Necrotizing Pneumonia and Bronchopleural Fistula in Children: The Use of Chest CT Total Severity Score to Predict BPF formation

PURPOSE: Bronchopleural fistula (BPF) is a serious complication of necrotizing pneumonia (NP) in children, yet risk factors for its development are unclear. This study aims to determine the occurrence, clinical outcomes, and potential risk factors for the development of a BPF among children with NP. METHODS: A retrospective chart review including children admitted with NP was performed at a single center over a 15-year period (2008-2023). Annual rates of NP and the odds of developing a BPF were analyzed. Demographics, clinical features, outcomes, and the Chest CT total severity score (TSS) were also analyzed and compared between patients with BPF and those without. RESULTS: The number of NP cases increased annually by 6% (OR: 1.16, 95% CI: 1.01-1.12). Among 114 NP cases, 26 (23%) developed a BPF, and the odds of developing a BPF did not change over time (OR: 1.04, 95% CI: 0.94-1.15). Patients with a BPF experienced prolonged hospitalizations and chest tube requirements and were also more likely to require some form of respiratory support. MRSA was found to be the most common pathogen in NP patients both with and without BPF (27%). The CT TSS was found to be an independent predictor for the development of BPF (OR 1.46, p< 0.001). CONCLUSION: Admissions with NP increased over 15 years while the odds of BPF development remained stable. Greater parenchymal involvement on chest CT, quantified by the TSS, was independently associated with BPF development and may provide a tool for early risk stratification. MRSA was the most frequently identified pathogen in NP at our center. Prospective validation of CT-based severity in NP warrants further study.