Mark I Neuman, MD, MPH,
Assistant Professor of Pediatrics, Harvard
Medical School; Attending Physician, Division of Emergency
Medicine, Children's Hospital Boston
Nothing to disclose.
Specialty Editor(s)
Garry Wilkes, MBBS, FACEM,
Director of Emergency Medicine, Bunbury
Hospital, Western Australia; Medical Consultant, St John
Ambulance, WA Ambulance Service; Adjunct Associate Professor,
Edith Cowan University; Clinical Associate Professor, Rural
Clinical School, University of Western
Australia
Nothing to disclose.
Grace M Young, MD,
Associate Professor, Department of
Pediatrics, University of Maryland Medical
Center
Nothing to disclose.
John D Halamka, MD, MS,
Associate Professor of Medicine, Harvard
Medical School, Beth Israel Deaconess Medical Center; Chief
Information Officer, CareGroup Healthcare System and Harvard
Medical School; Attending Physician, Division of Emergency
Medicine, Beth Israel Deaconess Medical
Center
Nothing to disclose.
Mary L Windle, PharmD,
Adjunct Associate Professor, University of
Nebraska Medical Center College of Pharmacy; Pharmacy Editor,
eMedicine
Nothing to disclose.
Chief Editor
Richard G Bachur, MD,
Associate Professor of Pediatrics, Harvard
Medical School; Associate Chief and Fellowship Director,
Attending Physician, Division of Emergency Medicine,
Children's Hospital of Boston
Nothing to disclose.
Background
Pneumonia and other lower respiratory tract infections are the leading cause of death worldwide. Other respiratory tract diseases such as croup (laryngotracheobronchitis), bronchiolitis, and bronchitis are beyond the scope of this article and are not discussed further. Approximately 150 million new cases of pneumonia occur annually among children younger than 5 years worldwide, accounting for approximately 10-20 million hospitalizations.[1] Although the diagnosis is usually made on the basis of radiographic findings in developed countries, the World Health Organization (WHO) has defined pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate.[2, 3, 4, 5]
It is important for the physician to understand that the typical causes and presentations of pneumonia in infants and children are variable, depending upon the child's age and underlying medical condition.
Pneumonia results from inflammation of the alveolar space and may compromise air exchange. While often complicating other lower respiratory infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also occur via hematogenous spread or aspiration. Most commonly, this inflammation is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury (eg, near drowning).
Four stages of lobar pneumonia have been described. In the first stage, occurring within 24 hours of infection, the lung is characterized microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present. The stage of red hepatization (2-3 d), so called because of its similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli. In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of red cells, and hemosiderin. The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. Fibrinous inflammation may extend into the pleural space, causing a rub heard by auscultation, and it may lead to resolution or to organization and pleural adhesions.
Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents. The neutrophilic exudate is centered in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli.
In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages. The alveoli do not contain a significant exudate, but protein-rich hyaline membranes similar to those found in adult respiratory distress syndrome (ARDS) may line the alveolar spaces. Bacterial superinfection of viral pneumonia can also produce a mixed pattern of interstitial and alveolar airspace inflammation.
Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream. The varying degrees of immunocompromise in miliary tuberculosis, histoplasmosis, and coccidioidomycosis may manifest as granulomas with caseous necrosis to foci of necrosis. Miliary herpesvirus, cytomegalovirus, or varicella-zoster virus infection in severely immunocompromised patients results in numerous acute necrotizing hemorrhagic lesions.
Factors that bypass or inactivate local defenses (eg, tracheostomy tubes, immotile cilia syndrome) predispose the child to pneumonia. The result is loss of surfactant activity with local collapse and consolidation.
Pneumonia may be classified by the causative organism, the anatomic location, or the tissue response.
