Pneumonia (peds): Difference between revisions

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{{Peds top}} [[pneumonia]]
==Background==
==Background==
fever and tachypnea have high degree of sens but not specific
[[File:Number of deaths from pneumonia in children under 5, OWID.svg|thumb|Death rates from pneumonia in children under 5 (2017).]]
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]
*Most common site of infection in neonates


==Causes==
===Bugs by Age Group===
===Common Causes===
*Newborn
# viruses- rsv, influenza, parainflu, adeno, rhino, measles
**[[Group B streptococci]]
# mycoplasma
**[[Gram-negative bacilli]]
# chlamydia- pneumoniae and trachomatis
**[[Listeria monocytogenes]]
# bacteria- strep, tb, staph, hflu, nontypable hflu
*1-3 months
# measles and nontypable hflu common in undeveloped world
**[[Streptococcus pneumoniae]]
# c. pneumonia frequently recovered from asymptomatic subjects
**[[Chlamydia trachomatis]]   
**[[Haemophilus influenzae]] 
**[[Bordetella pertussis]] 
**[[Staphylococcus aureus]]
*3 months-5 years
**[[S. pneumoniae]] 
**[[S. aureus]] 
**[[H. influenzae]] type b
**Nontypeable H. influenzae
**[[C. trachomatis]] 
**[[Mycoplasma pneumoniae]] 
*5–18 years
**[[M. pneumoniae]] 
**[[S. pneumoniae]] 
**[[C. pneumoniae]] 
**[[H. influenzae]] type b
**[[S. aureus]]


===Uncommon Causes===
==Clinical Features==
# viruses- varicella zoster, corona, entero, coxsackie, echo, cmv, ebv, mumps, hsv- newborns, hanta is animal exp,
''Fever and tachypnea are sensitive but not specific''
# chlamydia psittaci
*[[Fever]]
# coxiella
*[[Cough]]
# bacteria- strep pyogenes, anaerobic mouth, hflu, pertussis, klebsiella, ecoli, listeria, nesseria, legionella, pseudomonas, tularremia, brucella, leptospira,
**Productive cough is rarely seen before late childhood
# Fungi- cocci, histo, blasto


==Diagnosis==
==Differential Diagnosis==
# cxr cannot differentiate between viral and bact pna (but lobar infiltrate more often bacterial)
{{Pediatric fever DDX}}
{{Pediatric SOB DDX}}


===WHO Criteria===
==Evaluation==
# Tachypnea
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
##RR >50 (<1 yr old)
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]]
##RR >40 (>1 yr old)
[[File:PNA_US.gif|thumb|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]
# Retractions
===Workup===
====Likely Outpatient====
*Imaging
**[[CXR]], consider for:
***Age 0-3mo (as part of sepsis workup)
***<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:
**[[Covid-19]]
**[[RSV]]
**[[Influenza]]


==Treatment==
====Sick/Likely Inpatient====
tx with azithromycin or clarithromycin after 3 months
''Above plus:''
*CBC
*Chemistry
*Blood/nasal culture are low yield
**In prospective study, 91 blood cultures needed for one positive result for CAP; but in ICU one child had bacteremia for every 24 cultures obtained, one for every 12 with parapneumonic effusion <ref> Prevalence, risk factors, and outcomes of bacteremic pneumonia in children.  Pediatrics. 2019 Jun 19. </ref>
**consider for sicker ones, those with effusions
*IDSA does ''not'' support using initial serum [[procalcitonin]] levels to determine whether empiric antibiotics should be initiated.
**Clinical judgement ''plus'' radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)
 
