Characteristics of children readmitted with severe pneumonia in Kenyan hospitals

Background Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities. Methods We conducted a retrospective cohort study including children aged ≥2 months to 14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 22 primary referral hospitals in Kenya. Severe pneumonia was defined using the World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality. Results Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% confidence interval (CI) 10.62 to 11.47) were readmitted. Re-admission was independently associated with age (12-59 months vs 2-11 months: adjusted odds ratio (aOR) 1.70, 95% confidence interval (CI) 1.55 to 1.88; >5 years vs 2-11 months: aOR 1.86, 95% CI 1.55 to 2.23), malnutrition (weight for age z-score (WAZ) -2SD: aOR 2.03, 95%1.83 to 2.28); WAZ -2 to -3 SD vs WAZ> -2SD: aOR 1.37, 95% CI 1.20 to 1.56) and presence of a concurrent neurological disorder (aOR 4.04, 95% CI 1.57 to 10.42) . Chest radiography was ordered more frequently among those readmitted (540/2,274 vs 3,102/18,329, p<0.001). Readmitted patients were more likely to receive second-line antibiotics (808/2,256 vs 5,538/18,173 p<0.001), TB medication (69/2,256 vs 298/18,173 p<0.001), salbutamol (530/2,256 vs 3,707/18,173 p=0.003), and prednisolone (157/2,256 vs 764/18,173 p<0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.94, 95% CI 0.82-1.07). Age (12-59 months vs 2-11 months: aHR 0.62, 95% 0.57 to 0.67), female sex (aHR 1.23, 95% 1.14 to 1.33), malnutrition (WAZ -2SD: aHR 1.90 95% CI 1.74 to 2.08); WAZ -2 to -3 SD vs WAZ> -2SD: aHR 1.48, 95% CI 1.32 to 1.65), incomplete vaccination (aHR 1.43, 95% CI 1.16 to 1.75), and anaemia (aHR 2.16, 95% CI 1.90 to 2.45) were independently associated with mortality. Conclusions Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality.