Pneumonia (peds)
Background
- Most common site of infection in neonates
- Fever and tachypnea are Sensitive but not Specific
Causes
Neonatal
Etiology | Clinical Presentation | Management Approach |
---|---|---|
Bacterial Group B Streptococcus (most common), Escherichia coli, Listeria monocytogenes, Haemophilus influenzae, S. pneumoniae Klebsiella species, Enterobacter aerogenes |
Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment. | 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. |
Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present. | A lumbar puncture should be done if there are no contraindications. | |
Hospitalization, supportive care (O2), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available). | ||
Nosocomial infections in premature infants (Staphylococcus aureus,Pseudomonas aeruginosa) | Same as for common bacterial etiology. | Same as for common bacterial etiology. |
Chlamydia | Develops in 3%–16% of exposed neonates (in colonized mothers). | Sepsis evaluation as indicated. |
CXR may show hyperinflation with interstitial infiltrates. | ||
Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon. | Definitive diagnosis by nasopharyngeal swab PCR or cultures. | |
Eosinophilia may be seen on peripheral blood count. | ||
Treatment: macrolide (erythromycin, clarithromycin, or azithromycin). | ||
Bordetella pertussis |
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. | Sepsis evaluation as indicated. |
Diagnosis via nasopharyngeal swab for PCR and/or culture. | ||
Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis. | ||
Macrolides are efficient against B. pertussis but is not approved by the U.S. Food and Drug Administration for infants <6 mo. | ||
No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin. | ||
Neonates need to be admitted during treatment and monitored for severe adverse effects. | ||
Mycobacterium tuberculosis |
Half of infants born to actively infected mothers develop TB if not immunized or treated. | Sepsis evaluation as for bacterial pneumonia. |
CXR, culture of urine, gastric and tracheal aspirates. | ||
May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission. | Skin testing not sensitive in neonates. | |
Routine anti-TB treatment. | ||
Supportive treatment as needed. | ||
Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly). | ||
Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza) | Initial upper respiratory illness progressing to respiratory distress and feeding difficulty. | Sepsis evaluation as indicated. |
Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab). | ||
Hypoxia and apnea may be present. | ||
Often indistinguishable from bronchiolitis. | Rate of concurrent bacterial infections in confirmed viral infection is low. | |
CXR for significant respiratory distress. | ||
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)
- Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
Bugs by Age Group
- Newborn
- 1mo-3mo
- 3mo-5yr
- S. pneumoniae
- S. aureus
- H. influenzae type b
- Nontypeable H. influenzae
- C. trachomatis
- Mycoplasma pneumoniae
- 5–18 y
Diagnosis
- Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
- Productive cough is rarely seen before late childhood
- Imaging
- CXR is not the gold standard!
- Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
- Consider for:
- 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
- PNA that is prolonged or not responsive to abx
- Consider rapid assays for RSV, influenza
- Blood/nasal culture are low yield
Treatment[1]
Newborn
- Hospitalized
- Ampicillin (80-90mg/kg/day) + (gentamicin OR cefotaxime)
- Outpatient
- Initial outpatient management not recommended
1-3 Month
- Hospitalized
- Afebrile pneumonitis
- Febrile pneumonia
- Cefuroxime ± (erythromycin IV or clarithromycin PO)
- Severe: choose one of
- Outpatient
- Initial outpatient management not recommended
3mo - 5 year
- Hospitalized
- Mild
- PO: Amoxicillin or Amoxicillin-clavulanate
- IV: Ampicillin or cefuroxime
- Moderate or severe
- (Ampicillin or cefuroxime) + (erythromycin or clarithromycin) IV
- Mild
- Outpatient
5yr - 18yr
- Hospitalized
- Ampicillin IV + (erythromycin OR clarithromycin)
- Alternative
- Moderate to severe
- Cefuroxime + (erythromycin or clarithromycin)
- Outpatient
Disposition
- All Children less than 2 months should be hospitalized[1]
- 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%