A WHO Child Health Epidemiology Reference Group publication cited the incidence of community-acquired pneumonia among children younger than 5 years in developed countries as approximately 0.026 episodes per child-year.[1]
In a prospective multicenter study of 154 hospitalized children with acute community-acquired pneumonia in whom a comprehensive search for etiology was sought, a pathogen was identified in 79% of children. Bacteria accounted for 60%, of which 73% were due to Streptococcus pneumoniae;Mycoplasma pneumoniae and Chlamydia pneumoniae were detected in 14% and 9%, respectively. Viruses were documented in 45% of children. Notably, 23% of the children had concurrent acute viral and bacterial disease.[6] In the study, preschool-aged children had as many episodes of atypical bacterial lower respiratory infections as older children. Multivariable analyses revealed that high temperature (38.4°C) within 72 hours after admission and the presence of pleural effusion were significantly associated with bacterial pneumonia.
Thompson et al reported annual influenza-associated hospitalizations in the United States by hospital discharge category, discharge type, and age group.[7] After elderly persons, the second highest rates of influenza-associated hospitalizations were in children younger than 5 years.
In a randomized double-blind trial, the heptavalent pneumococcal vaccine reduced the incidence of clinically diagnosed and radiographically diagnosed pneumonia among children younger than 5 years by 4% and 20%, respectively.[8] Although the overall rate of pneumonia has decreased in the United States with the use of the 7-valent vaccine, the rate of empyema and complicated pneumonia has increased.[9]
International
The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0.28 episodes per child-year.[1] This equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission. Ninety-five percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries.
Over half of Kenyan children hospitalized for severe pneumonia (based upon WHO clinical criteria) had a respiratory virus detected. Respiratory syncytial virus was identified in 34% of these children.[10]
Mortality/Morbidity
According to the WHOs Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%]).
Most children are treated as outpatients and fully recover. However, in young infants and immunocompromised individuals, mortality is much higher.
In studies of adults with pneumonia, a higher mortality rate is associated with abnormal vital signs, immunodeficiency, and certain pathogens.
Race
Pneumonia affects children of all races; however, certain conditions that may predispose to pneumonia have racial predilections. For example, cystic fibrosis is far more common in white children. Children with sickle cell anemia are at increased risk for pneumonia as a result of sickling within the pulmonary vasculature and functional asplenia.
Age
Pneumonia in the pediatric population is most common in infants and toddlers and least common in adolescents and young adults.
In children, etiologic agent, age of the patient, and underlying illnesses all affect the historical features of the illness.
Neonates
The infant may present with tachypnea; signs of respiratory distress, such as grunting, flaring, and retractions; lethargy; poor feeding; or irritability. Fever may not be present in newborns; however, hypothermia and temperature instability may be observed.
Cyanosis may be present in severe cases.
Nonspecific complaints, such as irritability or poor feeding, may be the presenting symptoms.
Cough may be absent in the newborn period.
Early-onset group B streptococci infection usually presents via ascending perinatal infection as sepsis or pneumonia within the first 24 hours of life. Chlamydia trachomatis pneumonia should be considered in infants aged 2-4 weeks and is often associated with conjunctivitis.
Infants
After the first month of life, cough is the most common presenting symptom.
Infants may have a history of antecedent upper respiratory symptoms.
Depending upon the degree of illness, tachypnea, grunting, and retractions may be noted. Vomiting, poor feeding, and irritability are also common.
Infants with bacterial pneumonia often are febrile, but those with viral pneumonia or pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The child's caretakers may complain that the child is wheezing or has noisy breathing.
Toddlers and preschool children
A history of antecedent upper respiratory illness is common.
Cough is the most common presenting symptom.
Vomiting, particularly post-tussive emesis, may be present. Chest pain may be observed with inflammation of or near the pleura. Abdominal pain or tenderness is often seen in children with lower lobe pneumonia.
The presence and degree of fever is dependent upon the organism involved.
Older children and adolescents
Atypical organisms, such as Mycoplasma, are more common in this age group.
In addition to the symptoms observed in younger children, adolescents may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.
