Pneumonia (peds): Difference between revisions
ClaireLewis (talk | contribs) |
No edit summary |
||
(16 intermediate revisions by 5 users not shown) | |||
Line 1: | Line 1: | ||
{{Peds top}} [[pneumonia]] | |||
==Background== | ==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 | ||
Line 7: | Line 10: | ||
**[[Gram-negative bacilli]] | **[[Gram-negative bacilli]] | ||
**[[Listeria monocytogenes]] | **[[Listeria monocytogenes]] | ||
* | *1-3 months | ||
**[[Streptococcus pneumoniae]] | **[[Streptococcus pneumoniae]] | ||
**[[Chlamydia trachomatis]] | **[[Chlamydia trachomatis]] | ||
Line 13: | Line 16: | ||
**[[Bordetella pertussis]] | **[[Bordetella pertussis]] | ||
**[[Staphylococcus aureus]] | **[[Staphylococcus aureus]] | ||
* | *3 months-5 years | ||
**[[S. pneumoniae]] | **[[S. pneumoniae]] | ||
**[[S. aureus]] | **[[S. aureus]] | ||
Line 20: | Line 23: | ||
**[[C. trachomatis]] | **[[C. trachomatis]] | ||
**[[Mycoplasma pneumoniae]] | **[[Mycoplasma pneumoniae]] | ||
*5–18 | *5–18 years | ||
**[[M. pneumoniae]] | **[[M. pneumoniae]] | ||
**[[S. pneumoniae]] | **[[S. pneumoniae]] | ||
Line 35: | Line 38: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pediatric fever DDX}} | {{Pediatric fever DDX}} | ||
{{Pediatric SOB DDX}} | |||
== | ==Evaluation== | ||
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]] | |||
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]] | |||
[[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 | **[[CXR]], consider for: | ||
***Age 0-3mo (as part of sepsis workup) | |||
***<5yr with temperature >102.2, WBC >20K and no clear source of infection | |||
***Age 0-3mo (as part of sepsis | |||
***<5yr with | |||
***Ambiguous clinical findings | ***Ambiguous clinical findings | ||
***Pneumonia that is prolonged or not responsive to antibiotics | ***Pneumonia that is prolonged or not responsive to antibiotics | ||
*Consider rapid assays | *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) | |||
===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}} | {{Pediatric pneumonia treatment}} | ||
Line 55: | Line 85: | ||
''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>'' | ''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=== | ===Consider Admission For=== | ||
*Age: 2-3 months old | *Age: <2-3 months old | ||
*History of severe or relevant congenital disorders | *History of severe or relevant congenital disorders | ||
*Immune suppression (HIV, SCD, malignancy) | *Immune suppression (HIV, SCD, malignancy) | ||
*Toxic appearance/respiratory distress | *Toxic appearance/respiratory distress | ||
*SpO2 <90-93% | *SpO2 <90-93% | ||
*Vomiting/dehydration | |||
*Unstable social environment | |||
==See Also== | ==See Also== | ||
Line 70: | Line 102: | ||
[[Category:Pediatrics]] | [[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
- Most common site of infection in neonates
Bugs by Age Group
- Newborn
- 1-3 months
- 3 months-5 years
- S. pneumoniae
- S. aureus
- H. influenzae type b
- Nontypeable H. influenzae
- C. trachomatis
- Mycoplasma pneumoniae
- 5–18 years
Clinical Features
Fever and tachypnea are sensitive but not specific
Differential Diagnosis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Pediatric Shortness of Breath
Pulmonary/airway
- Airway obstruction
- Structural
- Infectious
- Other
Cardiac
- Congenital heart disease
- Vascular ring
- Cardiac tamponade
- Congestive Heart Failure (peds)
- Myocarditis (peds)
Other diseases with abnormal respiration
- Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
- Brief resolved unexplained event
- Anemia
- Abdominal distension (e.g. SBO, liver failure
- Neonatal abstinence syndrome
- Decreased perfusion states
- Metabolic acidosis
- CO Poisoning
- Diaphragm injury
- Renal Failure
- Electrolyte abnormalities
- Organophosphate toxicity
- Tick paralysis
- Fever (Peds)
- Panic attack
- Porphyria
Evaluation
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
- CXR, consider for:
- 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
- Hospitalized[4]
- Ampicillin (80-90mg/kg/day) + gentamicin +/- cefotaxime
- Add vancomycin if MRSA a concern
- Add erythromycin (12.g mg/kg QID) if concern for chlamydia
- Ampicillin (80-90mg/kg/day) + gentamicin +/- cefotaxime
- Outpatient[5]
- Initial outpatient management not recommended
1-3 Month
- Hospitalized[6]
- Afebrile pneumonitis
- Erythromycin (10 mg/kg q6) or Azithromycin (2.5 mg/kg q12)
- Febrile pneumonia
- Add Cefotaxime (200mg/kg per day divided q8h)
- Afebrile pneumonitis
- Outpatient[7]
- Erythromycin OR Azithromycin PO
>3mo - 18 years
- Hospitalized (PICU/severely ill)[8]
- Ceftriaxone IV AND Vancomycin AND consider Azithromycin
- Hospitalized (moderately ill)[9]
- Fully immunized: Ampicillin (50mg/kg q6) IV
- Not fully immunized: Ceftriaxone IV
- Outpatient[10]
- Amoxicillin (90 mg/kg divided BID) x 10 days PO
- Some studies have shown that 5 day course may also be adequate treatment
- Alternative: Clindamycin OR Azithromycin OR Amoxicillin-clavulanate
- Amoxicillin (90 mg/kg divided BID) x 10 days PO
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
- ↑ Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics. 2019 Jun 19.
- ↑ Feldman C. Pneumonia in the elderly. Clin Chest Med. 1999;20(3):563-573. doi:10.1016/s0272-5231(05)70236-7
- ↑ 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
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ Sanford Guide to Antimicrobial Therapy 2014
- ↑ AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011