https://doi.org/10.4081/monaldi.2026.3885
Inflammatory biomarkers associated with surgical intervention in pediatric pneumococcal pneumonia: a five-year retrospective cohort study
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Accepted: 14 September 2026
Published: 8 October 2026
Streptococcus pneumoniae remains an important cause of community-acquired pneumonia (CAP) in children, with complicated cases sometimes requiring surgical intervention. This 5-year retrospective cohort study included 104 children aged 1 month to 18 years hospitalized with microbiologically confirmed pneumococcal pneumonia at a tertiary referral center. We evaluated clinical and laboratory factors associated with surgical intervention, with particular emphasis on the C-reactive protein-to-albumin ratio (CAR) and fibrinogen-to-albumin ratio (FAR). Complications occurred in 72.1% of patients, and 45.2% required surgical intervention. Children requiring surgery were younger, had a longer duration of symptoms before hospitalization, and showed greater alterations in inflammatory biomarkers. In multivariable analysis, CAR [adjusted odds ratio (aOR) 1.29 per unit increase; 95% confidence interval (CI) 1.12-1.52; p=0.001] and FAR (aOR 1.14 per unit increase; 95% CI 1.03-1.28; p=0.021) remained independently associated with surgical intervention in separate adjusted models. Receiver operating characteristic curve analysis showed moderate discriminatory ability for CAR [area under the curve (AUC) 0.714; 95% CI 0.615-0.813] and FAR (AUC 0.701; 95% CI 0.580-0.822), while serum albumin showed the highest overall AUC (0.783; 95% CI 0.695-0.871). FAR demonstrated significantly greater discrimination than fibrinogen alone (p=0.005), whereas CAR did not significantly outperform CRP or albumin. These findings suggest that CAR and FAR may provide complementary information for identifying children at increased risk of surgical intervention. However, their clinical utility should be interpreted alongside clinical and radiological findings and requires prospective multicenter validation.
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Chen L, Miao C, Chen Y, et al. Age-specific risk factors of severe pneumonia among pediatric patients hospitalized with community-acquired pneumonia. Ital J Pediatr 2021;47:100. DOI: https://doi.org/10.1186/s13052-021-01042-3
Alcoba G, Keitel K, Maspoli V, et al. A three-step diagnosis of pediatric pneumonia at the emergency department using clinical predictors, C-reactive protein, and pneumococcal PCR. Eur J Pediatr 2017;176:815-24. DOI: https://doi.org/10.1007/s00431-017-2913-0
Djelantik IGG, Bradford DG, Augustinus S, et al. Case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. J Trop Pediatr 2003;49:327-32. DOI: https://doi.org/10.1093/tropej/49.6.327
Tingting S, Chen C, Li H, et al. Risk factors for mortality from severe community-acquired pneumonia in hospitalized children transferred to the pediatric intensive care unit. Pediatr Neonatol 2020;61:577-83. DOI: https://doi.org/10.1016/j.pedneo.2020.06.005
Krenke K, Krawiec M, Kraj G, et al. Risk factors for local complications in children with community-acquired pneumonia. Clin Respir J 2018;12:253-61. DOI: https://doi.org/10.1111/crj.12524
Krishna Y, Shally A. Care-seeking behavior of families of north Indian children suffering from WHO-defined severe community-acquired pneumonia: a hospital-based prospective study. Cureus 2023;15:e41953.