Early in the physical examination, identifying and treating respiratory distress, hypoxemia, and hypercarbia is important. Signs such as grunting, flaring, severe tachypnea, and retractions should prompt the clinician to provide immediate respiratory support. An assessment of oxygen saturation by pulse oximetry should be performed early in the evaluation of all children with respiratory symptoms. When appropriate and available, capnography may be useful in the evaluation of children with potential respiratory compromise.
Visual inspection of the degree of respiratory effort and accessory muscle use should be performed to assess for the presence and severity of respiratory distress. The examiner should simply observe the patient's respiratory effort and count the respirations for a full minute. In infants, observation should include an attempt at feeding, unless the baby has extreme tachypnea.
An ED-based study conducted in the United States found that respiratory rate alone and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia.[11] However, children with tachypnea as defined by WHO respiratory rate thresholds were more likely to have pneumonia than children without tachypnea.
Auscultation is perhaps the most important portion of the examination of the child with respiratory symptoms. The examination often is very difficult in infants and young children for several reasons.
Babies and young children often cry during the physical examination making auscultation difficult. The best chance of success lies in prewarming hands and instruments and in using a pacifier to quiet the infant. The opportunity to listen to a sleeping infant should never be lost.
Older infants and toddlers may cry because they are ill or uncomfortable, but, most often, they have stranger anxiety. For these children, it is best to spend a few minutes with the parents in the child's presence. If the child sees that the parent trusts the examining physician then he or she may be more willing to let the examiner approach. A small toy may help to gain the child's trust. Any part of the examination using instruments should be deferred as long as possible, because the child may find the medical equipment frightening. Occasionally, if the child is allowed to hold the stethoscope for a few minutes, it becomes less frightening. Even under the best of circumstances, examining a toddler is difficult. If the child is asleep when the physician begins the evaluation, auscultation should be performed early.
It is not unusual for children with respiratory symptoms to have a concomitant upper respiratory infection with copious upper airway secretions. This creates another potential problem, transmission of upper airway sounds. In many cases, the sounds created by upper airway secretions can almost obscure true breath sounds and lead to erroneous diagnoses. If doubt exists as to the etiology of sounds heard through the stethoscope, the examiner should listen to the lung fields and then hold the stethoscope near the child's nose. If the sounds from both locations are approximately the same, the likely source of the abnormal breath sounds is the upper airway.
Even when the infant or young child is quiet and has a clear upper airway, the child's normal physiology may make the examination difficult. The minute ventilation is the product of the respiratory rate and tidal volume. In young children, respiratory rate makes a very large contribution to the overall minute ventilation. In other words, babies take many shallow breaths as opposed to a few deep ones. Therefore, a subtle finding, particularly one at the pulmonary bases, can be missed.
The sine qua non for this disease has always been the presence of crackles or rales. Although often present, focal crackles as a stand-alone physical examination finding is neither sensitive nor specific for the diagnosis of pneumonia.[12, 13, 14] Additionally, not all children with pneumonia have crackles.
Other examination findings suggestive of pneumonia include focal wheezing or decreased breath sounds in one lung field.
Similarly, certain more diffuse lung infections may result in generalized crackles or wheezing.
Although the presence of wheezing may be associated with pneumonia, the overall presence of radiographic pneumonia among children with wheezing is uncommon.[15] Historical and clinical factors such as fever and hypoxia may be used to determine the need for chest radiography for wheezing children. The authors recommend that routine use of chest radiography for children with wheezing but without fever should be discouraged.
Percussion may reveal important information. Occasionally, a child presents with a high fever and cough but without ausculatory findings suggestive of pneumonia. In such cases, percussion may help to identify an area of consolidation.
Pneumonia may occur as a part of another generalized process. Therefore, signs and symptoms suggestive of other disease processes, such as rashes and pharyngitis, should be sought during the examination.
