Pneumonia (peds)

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Background

  • Most common site of infection in neonates
  • Fever and tachypnea are Sensitive but not Specific

Causes

Neonatal

Age Group Bacterial Pathogens Hospitalized Patients Outpatients
Newborn Group B streptococci Ampicillin Initial outpatient management not recommended
Gram-negative bacilli plus 
Listeria monocytogenes  Gentamicin or cefotaxime
1–3 mo Streptococcus pneumoniae  Afebrile pneumonitis Initial outpatient management not recommended
Chlamydia trachomatis    Erythromycin or clarithromycin
Haemophilus influenzae  Febrile pneumonia:
Bordetella pertussis    Cefuroxime
Staphylococcus aureus    ± erythromycin IV or clarithromycin PO
  Severe: choose one of
    Cefuroxime + erythromycin or clarithromycin
    Cefotaxime + erythromycin
    Cloxacillin + clarithromycin
 

3 mo–5 y

(majority of PNA

in this group is

viral)

S. pneumoniae  Ampicillin IV or cefuroxime IV Amoxicillin
S. aureus  or amoxicillin if PO or amoxicillin-clavulanate
H. influenzae type b
 
or amoxicillin-clavulanate if PO or cefuroxime axetil x7-10d
Nontypeable H. influenzae  Moderate to severe  
C. trachomatis    Add erythromycin or clarithromycin  
Mycoplasma pneumoniae     
5–18 y M. pneumoniae  Ampicillin IV Erythromycinor clarithromycin
 
S. pneumoniae  plus  or amoxicillin ± clavulanate
C. pneumoniae  Erythromycin or clarithromycin or cefuroxime axetil x7-10d
H. influenzae type b
 
Alternative   
S. aureus    Cefuroxime
    or amoxicillin-clavulanate
    or erythromycin  
    or clarithromycin  
  Moderate to severe:  
    Cefuroxime + erythromycin or clarithromycin  

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

Age Group Bacterial Pathogens Hospitalized Patients Outpatients
Newborn Group B streptococci Ampicillin Initial outpatient management not recommended
Gram-negative bacilli plus 
Listeria monocytogenes  Gentamicin or cefotaxime
1–3 mo Streptococcus pneumoniae  Afebrile pneumonitis Initial outpatient management not recommended
Chlamydia trachomatis    Erythromycin or clarithromycin
Haemophilus influenzae  Febrile pneumonia:
Bordetella pertussis    Cefuroxime
Staphylococcus aureus    ± erythromycin IV or clarithromycin PO
  Severe: choose one of
    Cefuroxime + erythromycin or clarithromycin
    Cefotaxime + erythromycin
    Cloxacillin + clarithromycin
 

3 mo–5 y

(majority of PNA

in this group is

viral)

S. pneumoniae  Ampicillin IV or cefuroxime IV Amoxicillin
S. aureus  or amoxicillin if PO or amoxicillin-clavulanate
H. influenzae type b
 
or amoxicillin-clavulanate if PO or cefuroxime axetil x7-10d
Nontypeable H. influenzae  Moderate to severe  
C. trachomatis    Add erythromycin or clarithromycin  
Mycoplasma pneumoniae     
5–18 y M. pneumoniae  Ampicillin IV Erythromycinor clarithromycin
 
S. pneumoniae  plus  or amoxicillin ± clavulanate
C. pneumoniae  Erythromycin or clarithromycin or cefuroxime axetil x7-10d
H. influenzae type b
 
Alternative   
S. aureus    Cefuroxime
    or amoxicillin-clavulanate
    or erythromycin  
    or clarithromycin  
  Moderate to severe:  
    Cefuroxime + erythromycin or clarithromycin  


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

1-3 Month

3mo - 5 year

5yr - 18yr

Age Group Bacterial Pathogens Hospitalized Patients Outpatients
Newborn Group B streptococci Ampicillin Initial outpatient management not recommended
Gram-negative bacilli plus 
Listeria monocytogenes  Gentamicin or cefotaxime
1–3 mo Streptococcus pneumoniae  Afebrile pneumonitis Initial outpatient management not recommended
Chlamydia trachomatis    Erythromycin or clarithromycin
Haemophilus influenzae  Febrile pneumonia:
Bordetella pertussis    Cefuroxime
Staphylococcus aureus    ± erythromycin IV or clarithromycin PO
  Severe: choose one of
    Cefuroxime + erythromycin or clarithromycin
    Cefotaxime + erythromycin
    Cloxacillin + clarithromycin
 

3 mo–5 y

(majority of PNA

in this group is

viral)

S. pneumoniae  Ampicillin IV or cefuroxime IV Amoxicillin
S. aureus  or amoxicillin if PO or amoxicillin-clavulanate
H. influenzae type b
 
or amoxicillin-clavulanate if PO or cefuroxime axetil x7-10d
Nontypeable H. influenzae  Moderate to severe  
C. trachomatis    Add erythromycin or clarithromycin  
Mycoplasma pneumoniae     
5–18 y M. pneumoniae  Ampicillin IV Erythromycinor clarithromycin
 
S. pneumoniae  plus  or amoxicillin ± clavulanate
C. pneumoniae  Erythromycin or clarithromycin or cefuroxime axetil x7-10d
H. influenzae type b
 
Alternative   
S. aureus    Cefuroxime
    or amoxicillin-clavulanate
    or erythromycin  
    or clarithromycin  
  Moderate to severe:  
    Cefuroxime + erythromycin or clarithromycin  
  • High dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice for uncomplicated outpatient community acquired pneumonia[1]
  • For Inpatient treatment of pneumonia preference is to Vancomycin along with a second- or third- generation Cephalosporins.[1]

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%

Source

  1. 1.0 1.1 1.2 1.3 AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.