Heinige P, Slováková L, Vočková J, et al. Impact of the COVID-19 pandemic on pediatric pneumonia outcomes: a five-year retrospective cohort study. Infect Drug Resist 2025;18:3511-25. DOI: https://doi.org/10.2147/IDR.S524238
Skouras V, Boultadakis E, Nikoulis D, et al. Prognostic value of C-reactive protein in parapneumonic effusions. Respirology 2012;17:308-14. DOI: https://doi.org/10.1111/j.1440-1843.2011.02078.x
Barak-Corren Y, Horovits Y, Erlichman M, Picard E. The prognostic value of C-reactive protein for children with pneumonia. Acta Paediatr 2021;110:970-6. DOI: https://doi.org/10.1111/apa.15580
Anam B, Raheel K, Stephanie T, Manuel C. A retrospective observational study of biomarker levels and severity assessment in pediatric community-acquired pneumonia. Medicine 2022;101:e30010. DOI: https://doi.org/10.1097/MD.0000000000030010
Agnello L, Belia C B, Di Gangi M, et al. Utility of serum procalcitonin and C-reactive protein in severity assessment of community-acquired pneumonia in children. Clin Biochem 2016;49:47-50. DOI: https://doi.org/10.1016/j.clinbiochem.2015.09.008
Okay ZU, Okay B, Hatipoglu HU, et al. The association of fibrinogen-albumin ratio and neutrophil-lymphocyte ratio with the severity of respiratory syncytial virus infection in children. Rev Inst Med Trop Sao Paulo 2024;66:e26.
Prais D, Kuzmenko E, Amir J, Harel L. Association of hypoalbuminemia with the presence and size of pleural effusion in children with pneumonia. Pediatrics 2008;121:e533-8. DOI: https://doi.org/10.1542/peds.2007-0317
Quinton LJ, Jones MR, Robson ME, Mizgerd JP. Mechanisms of the hepatic acute-phase response during bacterial pneumonia. Infect Immun 2009;77:2417-26. DOI: https://doi.org/10.1128/IAI.01300-08
Hiba A, Nina M, Joshua PG, Alejandro PA. Interleukin-6 promotes a sustained loss of endothelial barrier function via Janus kinase-mediated STAT3 phosphorylation and de novo protein synthesis. Am J Physiol Cell Physiol 2018;314:C589-602. DOI: https://doi.org/10.1152/ajpcell.00235.2017
Kang P, Kang W, Li Y, Li T. C-reactive protein-to-albumin ratio as an early biomarker to identify sepsis in neonates with pneumonia. Mediators Inflamm 2022;2022:4711018. DOI: https://doi.org/10.1155/2022/4711018
Gazi A, Tolga B, Göktuğ Ö, et al. Predictive value of PRISM-4, PIM-3, CRP, albumin, CRP/albumin ratio and lactate in critically ill children. Children 2023;10:1731. DOI: https://doi.org/10.3390/children10111731
Luo B, Sun M, Huo X, Wang Y. Two new inflammatory markers related to the CURB-65 score for disease severity in patients with community-acquired pneumonia: the hypersensitive C-reactive protein to albumin ratio and fibrinogen to albumin ratio. Open Life Scie 2021;16:84-91. DOI: https://doi.org/10.1515/biol-2021-0011
Cetin EU, Kurtkulagi O, Kamis F, et al. Advancing ICU mortality prediction in community-acquired pneumonia: combining fibrinogen-to-albumin ratio, CT severity score, PSI, and CURB-65. Biomol Biomed 2025;25:2083-91. DOI: https://doi.org/10.17305/bb.2025.12127
Yavuz S, Sherif A, Amirrad M, et al. A retrospective chart review of pediatric complicated community-acquired pneumonia: an experience in the Al Qassimi women and children hospital. Cureus 2022;14:e31119. DOI: https://doi.org/10.7759/cureus.31119
Valdivielso Martínez AI, Ramos Fernández JM, Pérez Frías J, Pérez DM. Influence of pneumococcal vaccination on the hospitalization of healthy pediatric patients due to typical community-acquired pneumonia. Int J Infect Dis 2020;98:194-9. DOI: https://doi.org/10.1016/j.ijid.2020.06.034
Ouldali N, Levy C, Minodier P, et al. Long-term association of 13-valent pneumococcal conjugate vaccine implementation with rates of community-acquired pneumonia in children. JAMA Pediatr 2019;173:362-70. DOI: https://doi.org/10.1001/jamapediatrics.2018.5273
Omid M, Rafieezadeh A, Talebi Anaraki K, et al. Comparing the efficacy of video assisted thoracoscopic surgery (VATS) vs intrapleural fibrinolytic therapy in children with pleural empyema. Pediatr Surg Int 2025;41:111. DOI: https://doi.org/10.1007/s00383-025-06006-w
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