The presence of occult pneumonia (ie, radiographic pneumonia) in a child without lower respiratory tract findings is described in young febrile children.[16] Studies conducted in the pre-Prevnar era estimated the rate of occult pneumonia at 10-20%; leukocytosis was associated with the presence of occult pneumonia.[17] A more recent prospective study identified occult pneumonia in 1 of 15 children undergoing chest radiography without respiratory distress or ausculatory findings.[18] Chest radiographs should not be obtained in children without fever for longer than 1 day, and without cough, because these children are at particularly low risk for occult pneumonia.
Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.
Newborns and infants
In the neonate, pathogens that may infect the infant via the maternal genital tract include group B streptococci, Escherichia coli and other fecal coliforms, and C trachomatis. Group B streptococci most often is transmitted to the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism. Affected infants commonly present within the first few hours after birth, but if infection is acquired during the delivery, the presentation may be delayed. The usual presenting symptoms include tachypnea, hypoxemia, and signs of respiratory distress. Physical examination may reveal diffuse fine crackles, and the chest radiograph may demonstrate a ground-glass appearance and air bronchograms.
Newborns may be affected by the bacteria and viruses that cause infections in older infants and children. Risk factors for infection include older siblings, group daycare, and lack of immunization, particularly against pertussis.
In the young infant, aged 1-3 months, continued concern about perinatally acquired pathogens mentioned above as well as the unusual Listeria monocytogenes remains. However, most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable Haemophilus influenzae.
Although the young unimmunized or incompletely immunized infant remains at theoretical risk for H influenzae and pneumococcal disease, herd immunity gained from widespread immunization of the population has been generally protective.
Most lower respiratory disease in the young infant occurs during the respiratory virus season and is viral in origin, particularly in the patient with clinical bronchiolitis. The most common agents include parainfluenza viruses, influenza virus, adenovirus, metapneumovirus, and respiratory syncytial virus (RSV). Morbidity and mortality from RSV and other viral infections is higher among premature infants and infants with underlying lung disease.
Atypical organisms may also cause infection in infants. Of these, C trachomatis, Ureaplasma urealyticum, cytomegalovirus, and Pneumocystis carinii (PCP) are the most common. Pneumocystis pneumonia is generally limited to immunocompromised infants.
Bordetella pertussis may affect infants. Only 80% of fully immunized children are protected against pertussis and immunity to this disease wanes in late adolescence. Since infants have not completed the vaccination series and because adults are a potential reservoir for infection, both groups are at risk.
Streptococcus pneumoniae is by far the most common bacterial pathogen in this age group.
Infection with Staphylococcus aureus may be complicated by lung abscess, parapneumonic effusions, and empyema.[19]
Young children
Viruses are a common cause of pneumonia among toddlers and preschoolers. The usual culprits are those previously discussed. Tsolia et al identified a viral infection among 65% of hospitalized children with community-acquired pneumonia.[20]
Streptococcus pneumoniae is by far the most common bacterial cause of pneumonia. Among hospitalized children, Streptococcus pneumoniae accounts for 21-44% of disease.[6, 21, 22] In a recent study to evaluate the effectiveness of heptavalent pneumococcal conjugate vaccine in prevention of pneumonia in children younger than 5 years, Black et al showed a 32.2% reduction in the first year of life and a 23.4% reduction between 1-2 years, but only a 9.1% reduction in children older than 2 years.[23, 8]
Children in this age group are also at risk for infection by M pneumoniae.
Older children and adolescents
M pneumoniae is a frequent cause of pneumonia among older children and adolescents. Mycoplasma accounts for 14-35% of pneumonia hospitalizations in this age group.[6, 20, 24]
C pneumoniae can cause pneumonia in this age group.
Older adolescents may have lost their immunity to pertussis and may become infected by this organism. Unlike the whooping cough in infants, pertussis in older patients usually causes a paroxysmal cough, which persists for more than 3 weeks and may last up to 3 months.
Bacterial pneumonia in this age group most often is caused by Streptococcus pneumoniae.
Other rare organisms
Histoplasma capsulatum, which is found in nitrate-rich soil, usually is acquired as a result of inhalation of spores. Chicken coops and other bird roosts and decaying wood are oft-cited sources. The infection is usually asymptomatic; however, infants and young children are at risk for symptomatic infection, which may cause respiratory distress and hypoxemia.
Blastomyces dermatitides is a dimorphic yeast, which is found in certain geographic locations, most notably the Ohio and Mississippi River valleys. As with histoplasmosis, blastomycosis is acquired by inhalation of spores. Although 3 distinct forms of infection exist, the most common is acute pneumonia, which most often resolves without treatment.
Cryptococcus neoformans is a common infection among pigeon breeders, but it is unusual in other immunocompetent individuals. Cryptococcosis may occur in as many as 5-10% of patients with AIDS. In immunocompetent patients, this organism causes no symptoms or a mild pneumonia and requires no treatment.
Mycobacterial pneumonia has recently been noted with increasing frequency in some inner-city areas. Children in homeless shelters and group homes and those with household contacts are at particular risk. Similarly, the diagnosis must be considered in immunocompromised children.
RSV is a common cause of lower respiratory tract infection in children. Serious infections with this organism usually occur in infants with underlying lung disease. Bacterial superinfection may also complicate RSV pneumonia.
The herpesviruses rarely may cause pneumonia. In infants, the usual agent is herpes simplex, and, in older children, pneumonia may complicate common varicella infections.
Influenza A is a less common pathogen.
Legionella species may cause pneumonia in immunocompromised children.
Children with cystic fibrosis may be infected with various organisms such as Staphylococcus aureus,Pseudomonas aeruginosa,Burkholderia cepacia, and other multidrug-resistant organisms.
Not all pneumonia is caused by infectious agents. Children who have severe gastroesophageal reflux may develop chemical pneumonitis secondary to recurrent aspiration. Inhalation of certain chemicals or smoke may cause pulmonary inflammation. Additionally, children with impaired swallowing, gastrointestinal motility, or a gastrostomy tube may be prone to aspiration pneumonia.
Very few laboratory studies are particularly useful in the evaluation of the child with pneumonia.
Although it is true that many of the etiologic organisms may be identified by culture or immunofluorescent antibody techniques, in practice, these are too costly and time consuming for routine use. Furthermore, the results of such tests are rarely available in less than several hours, thus making them even less useful to the emergency clinician.
CBC count
In cases of pneumococcal pneumonia, the WBC count is often elevated.
Prior to widespread pneumococcal immunization, Bachur et al observed that approximately 25% of febrile children with a WBC count >20,000/mm3, but without lower respiratory tract findings on examination, had radiographic pneumonia (termed occult pneumonia).[25]
Although blood testing was obtained less frequently in the post-Prevnar era, recent studies by the same group demonstrated that leukocytosis was still associated with occult pneumonia.[26, 27]
Cultures
Bacteremia is rarely associated with pneumonia in children, and blood culture is not routinely required in immunocompetent children.[28]
Blood cultures should be obtained when the patient is critically ill, immunocompromised, or has persistent symptoms. Additionally, blood cultures are useful in patients with high fever and large areas of consolidation—mostly to make a microbiologic diagnosis.
Sputum cultures should be reserved for unusual cases or very ill patients.
Sputum Gram stain
In the cooperative older child with a productive cough, a sputum Gram stain may be obtained.
In order to be useful, the specimen must contain less than 10 epithelial cells and more than 25 WBC per high-powered field. Very few children are able to cooperate with such a test.
Consideration should be given for rapid viral testing in young infants with simple infiltrates.
The criterion standard test for the diagnosis of pneumonia is a 2-view plain chest radiograph. However, when chest radiographs are subjected to blinded readings, they may not differentiate between viral disease and bacterial disease.
View Image
A, Anteroposterior radiograph of a child with a left lower lobe infiltrate. B, Lateral radiograph of the same child with a left lower lobe infiltrate.....
View Image
A, Anteroposterior radiograph of a child with presumptive viral pneumonia. B, Lateral radiograph of the same child with presumptive viral pneumonia.
Although unilateral and/or lobar infiltrates are often seen in bacterial pneumonia, several studies have found that the pattern of radiologic features could not accurately distinguish a bacterial etiology from a viral etiology.[29, 30]
In contrast, a large Finnish series concluded that an alveolar (equivalent to a lobar) infiltrate is an insensitive but reasonably specific indication of bacterial infection.[31]
At either extreme (from typical bronchiolitis with scattered infiltrates to dense lobar pneumonia with a large pleural effusion), the level of diagnostic certainty provided by radiologic findings increases.
For M pneumoniae, 3 radiographic patterns may be observed: (1) peribronchial and perivascular interstitial infiltrates, (2) patchy consolidations, and (3) homogeneous acinar consolidations like ground-glass.[32] The lower fields of the lungs are most often affected, and enlargement of the hilar glands is common.
In viral pneumonias, 4 common radiographic findings were detected: parahilar peribronchial infiltrates, hyperexpansion, segmental or lobar atelectasis, and hilar adenopathy.[33]
Although no radiographic findings are specific for C pneumoniae, a combination of the clinical and radiographic findings strongly suggests the diagnosis before laboratory diagnosis is available. In a study of 125 cases of Chlamydia pneumonia, Radkowski et al demonstrated that most chest films showed bilateral hyperexpansion and diffuse infiltrates with a variety of radiographic patterns including interstitial, reticular nodular, atelectasis, coalescence, and bronchopneumonia. Pleural effusion and lobar consolidation were not seen.[34]
Round pneumonia on chest radiographs should raise suspicion for a bacterial etiology, particularly Streptococcus pneumoniae and Staphylococcus aureus. Round pneumonia is shown in the radiograph below.
View Image
Anteroposterior radiograph of a child with a round pneumonia.
On occasion, it may be prudent to perform skin testing for tuberculosis, particularly if high risk for exposure.
Cold agglutinins
In the young child or school-aged child with pneumonia, particularly the patient with a gradual onset of symptoms and a prodrome consisting of headache and abdominal symptoms, a bedside cold agglutinins test may help confirm the clinical suspicion of mycoplasmal infection.
This test is easily performed by placing a small amount of blood in a specimen tube containing anticoagulant and inserting this into a cup filled with ice water. After a few minutes in the cold water, the tube is held up to the light, tilted slightly, and slowly rotated. Small clumps of red blood cells coating the tube are indicative of a positive test result.
Unfortunately, this test is positive in only half the cases of mycoplasmal infection and is not very specific.
Urine latex agglutination test
Although antigen detection assays for S pneumoniae lack a high specificity in children, Neuman and Harper observed that 76% of febrile children with a lobar infiltrate on chest radiograph had a positive rapid urine antigen assay.[35]
When a child has a significant pleural effusion identified on chest radiograph, a thoracentesis should be performed. A lateral decubitus radiograph may be obtained to determine whether the thoracic fluid is free-flowing. Ultrasonography or fluoroscopy may be useful to aid in placement of a traditional or pigtail thoracostomy tube for small-to-moderate–sized effusions.
Fluid recovered from the pleural space should be sent for Gram stain and culture, along with pH, glucose, protein, and lactate dehydrogenase (LDH).
If the thoracentesis reveals an empyema, a thoracostomy tube may be required.
Pulse oximetry should be performed during the prehospital evaluation of such children, and supplemental oxygen should be administered.
Children who are in severe respiratory distress should undergo tracheal intubation if unable to maintain oxygenation or decreasing levels of consciousness.
Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) may be used to help support respiratory effort as a stand-alone intervention or as a bridge to intubation.
Initial priorities in children with pneumonia include the identification and treatment of respiratory distress, hypoxemia, and hypercarbia. Grunting, flaring, severe tachypnea, and retractions should prompt immediate respiratory support.
The vast majority of children diagnosed with pneumonia in the ED may be treated on an outpatient basis with oral antibiotics. High-dose amoxicillin may be used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for Streptococcus pneumoniae. Cephalosporins are also acceptable alternatives. Macrolide antibiotics, such as azithromycin, may be added if Mycoplasma is suspected. One study suggests that penicillin and macrolide resistance among Streptococcus pneumoniae isolates has been increasing.[36]
Viral pneumonia
Most infants with RSV pneumonia do not require antimicrobials. Hospitalization should be considered for infants who are younger than 2 months of age or premature, due to risk of apnea in this age group.[37] Serious infections with this organism usually occur in infants with underlying lung disease.
Influenza A pneumonia that is particularly severe or when it occurs in a high-risk patient may be treated with zanamivir or oseltamivir. Check for resistance patterns for other antiviral agents indicated for treatment or chemoprophylaxis of influenza.
Oseltamivir (Tamiflu) resistance has emerged in the United States during the 2008-2009 influenza season.
The US Centers for Disease Control and Prevention (CDC) has issued revised interim recommendations for antiviral treatment and prophylaxis of influenza. Preliminary data from a limited number of states indicate a high prevalence of influenza A (H1N1) virus strains resistant to oseltamivir (Tamiflu). Because of this, zanamivir (Relenza) is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected. A second-line alternative is a combination of oseltamivir plus rimantadine rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.
Influenza A viruses, including 2 subtypes (H1N1) and (H3N2), and influenzaB viruses currently circulate worldwide, but the prevalence of each can vary among communities and within a single community over the course of an influenza season. In the United States, 4 prescription antiviral medications (oseltamivir, zanamivir, amantadine, rimantadine) are approved for treatment and chemoprophylaxis of influenza. Since January 2006, the neuraminidase inhibitors (oseltamivir, zanamivir) have been the only recommended influenza antiviral drugs because of widespread resistance to the adamantanes (amantadine, rimantadine) among influenza A (H3N2) virus strains. The neuraminidase inhibitors have activity against influenza A and B viruses, whereas the adamantanes have activity against only influenza A viruses.
In 2007-2008, a significant increase in the prevalence of oseltamivir resistance was reported among influenza A (H1N1) viruses worldwide. During the 2007-2008 influenza season, 10.9% of H1N1 viruses tested in the United States were resistant to oseltamivir. Complete recommendations are available from the CDC.
Children appearing toxic
Children who are toxic appearing may require resuscitation and respiratory support. Chest radiography should be performed to identify the presence of an effusion/empyema.
Antibiotic therapy should include vancomycin (particularly in areas where penicillin-resistant streptococci have been identified) and a second- or third-generation cephalosporin.
Consultation is not needed in the care of most children with pneumonia.
Children who have underlying diseases may benefit from consultation with the specialist involved in their long-term care. For example, most children with cystic fibrosis are monitored by a pulmonologist.
Consultation with a pediatric infectious disease specialist may be appropriate in the treatment of a child with persistent or recurrent pneumonia.
Children with pleural effusions or empyema should be referred to a tertiary medical center, where thoracentesis can be performed. This procedure may be performed in an emergency department setting and may require subspecialty consultation.
Clinical Context:
Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria. Appropriate first-line agent in children in whom pneumococcal disease is strongly suspected. It offers the advantages of being relatively palatable and having a tid-dosing schedule. It has limited activity against gram-negative bacteria due to resistance.
Clinical Context:
Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. May be used as an alternative to amoxicillin in treatment of outpatients with pneumonia in whom pneumococcal disease is strongly suspected. Penicillin has limited activity against gram-negative bacteria.
Clinical Context:
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
Clinical Context:
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins. The tablet should be administered with food.
Clinical Context:
Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.
