\WKH
pediatrician at the Respirology Division, Department
RI&KLOG+HDOWK8GD\DQD8QLYHUVLW\6DQJODK+RVSLWDO
Denpasar. Blood extraction was carried out by trained
nurses in the emergency room or pediatric ward. Blood
YROXPHFROOHFWHGZDVPORIZKLFKPOZDVXVHGIRU
a complete blood count and 3 ml for blood culture
examination with the standard aseptic technique.7
%36 LV D WRRO WR DVVHVV WKH ULVN RI EDFWHUHPLD
in children with pneumonia. It consists of five

SDUDPHWHUV DJH WHPSHUDWXUH SHUFHQWDJH RI EDQGV

DEVROXWH QHXWURSKLO FRXQW DQG ;UD\ VFRUHV 7KH
points attributed for each parameter are 3 points for
D[LOODU\WHPSHUDWXUHRIo&SRLQWVIRUDJH>
PRQWKV  SRLQWV IRU DEVROXWH QHXWURSKLO FRXQW RI
FHOOVPP3SRLQWIRUEDQGVRIDQG
WRSRLQWVIRUYDULRXVFKHVW;UD\ILQGLQJV7KH%36
RIRXUVXEMHFWVLVGHVFULEHGLQTable 1.
Table 1. Bacterial pneumonia score (BPS)
Predictors

Points

#ZKNNCT[VGORGTCVWTG0C
#IGOQPVJU
#DUQNWVGPGWVTQRJKNEQWPVOO3
$CPFU
Chest X-ray
+PNVTCVGU
YGNNFGPGF NQDWNCT UGIOGPVCN UWD UGIOGPVCN
(rounded)
RQQTN[FGPGFRCVEJ[
interstitial, peribronchial
.QECVKQP
Single lobe
/WNVKRNGNQDGUKPQPGQTDQVJNWPIUDWVYGNNFGPGF
CUKPNVTCVGU
/WNVKRNGUKVGURGTKJKNCTRQQTN[FGPGF
(NWKFKPRNGWTCNURCEG
Minimal blunting of angle
1DXKQWUWKF
#DUEGUUDWNNCGQTRPGWOCVQEGNG
Equivocal
Obvious
#VGNGEVCUKU
Sub-segmental (usually multiple sites)
Lobar, involving right medium lobe or right upper
lobe
Lobar, involving other lobes

3
2
2
1

2
1
-1
1
1
-1
1
2
1
2
-1
-1
0

Table 2. Baseline characteristics of subjects

Variables
Sex, male, n (%)
Nutritional status, n (%)
Good
Moderate
Poor
Overweight
Duration of fever, n (%)
< 2 days
FC[U
History of antibiotic use, n (%)
Yes
No
Leukocyte count, n (%)
<15,000/mm3
OO3
Median age, months, (interquartile range)

Numbers
(n=229)
136 (59.4)
117 (51.1)
101 (44.1)
1 (0.4)
10 (4.4)
105 (45.9)
124 (54.1)
94 (41.0)
135 (59.0)
173 (75.5)
56 (24.5)
11

Paediatr Indones, Vol. 51, No. 6, November 2011 323

Rosalia T.D. Beyeng et al: Bacterial pneumonia score for predicting bacteremia in pneumonia
Table 3.5GPUKVKXKV[URGEKEKV[NKMGNKJQQFTCVKQURTGFKEVKXGXCNWGUCPFRQUV
VGUVRTQDCDKNKV[QH$25
Parameters
Sensitivity, %
5RGEKEKV[
Positive likelihood ratio
Negative likelihood ratio
PPV, %
NPV, %
Post-test probability, %

Value
83.3
49.7
1.66
0.31
8.4
98.2
8.4

95% CI
55.2%to 95.3%
43.1% to 56.3%
1.25% to 2.21%
0.09 %to 1.20%
4.9% to 11.9%
96%to 99.8%
4.9% to 11.9%

&KLOGUHQDJHGPRQWKVKRVSLWDOL]HGZLWK
pneumonia
Inclusion criteria

Exclusion criteria

6XEMHFWV1 

%DFWHULDO3QHXPRQLD
6FRUH%36

%36
Q 

%36
Q 

Bacteremia
Q 

Bacteremia
Q 

Blood culture

Bacteremia
Q 

No Bacteremia
Q 

1 child ruled out due

to contaminated blood
culture

Figure 1. The recruitment scheme of study subjects

&ROOHFWHG GDWD ZDV DQDO\]HG WR GHWHUPLQH

VHQVLWLYLW\ VSHFLILFLW\ 339 139 3/5 1/5
SUHYDOHQFH DQG SRVWWHVW SUREDELOLW\ RI EDFWHULDO
SQHXPRQLDVFRUHRI7KH%36FXWRIISRLQWRI
was considered high risk for bacteremia.

