Basics
Description
- Mechanism is often unknown.
- Source is oropharyngeal aspiration (most common) or hematogenous.
- Distribution depends on the organism: Interstitial (Mycoplasma pneumoniae, virus), lobar (Streptococcus pneumoniae), abscesses (Staphylococcus aureus), or diffuse (Pneumocystis carinii)
Etiology
- <2 wk:
- Group B Streptococcus species
- Enteric gram-negative organisms
- Respiratory syncytial virus (RSV)
- Herpes simplex virus
- S. aureus
- 2 wk " “3 mo:
- Chlamydia trachomatis
- Parainfluenza virus
- RSV
- S. pneumoniae
- S. aureus
- H. influenza
- Bordetella pertussis
- 3 mo " “8 yr:
- Viral (predominate):
- RSV
- Parainfluenza virus
- Influenza virus
- Adenovirus
- S. pneumoniae
- H. influenza in unimmunized children
- Group A streptococcus
- S. aureus
- B. pertussis
- >8 yr:
- M. pneumoniae most common
- Viral
- S. pneumoniae
- Recent immigrants from developing countries:
- Mycoplasma tuberculosis
- H. influenza
- B. pertussis
- Immunocompromised (e.g., HIV, cancer):
- P. carinii
- Mycoplasma avium complex
- M. tuberculosis
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Less common:
- Fungal (coccidioidomycosis, histoplasmosis)
- Rickettsia (Q fever)
Diagnosis
Signs and Symptoms
- General (in all ages):
- Cough
- Rales
- Fever
- Hypoxia
- Tachycardia
- Tachypnea, retractions, grunting
- Rash (up to 10% of cases); usually maculopapular
- Nonspecific symptoms of toxicity
- Pulmonary exam:
- Decreased breath sounds, ventilation
- Dullness to percussion
- Wheezing, ronchi, rales
- Infants <6 mo:
- Altered behavior: Listless, irritable
- Apnea (esp. RSV in premature infants)
- Conjunctivitis (Chlamydia <1 mo old)
- Cyanosis
- Grunting
- Poor feeding
- Temperature instability (hypothermia/hyperthermia)
- Vomiting, often with coughing
- Cough
- Nasal congestion
- Nasal flaring
- Wheezing
- Staccato cough (Chlamydia)
- Children >5 yr:
- Pleuritic chest pain
- Productive cough
- Rigors, chills
History
- Immunization history
- Past medical history include immune status
- Exposures
- Progression of signs and symptoms
Physical Exam
- Pulmonary exam may be helpful, particularly in children >5 yr.
- Peripheral and central cyanosis should be assessed.
- Evidence of respiratory compromise, distress, failure
Essential Workup
- Pulse oximetry
- Chest radiograph:
- Gold standard for diagnosis
- Should be ordered for patients with signs of lower respiratory tract infection and patients <36 mo old with marked leukocytosis or neutrophilia (WBC >15,000 or absolute neutrophil count [ANC] >9,000).
- Much overlap between viral and bacterial findings
- Viral and M. pneumoniae tend to show interstitial infiltrates, often perihilar and peribronchial.
- Bacterial pneumonias may show focal lobar consolidation, focal alveolar infiltrates, and possibly effusion or pneumatocele.
- Round pneumonia pathognomonic of S. pneumonia
- Lateral decubitus films may aid in demonstrating effusion.
Diagnosis Tests & Interpretation
Lab
- CBC with differential:
- Patients with bacteremia tend to have leukocytosis with left shift.
- Sensitivity and specificity are poor.
- Patients with WBC ≥20,000 or ANC >9,000 are at increased risk of pneumococcal bacteremia.
- B. pertussis usually has elevated WBC with lymphocytosis.
- Blood culture:
- Low yield (<10 " “20%)
- Recommended in children <36 mo
- Probably worthwhile in toxic patients requiring hospitalization
- Arterial blood gas may be useful in determining degree of respiratory insufficiency in critically ill patients.
- Electrolytes to exclude syndrome of inappropriate antidiuretic hormone secretion and in hypotensive children
- Sputum for Gram stain and culture may be obtained in older children with suspected bacterial infection.
- Mycoplasma IgM or cold agglutinin titers:
- Useful if suspecting this organism
- More likely positive with severe illness
- Nasopharyngeal washes for direct fluorescent antibody and culture:
- Identify RSV, C. trachomatis, and B. pertussis infections
Imaging
Chest radiographs are still the imaging modality of choice: ‚
- Posteroanterior and lateral films should be obtained whenever possible.
- CT provides additional detail and better identification of underlying lung pathology but adds little as an initial testing modality.
Diagnostic Procedures/Surgery
Pleural fluid (if present) for culture, Gram stain, protein, glucose, and cell counts ‚
Differential Diagnosis
- Reactive airway disease (asthma, bronchiolitis [age <2 yr])
- Aspiration:
- Gastroesophageal reflux
- Vascular ring
- H-type tracheoesophageal fistula
- Foreign body
- Hydrocarbon
- Congestive heart failure
- Congenital:
- Cystic fibrosis
- Sequestered lobe
- Congenital lobe absence
- Hemangioma
- Neoplasm
Treatment
Pre-Hospital
- Pulse oximetry
- Administer high-flow oxygen for respiratory distress.
- IV fluids (0.9% normal saline [NS] 20 mL/kg initial bolus) for volume depletion, hypotension
- Support and intubation for respiratory failure
Initial Stabilization/Therapy
- If moderately or severely ill:
- Secure airway, as appropriate; intubate for clinical respiratory failure. Children with severe sepsis or septic shock benefit from aggressive airway management.
