Pneumonia (peds): Difference between revisions

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== Background ==
{{Peds top}} [[pneumonia]]
 
==Background==
[[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
*Most common site of infection in neonates
*Fever and tachypnea are Sensitive but not Specific


== Causes ==
===Bugs by Age Group===
*Newborn
**[[Group B streptococci]]
**[[Gram-negative bacilli]]
**[[Listeria monocytogenes]]
*1-3 months
**[[Streptococcus pneumoniae]]
**[[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]]


=== Neonatal Pneumonia ===
==Clinical Features==
{| class="wikitable"
''Fever and tachypnea are sensitive but not specific''
|-
*[[Fever]]
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Etiology
*[[Cough]]
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Clinical Presentation
**Productive cough is rarely seen before late childhood
! 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 ''B, ''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
==Differential Diagnosis==
**Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
{{Pediatric fever DDX}}
***Pneumococus, H. flu, staph, pertussis
{{Pediatric SOB DDX}}
**If age >5 consider mycoplasma (treat w/ macrolide)


== Diagnosis ==
==Evaluation==
 
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
*Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]]
**Productive cough is rarely seen before late childhood
[[File:PNA_US.gif|thumb|Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas]]
===Workup===
====Likely Outpatient====
*Imaging
*Imaging
**CXR is not the gold standard!
**[[CXR]], consider for:
**Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
***Age 0-3mo (as part of sepsis workup)
**Consider for:
***<5yr with temperature >102.2, WBC >20K and no clear source of infection
***Age 0-3mo (part of w/u for sepsis)
***<5yr w/ temp >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:
**[[Covid-19]]
**[[RSV]]
**[[Influenza]]
 
====Sick/Likely Inpatient====
''Above plus:''
*CBC
*Chemistry
*Blood/nasal culture are low yield
*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)


== Treatment ==
===Diagnosis===
*Recommendations from AAP<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>
*Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
{| class="wikitable"
*[[CXR]]
|-  
**Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Age Group
**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>
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Bacterial Pathogens
**Absence of CXR findings does not preclude diagnosis; high clinical suspicion with adventitious breath sounds can be consistent with pneumonia despite negative imaging
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Hospitalized Patients
**Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Outpatients
**Clinical and radiographic findings do not necessarily correspond: the patient may be improving clinically despite having a worsening appearance on the CXR
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
*[[Ultrasound]]
| 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;" | Newborn
**Can be considered as an alternative to CXR
| 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;" | Group B streptococci
**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>
| 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;" | Ampicillin
| 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;" | Initial outpatient management not recommended
|- 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;" | Gram-negative bacilli
| 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;" | ''plus''&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;" | ''Listeria monocytogenes''&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;" | Gentamicin&nbsp;''or''&nbsp;cefotaxime
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- 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;" | ''Chlamydia trachomatis''&nbsp;
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|- 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;" | ''Haemophilus influenzae''&nbsp;
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- 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;" | &nbsp;
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|- 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;" | &nbsp;
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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3 mo–5 y


(majority of PNA
==Management==
{{Pediatric pneumonia treatment}}


in this group is
==Disposition==
''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>''
===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


viral)
==See Also==
 
*[[Pneumonia (Main)]]
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*[[Pediatric fever]]
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- 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;" | Nontypeable&nbsp;''H. influenzae''&nbsp;
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- 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;" | ''Mycoplasma pneumoniae''&nbsp;
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|- 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="10" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | 5–18 y
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- 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;" | ''S. aureus''&nbsp;
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
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|}
 
*All Children less than 2 months should be hospitalized<ref name="AAP"></ref>
*High dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice for uncomplicated outpatient community acquired pneumonia<ref name="AAP"></ref>
*For Inpatient treatment of pneumonia preference is to [[Vancomycin]] along with a second- or third- generation [[Cephalosporins]].<ref name="AAP"></ref>
 
==Disposition==
*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]]
[[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