Difference between revisions of "Pneumonia (peds)"

(TreatmentAAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.)
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== Background ==
+
==Background==
 
 
 
*Most common site of infection in neonates
 
*Most common site of infection in neonates
*Fever and tachypnea are Sensitive but not Specific
 
 
=== Causes ===
 
 
==== Neonatal ====
 
{| class="wikitable"
 
|-
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Etiology
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Clinical Presentation
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Management Approach
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
 
Bacterial
 
 
[[Group B Streptococcus]] (most common), [[Escherichia coli]], [[Listeria monocytogenes]], [[Haemophilus influenzae]], [[S. pneumoniae]] [[Klebsiella]] species, [[Enterobacter]] aerogenes
 
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Full evaluation for sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative. Two culture samples may increase diagnostic yield fourfold.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | A lumbar puncture should be done if there are no contraindications.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Hospitalization, supportive care (<small>O</small><sub>2</sub>), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available).<br/>&nbsp;
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nosocomial infections in premature infants (''Staphylococcus aureus'',''Pseudomonas aeruginosa'')&nbsp;
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Same as for common bacterial etiology.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Same as for common bacterial etiology.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ''Chlamydia''&nbsp;
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Develops in 3%–16% of exposed neonates (in colonized mothers).
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR may show hyperinflation with interstitial infiltrates.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Definitive diagnosis by nasopharyngeal swab PCR or cultures.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Eosinophilia may be seen on peripheral blood count.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Treatment: macrolide (erythromycin, clarithromycin, or azithromycin).
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
 
''Bordetella pertussis''
 
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | In addition to pneumonia, may causes paroxysms of cough, ± cyanosis and post-tussive emesis in otherwise well-looking infant. Characteristic whoop is not present in neonates. Apnea may be the only symptom. Suspect when adult caregiver also has persistent cough.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Diagnosis via nasopharyngeal swab for PCR and/or culture.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Macrolides are efficient against&nbsp;''B. pertussis''&nbsp;but is not approved by the U.S. Food and Drug Administration for infants <6 mo.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Neonates need to be admitted during treatment and monitored for severe adverse effects.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
 
''Mycobacterium tuberculosis''
 
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Half of infants born to actively infected mothers develop TB if not immunized or treated.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as for bacterial pneumonia.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR, culture of urine, gastric and tracheal aspirates.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Skin testing not sensitive in neonates.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Routine anti-TB treatment.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Supportive treatment as needed.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly).
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza)
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Initial upper respiratory illness progressing to respiratory distress and feeding difficulty.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab).
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Hypoxia and apnea may be present.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Often indistinguishable from bronchiolitis.
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Rate of concurrent bacterial infections in confirmed viral infection is low.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR for significant respiratory distress.
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Supportive therapy; monitoring for apnea in young and premature infants.
 
|}
 
 
==== Infants and Children ====
 
*More likely to have viral cause
 
**Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
 
***Pneumococus, H. flu, staph, pertussis
 
**If age >5 consider mycoplasma (treat w/ macrolide)
 
  
 
===Bugs by Age Group===
 
===Bugs by Age Group===
Line 103: Line 7:
 
**[[Gram-negative bacilli]]
 
**[[Gram-negative bacilli]]
 
**[[Listeria monocytogenes]]
 
**[[Listeria monocytogenes]]
*1mo-3mo
+
*1-3 months
 
**[[Streptococcus pneumoniae]]  
 
**[[Streptococcus pneumoniae]]  
 
**[[Chlamydia trachomatis]]     
 
**[[Chlamydia trachomatis]]     
Line 109: Line 13:
 
**[[Bordetella pertussis]]   
 
**[[Bordetella pertussis]]   
 
**[[Staphylococcus aureus]]
 
**[[Staphylococcus aureus]]
*3mo-5yr
+
*3 months-5 years
 
**[[S. pneumoniae]]   
 
**[[S. pneumoniae]]   
 
**[[S. aureus]]   
 
**[[S. aureus]]   
Line 116: Line 20:
 
**[[C. trachomatis]]   
 
**[[C. trachomatis]]   
 
**[[Mycoplasma pneumoniae]]   
 
**[[Mycoplasma pneumoniae]]   
*5–18 y
+
*5–18 years
 
**[[M. pneumoniae]]   
 
**[[M. pneumoniae]]   
 
**[[S. pneumoniae]]   
 
**[[S. pneumoniae]]   
Line 123: Line 27:
 
**[[S. aureus]]
 
**[[S. aureus]]
  
== Diagnosis ==
+
==Clinical Features==
 +
''Fever and tachypnea are sensitive but not specific''
 +
*[[Fever]]
 +
*[[Cough]]
 +
**Productive cough is rarely seen before late childhood
 +
 
 +
==Differential Diagnosis==
 +
{{Pediatric fever DDX}}
  
*Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
+
==Evaluation==
**Productive cough is rarely seen before late childhood
+
*Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
 
*Imaging
 
*Imaging
**CXR is not the gold standard!
+
**[[CXR]] is not the gold standard!
**Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
+
**Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
 
**Consider for:
 
**Consider for:
***Age 0-3mo (part of w/u for sepsis)
+
***Age 0-3mo (as part of sepsis work up)
***<5yr w/ temp >102.2, WBC >20K and no clear source of infection
+
***<5yr with temperature >102.2, WBC >20K and no clear source of infection
 
***Ambiguous clinical findings
 
***Ambiguous clinical findings
***PNA that is prolonged or not responsive to abx
+
***Pneumonia that is prolonged or not responsive to antibiotics
*Consider rapid assays for RSV, influenza
+
*Consider rapid assays for RSV, [[influenza]]
 
*Blood/nasal culture are low yield
 
*Blood/nasal culture are low yield
  
== Treatment<ref name="AAP">AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.</ref>==
+
==Treatment<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>==
===Newborn===
+
{{Pediatric pneumonia treatment}}
*Hospitalized
 
**[[Ampicillin]] (80-90mg/kg/day) + ([[gentamicin]] OR [[cefotaxime]])
 
*Outpatient
 
**Initial outpatient management not recommended
 
  
===1-3 Month===
+
==Disposition==
*Hospitalized
+
''All Children less than 2 months should be hospitalized<ref>AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011</ref>''
**Afebrile pneumonitis
+
===Consider Admission For===
***[[Erythromycin]] or [[clarithromycin]]
+
*Age: <2-3 months old
**Febrile pneumonia
+
*History of severe or relevant congenital disorders
***[[Cefuroxime]] ± ([[erythromycin]] IV or [[clarithromycin]] PO)
+
*Immune suppression (HIV, SCD, malignancy)
**Severe: choose one of
+
*Toxic appearance/respiratory distress
***[[Cefuroxime]] + ([[erythromycin]] or [[clarithromycin]])
+
*SpO2 <90-93%
***[[Cefotaxime]] + [[erythromycin]]
+
*Vomiting/dehydration
***[[Cloxacillin]] + [[clarithromycin]]
+
*Unstable social environment
*Outpatient
 
**Initial outpatient management not recommended
 
  
===3mo - 5 year===
+
==See Also==
*Hospitalized
+
*[[Pneumonia (Main)]]
**[[Ampicillin]] IV or [[cefuroxime]] IV
+
*[[Pediatric fever]]
**or [[amoxicillin]] if PO
 
**or [[amoxicillin-clavulanate]] if PO
 
**Moderate or severe
 
***Add [[erythromycin]] or [[clarithromycin]]
 
*Outpatient
 
**[[Amoxicillin]]
 
**or [[amoxicillin-clavulanate]]
 
**or [[cefuroxime axetil]] x7-10d
 
 
 
===5yr - 18yr===
 
*Hospitalized
 
**[[Ampicillin]] IV + ([[erythromycin]] OR [[clarithromycin]])
 
**Alternative
 
***[[Cefuroxime]] or [[amoxicillin-clavulanate]] or [[erythromycin]] or [[clarithromycin]] 
 
**Moderate to severe
 
***[[Cefuroxime]] + ([[erythromycin]] or [[clarithromycin]])
 
*Outpatient
 
**[[Erythromycin]] or [[clarithromycin]]
 
**or [[amoxicillin]] ± [[clavulanate]]
 
**or [[cefuroxime axetil]] x7-10d
 
 
 
==Disposition==
 
*All Children less than 2 months should be hospitalized<ref name="AAP"></ref>
 
*Consider admission for:
 
**Age of birth to 3mo
 
**History of severe or relevant congenital disorders
 
**Immune suppression (HIV, SCD, malignancy)
 
**Toxic appearance/resp distress
 
**SpO2 <90-93%
 
  
==Source==
+
==References==
 
<references/>
 
<references/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
 
[[Category:ID]]
 
[[Category:ID]]

Revision as of 17:49, 19 April 2018

Background

  • Most common site of infection in neonates

Bugs by Age Group

Clinical Features

Fever and tachypnea are sensitive but not specific

  • Fever
  • Cough
    • Productive cough is rarely seen before late childhood

Differential Diagnosis

Pediatric fever

Evaluation

  • Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
  • Imaging
    • CXR is not the gold standard!
    • Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
    • Consider for:
      • Age 0-3mo (as part of sepsis work up)
      • <5yr with temperature >102.2, WBC >20K and no clear source of infection
      • Ambiguous clinical findings
      • Pneumonia that is prolonged or not responsive to antibiotics
  • Consider rapid assays for RSV, influenza
  • Blood/nasal culture are low yield

Treatment[1]

Newborn

1-3 Month

>3mo - 18 years

Disposition

All Children less than 2 months should be hospitalized[2]

Consider Admission For

  • Age: <2-3 months old
  • History of severe or relevant congenital disorders
  • Immune suppression (HIV, SCD, malignancy)
  • Toxic appearance/respiratory distress
  • SpO2 <90-93%
  • Vomiting/dehydration
  • Unstable social environment

See Also

References

  1. Sanford Guide to Antimicrobial Therapy 2014
  2. AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011