===Diagnosis===
*Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
*[[CXR]]
**Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
**May have negative CXR early in disease or in cases of dehydration; infiltrate may "blossom" after providing rehydration and repeat imaging<ref>Feldman C. Pneumonia in the elderly. Clin Chest Med. 1999;20(3):563-573. doi:10.1016/s0272-5231(05)70236-7</ref>
**Absence of CXR findings does not preclude diagnosis; high clinical suspicion with adventitious breath sounds can be consistent with pneumonia despite negative imaging
**Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
**Clinical and radiographic findings do not necessarily correspond: the patient may be improving clinically despite having a worsening appearance on the CXR
*[[Ultrasound]]
**Can be considered as an alternative to CXR
**Sensitivity 82% and specificity 94% (adults)<ref>Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. J Emerg Med. 2019;56(1):53-69. doi:10.1016/j.jemermed.2018.09.009</ref>
 
==Management==
{{Pediatric pneumonia treatment}}


==Disposition==
==Disposition==
ADMIT
''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>''
# <3months old
===Consider Admission For===
#SaO2 <91%
*Age: <2-3 months old
#severe dehydration
*History of severe or relevant congenital disorders
#moderate dehydration and unable to hydrate themselves orally after intravenous (IV) hydration
*Immune suppression (HIV, SCD, malignancy)
#moderate or severe respiratory distress
*Toxic appearance/respiratory distress
#failed outpatient antibiotic treatment, or
*SpO2 <90-93%
#unsafe to send home
*Vomiting/dehydration
*Unstable social environment
 
==See Also==
*[[Pneumonia (Main)]]
*[[Pediatric fever]]


==Sources==
==References==
Adapted from Donaldson, Pani
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Pulm]]
[[Category:ID]]
[[Category:Pulmonary]]

Latest revision as of 23:05, 13 December 2023

This page is for pediatric patients. For adult patients, see: pneumonia

Background

Death rates from pneumonia in children under 5 (2017).
Lobes of the lung with related anatomy.
  • 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

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

CXR showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial pneumonia.
CT chest showing right sided pneumonia
Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas

Workup

Likely Outpatient

  • Imaging
    • CXR, consider for:
      • Age 0-3mo (as part of sepsis workup)
      • <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:

Sick/Likely Inpatient

Above plus:

  • CBC
  • Chemistry
  • Blood/nasal culture are low yield
    • In prospective study, 91 blood cultures needed for one positive result for CAP; but in ICU one child had bacteremia for every 24 cultures obtained, one for every 12 with parapneumonic effusion [1]
    • consider for sicker ones, those with effusions
  • IDSA does not support using initial serum procalcitonin levels to determine whether empiric antibiotics should be initiated.
    • Clinical judgement plus radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)

Diagnosis

  • Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
  • CXR
    • Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
    • May have negative CXR early in disease or in cases of dehydration; infiltrate may "blossom" after providing rehydration and repeat imaging[2]
    • Absence of CXR findings does not preclude diagnosis; high clinical suspicion with adventitious breath sounds can be consistent with pneumonia despite negative imaging
    • Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
    • Clinical and radiographic findings do not necessarily correspond: the patient may be improving clinically despite having a worsening appearance on the CXR
  • Ultrasound
    • Can be considered as an alternative to CXR
    • Sensitivity 82% and specificity 94% (adults)[3]

Management

Newborn

1-3 Month

>3mo - 18 years

Disposition

All Children less than 2 months should be hospitalized[11]

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. ↑ Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics. 2019 Jun 19.
  2. ↑ Feldman C. Pneumonia in the elderly. Clin Chest Med. 1999;20(3):563-573. doi:10.1016/s0272-5231(05)70236-7
  3. ↑ Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. J Emerg Med. 2019;56(1):53-69. doi:10.1016/j.jemermed.2018.09.009
  4. ↑ Sanford Guide to Antimicrobial Therapy 2014
  5. ↑ Sanford Guide to Antimicrobial Therapy 2014
  6. ↑ Sanford Guide to Antimicrobial Therapy 2014
  7. ↑ Sanford Guide to Antimicrobial Therapy 2014
  8. ↑ Sanford Guide to Antimicrobial Therapy 2014
  9. ↑ Sanford Guide to Antimicrobial Therapy 2014
  10. ↑ Sanford Guide to Antimicrobial Therapy 2014
  11. ↑ AAP. 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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