Results
$WRWDORIFKLOGUHQZHUHLQFOXGHGLQRXUVWXG\2QH
VXEMHFWZDVH[FOXGHGGXHWRWKHSUHVHQFHRIFRQWDPLQDQW
EDFWHULDLQWKHFXOWXUH0RUHWKDQKDOIRIRXUVXEMHFWV
ZHUHPDOH)RUW\IRXUSHUFHQWRIWKHVXEMHFWV

324Paediatr Indones, Vol. 51, No. 6, November 2011

were moderately malnourished at the time of admission.

+LVWRU\RIDQWLELRWLFXVHZDVIRXQGLQVXEMHFWV
%DFWHUHPLDZDVIRXQGLQRIRXUVXEMHFWV7DEOH
VKRZVWKHEDVHOLQHFKDUDFWHULVWLFVRIVXEMHFWV
)URPVXEMHFWVZLWK%36EDFWHUHPLDZDV
IRXQGLQWHQVXEMHFWV)URPVXEMHFWVZLWK%36
EDFWHUHPLDZDVSUHVHQWLQRQO\WZRVXEMHFWVFigure 1
VKRZVWKHUHFUXLWPHQWVFKHPHRIVWXG\VXEMHFWV)DOVH
SRVLWLYHYDOXHZDV&,WR
DQGIDOVHQHJDWLYHYDOXHZDV&,
WRZKLOHWKH339ZDVDQGWKH139
ZDV7KHVHQVLWLYLW\VSHFLILFLW\DQGOLNHOLKRRG
UDWLRVRI%36DUHVKRZQLQTable 3.

Rosalia T.D. Beyeng et al: Bacterial pneumonia score for predicting bacteremia in pneumonia

Discussion
Blood culture has typically been used as the standard to
determine the presence of bacteremia.Microorganisms
are not always free to circulate in blood, since they
are often present intracellularly in lymphocytes or
macrophages. As microorganisms may stay in the blood
for a limited time, blood culture results may not always
give a positive result, even if a patient is bacteremic.
The positive rate of blood culture examinations
depends on the number of samples processed, and the
quantity, as well as virulence of microorganisms. The
smallest number of bacteria detectable in blood cultures
DUH  WR  EDFWHULD SHU PLOOLOLWHU RI EORRG YROXPH
Furthermore, blood culture media contains specific
inhibitory substances that may restrict the growth of
some bacteria, as well as other substances that can limit
the antibiotic effect in the blood. Each blood culture
PHGLXPVKRXOGPHHWWKHGLOXWHGEORRGPHGLXPUDWLR
RIWR7KHEORRGYROXPHUHTXLUHGIRURSWLPDO
bacterial growth is 1 ml per year of age for children
XQGHU\HDUV$OWHUQDWHO\RQHUHTXLUHVPORIEORRG
in neonates weighing <NJPOIRUFKLOGUHQXSWR
NJDQGPOIRUFKLOGUHQXSWRNJ7
Complete blood lab tests alone do not provide
significant sensitivity and specificity for the presence
RIEDFWHULDORUYLUDOLQIHFWLRQV3DUDPHWHUVUHTXLUHGDV
markers of bacterial infection include history of acute
fever, increased white blood cell counts, percentage
of bands, and absolute neutrophil counts. Increased
numbers of leukocytes itself can be a predictive factor
of serious bacterial infection. However, Isaacman
et al. found the numbers of white blood cells and
percentage of bands to be inaccurate for predicting
the incidence of bacteremia.
In a previous study, the prevalence of bacteremia
in patients with pneumonia was shown to vary from
WR4:HREVHUYHGEDFWHUHPLDLQRIRXU
VXEMHFWV $ SUHYLRXV 6DQJODK +RVSLWDO VWXG\ IRXQG
that bacteremia in pediatric pneumonia patients
ZDVThis difference may be attributed to the
GLIIHULQJEDVHOLQHFKDUDFWHULVWLFVRIVXEMHFWV$QRWKHU
difference is that we observed the use of antibiotics
prior to the blood culture examination in as many as
RIRXUVXEMHFWVZKLOHWKDWLQWKHSUHYLRXVVWXG\
ZDV  $ VXUYHLOODQFH VWXG\ LQ 7KDLODQG IURP
WRIRXQGWKHSUHYDOHQFHRIEDFWHUHPLDLQ
SQHXPRQLDSDWLHQWVWREHIURPDWRWDORI