Clinical Context:
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Clinical Context:
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. DOC for adults and children >4 y, unless suspect pneumococcal disease. These agents are effective against many of the atypical organisms. Erythromycin is available in 4 forms: base, stearate, estolate, and ethylsuccinate. Erythromycin estolate causes the least GI distress.
Clinical Context:
Erythromycin is a macrolide antibiotic with a large spectrum of activity. Binds to the 50S ribosomal subunit of the bacteria, which inhibits protein synthesis. Sulfisoxazole expands erythromycin's coverage to include gram-negative bacteria. Sulfisoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid. Dose is based on the erythromycin component.
Clinical Context:
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Clinical Context:
Inhibits activity of both HSV-1 and HSV-2. DOC for treatment of pneumonia in children with herpes viruses (eg, herpes simplex, varicella).
Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset.
Clinical Context:
For treatment of severe lower respiratory tract RSV infections in infants and children with an underlying compromising condition. Inhibits replication of RNA and DNA viruses.
Most children with uncomplicated pneumonia recover without sequelae.
In children who remain well appearing but have recurrent or chronic symptoms, further testing is warranted. Further testing may include skin testing to identify fungal pathogens and tuberculosis, sweat testing to identify cystic fibrosis, titers against rare organisms, and bronchoscopy.
The initial outpatient treatment of children with pneumonia depends upon the clinical findings and the patient's age.
Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin.
A macrolide antibiotic alone, or in combination with sulfisoxazole or an oral cephalosporin is an alternative.
For most other children, particularly school-aged children, azithromycin alone or in combination with sulfisoxazole may be given. Other macrolide agents are acceptable alternatives to erythromycin.
Children who are being admitted should be treated with cefuroxime or another broad-spectrum cephalosporin.
Vancomycin may be added to the treatment of toxic-appearing children in areas where there is a high rate of penicillin resistance among pneumococcal isolates.
Acyclovir is indicated for the treatment of pneumonia caused by herpesviruses.
Infants and children being admitted for pneumonia may require transfer because they need admission to a critical care unit.
Transfer should be considered when pneumonia complicates chronic illness. In such patients, the purpose of the transfer is continuity of care with the child's subspecialist.
Since the great risk faced by children with pneumonia is respiratory compromise, the unit performing the transfer should feel comfortable with the full spectrum of respiratory support that may be required.
Several vaccines exist that may prevent certain types of pneumonia. Heptavalent pneumococcal vaccine is recommended for all children in the United States.
Since the initiation of the heptavalent pneumococcal vaccine in 2000, researchers have found that nearly two thirds of invasive pneumococcal disease cases in young children have been caused by 6 serotypes not included in that vaccine. Those serotypes, along with the original 7, have been incorporated into pneumococcal vaccine valent-13 (Prevnar 13) that was approved in February 2010.[38]
Influenza vaccines are recommended for young children and those with chronic pulmonary disease including asthma.
H influenzae type b vaccine is given to all children and has reduced the incidence of infections caused by this organism.
Varicella vaccine has a dramatic impact upon the incidence of varicella.
An injection of RSV-specific immunoglobulins holds some promise for the prevention of severe RSV infections in certain infants. Likely candidates for this treatment are former premature infants and those with chronic heart and lung diseases.
Patients who were placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes.
The prognosis for most forms of pneumonia is excellent. Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy.
The prognosis for varicella pneumonia is somewhat more guarded.
Staphylococcal pneumonia, although rare, can be very serious despite treatment.
Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae.
Some forms of viral pneumonia, particularly adenoviral disease, may cause necrotizing bronchiolitis or bronchiolitis obliterans.
FDA News Release. FDA Approves Pneumococcal Disease Vaccine with Broader Protection. February 24, 2010. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm201758.htm. Accessed February 25, 2010.
[Guideline] Cincinnati Children's Hospital Medical Center. Evidence based care guideline for community acquired pneumonia in children 60 days through 17 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center. Jul. 2006;
){kind=link}
){kind=link}
){kind=link}