patients. Again, the different results may be due to

GLIIHULQJVWXG\GHVLJQVDQGDJHUDQJHRIVXEMHFWV,Q
WKH7KDLVWXG\VXEMHFWVUDQJHGLQDJHIURPPRQWK
to 65 years.11
The sensitivity, specificity, likelihood ratios,
DQGSRVWWHVWSUREDELOLW\LQRXUVWXG\GLIIHUHGIURP
those reported by Moreno et al.5'LIIHUHQWVXEMHFWV
characteristics and definitions for bacteremia
diagnosis may explain the discrepancy. In their study,
antibiotics were administered after the blood culture
examination, and the diagnosis of bacteremia was
based not only on blood culture, but also on a positive
agglutination latex examination of pleural effusion.
A limitation of our study was the application of the
%36VFRUHFXWRIIRILQVSLWHRIWKHGLIIHUHQWEDVHOLQH
FKDUDFWHULVWLFV RI RXU VXEMHFWV FRPSDUHG WR SUHYLRXV
%36VWXGLHV0RUHRYHUZHGLGQRWFDOFXODWHWKHLQWHU
REVHUYHU DJUHHPHQW IRU FKHVW ;UD\ LQWHUSUHWDWLRQ
Blood culture as the available gold standard for
EDFWHUHPLDDOVRQHHGVIXUWKHULQGHSWKHYDOXDWLRQ,Q
FRQFOXVLRQ%36RIFDQQRWEHXVHGIRUSUHGLFWLQJ
bacteremia in pediatric patients with pneumonia.

Acknowledgments
:HH[SUHVVRXUKLJKHVWJUDWLWXGHWR3URI,*GH5DND:LGLDQD
MD for his help in constructing the methodology and statistical
analysis in this study. Our respect and gratitude is extended to all
patients and their families who participated in this study.

References
 8QLWHG 1DWLRQV &KLOGUHQV )XQG 81,&() DQG :RUOG
+HDOWK 2UJDQL]DWLRQ 3QHXPRQLD 7KH IRUJRWWHQ NLOOHU RI
FKLOGUHQ1HZ<RUN81,&():+2
 6LDGL3,VPRHGLMDQWR&.6UL5++5RELQ+6WUHSWRFRFFXV
SQHXPRQLDGL,QGRQHVLD,Q+DQLIDK26UL5++3DUWLQL
375LQL6HGLWRUV1DWLRQDOV\PSRVLXPRQLPPXQL]DWLRQ
nd HG-DNDUWD,'$,S
3. American Thoracic Society. Guidelines for the management
RIDGXOWVZLWKFRPPXQLW\DFTXLUHGSQHXPRQLD$P-5HVSU
&ULW&DUH0HG
 0HWHUVN\0/0D$%UDW]OHU':+RXFN303UHGLFWLQJ
EDFWHUHPLDLQSDWLHQWVZLWKFRPPXQLW\DFTXLUHGSQHXPR
nia. Am J Respr Crit &DUH0HG
 0RUHQR0.ULVKQDQ-$'XUHQ3)HUHUR)'HYHORSPHQWDQG
validation of a clinical prediction rule to distinguish bacterial

Paediatr Indones, Vol. 51, No. 6, November 2011 325

Rosalia T.D. Beyeng et al: Bacterial pneumonia score for predicting bacteremia in pneumonia
IURP YLUDO SQHXPRQLD LQ FKLOGUHQ 3HGLDWULF 3XOPRQRORJ\

 5HWQR 6 /DQGLD 6 0DNPXUL 6 HGLWRUV 3QHXPRQL
3URFHHGLQJVRIWKHFRQWLQXLQJHGXFDWLRQRIFKLOGKHDOWK
-XO\6XUDED\D,QGRQHVLD6XUDED\D%DGDQ3HQHUELW
)DNXOWDV.HGRNWHUDQ8QDLU
 )ODZV0/%DFWHUHPLDDQGVHSVLV,Q0DKRQ&5/HKPDQ'&
Manuselis G, editors. Text book of diagnostic microbiology.
4th ed. 0LVVRXUL:%6DXQGHUVS
 :HLVWHLQ 03 7RZQV 0/ 4XDUWH\ 60 7KH FOLQLFDO
VLJQLILFDQFH RI SRVLWLYH EORRG FXOWXUHV LQ WKH  D
prospective comprehensive evaluation of the microbiology,

326Paediatr Indones, Vol. 51, No. 6, November 2011

epidemiology, and outcome of bacteremia and fungiemia in

DGXOWV&OLQ,QIHFW'LV
 6WHSKHQV06PLWK:5+LWFKFRFN.&DQ\RXGLIIHUHQWLDWH
bacterial from viral pediatric infections based on the CBC?
)DPLO\3K\VLFLDQV,QTXLULHV1HWZRUN
 ,VDDFPDQ '- 6KXOWV - *URVV 7. 'DYLV 3+ +DUSHU 0
3UHGLFWRUVRIEDFWHUHPLDLQIHEULOHFKLOGUHQWRPRQWKV
RIDJH3HGLDWULFV
 3UDEGD36XWWKL-$QHN.7HHUDVDN&+HQU\&6RPVDN
7 HW DO (SLGHPLRORJ\ RI UDGLRJUDSKLFDOO\FRQILUPHG DQG
bacteremic pneumonia in Rural Thailand. Southeast Asian
-7URS0HG3XEOLF+HDOWK