- High-flow oxygen
- IV hydration (0.9% NS 20 mL/kg initial bolus) and resuscitation if in shock or hypovolemia
- Monitor
- Ongoing pulse oximetry
- Arterial blood gas if inadequate ventilation
- Check bedside glucose in severely ill-appearing infants and toddlers:
- If hypoglycemic, administer glucose D25 at 2 mL/kg IV for toddlers or D10 at 5 mL/kg IV for neonates.
Ed Treatment/Procedures
- Continue pre-hospital and initial stabilization therapy.
- Early antibiotic therapy should be broad enough to address local resistance patterns in your area.
- Often have concurrent reactive airway disease that needs specific treatment with bronchodilator (albuterol or levalbuterol)
- Perform thoracentesis if pleural effusion is compromising respiratory function or for diagnostic tests.
Medication
- Empiric therapy with oral antibiotics for most well-appearing children ≥6 mo:
- Infants <2 mo:
- Outpatient treatment generally not recommended unless child has no respiratory distress or associated conditions or issues.
- Children 3 mo " “5 yr:
- Amoxicillin
- Amoxicillin " ”clavulanate
- Trimethoprim " ”sulfamethoxazole
- Erythromycin " ”sulfisoxazole
- Macrolide (azithromycin or clarithromycin)
- Children 5 " “18 yr:
- Macrolide (azithromycin or clarithromycin)
- Initiate IV antibiotic therapy for moderate to severely ill children who require admission:
- Neonate:
- Ampicillin, and cefotaxime or gentamicin
- Azithromycin for suspected C. trachomatis or B. pertussis pneumonia
- Infants 1 " “2 mo:
- Ampicillin and cefotaxime
- Azithromycin or erythromycin for suspected C. trachomatis or B. pertussis
- Children ≥3 mo:
- Cefotaxime, cefuroxime, or ceftriaxone
- Vancomycin for suspected or confirmed penicillin-resistant S. pneumoniae
- Macrolide (i.e., azithromycin) for suspected M. pneumoniae
- Clindamycin if group A strep suspected in patient with severe disease
- Unusual organisms require specific therapy in coordination with infectious disease consultation.
- Albuterol (0.5% solution or 5 mg/mL): Nebulizer 0.015 mg (0.03 mL)/kg per dose up to 5 mg per dose q10 " “20min as needed; metered dose inhaler (with spacer; 90 mg per puff) 2 puffs q10 " “20min up to total of 10 puffs
- Amoxicillin: 80 mg/kg/24 h q12h PO
- Amoxicillin " “clavulanate: 30 mg/kg/24 h q12h PO
- Ampicillin: 100 " “150 mg/kg/24 h q6h IV
- Azithromycin: 10 mg/kg/24 h daily for 1 day, then 5 mg/kg/24 h daily for 4 days
- Cefotaxime: 50 " “75 mg/kg/24 h q8h IV, max. 2 g q8h
- Ceftriaxone: 100 mg/kg/24 h q12 " “24 h IV, max. 2 g q12h
- Cefuroxime: 100 mg/kg/24 h q8h IV, max. 2 g q8h
- Clarithromycin: 15 mg/kg/24 h q12h PO, max. 500 g q12h
- Clindamycin 30 " “40 mg/kg/24 h q6 " “8h IV
- Erythromycin " “sulfisoxazole: 40 mg/kg/24 h as erythromycin q8h PO, max. 2 g/d
- Gentamicin: 5 " “7.5 mg/kg/24 h q8 " “12h IV
- Trimethoprim " “sulfamethoxazole: 8 " “10 mg/kg/24 h as TMP q12h PO
- Vancomycin: 10 " “15 mg/kg/24 h q8 " “12h IV; max. 1,000 mg
Follow-Up
Disposition
Admission Criteria
- Toxic appearance
- Respiratory distress or failure
- Dehydration/vomiting
- Apnea
- Infants <2 mo
- Infants <6 mo with lobar pneumonia
- Hypoxia (O2 saturation <92% on room air [sea level])
- Pleural effusion
- Poor response to outpatient oral therapy
- Immunocompromised children
- Concern about noncompliant parents
Discharge Criteria
- Most cases are mild and can be discharged home if no evidence of hypoxia, significant work-of-breathing, dehydration, vomiting, or noncompliance.
- Ensured follow-up within 1 " “2 days
Issues for Referral
Respiratory failure, effusion, toxicity ‚
Followup Recommendations
Clinical resolution should be ensured through follow-up. ‚
Pearls and Pitfalls
- Early, aggressive airway management for patients with severe sepsis and septic shock
- Delays to antibiotic therapy should be avoided.
- Discharged patients should have clear evidence of good support, follow-up, and lack of toxicity.
- Local patterns of drug resistance should be known and empiric therapy should take these resistance patterns into consideration.
Additional Reading
- Cevey-Macherel ‚ M, Galetto-Lacour ‚ A, Gervaix ‚ A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr. 2009;168(12):1429 " “1436.
- Kronman ‚ MP, Hersh ‚ AL, Feng ‚ R, et al: Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics 2011;127:411 " “418.
- Michelow ‚ IC, Olsen ‚ K, Loranzo ‚ J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004;113(4):701 " “707.
- Murphy ‚ CG, van de Pol ‚ AC, Harper ‚ MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243 " “249.
- Shah ‚ SS, Dugan ‚ MH, Bell ‚ LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia. Pediatr Infect Dis J. 2011;30:475 " “479.
See Also (Topic, Algorithm, Electronic Media Element)
Asthma ‚
Codes
ICD9
- 483.0 Pneumonia due to mycoplasma pneumoniae
- 486 Pneumonia, organism unspecified
- 507.0 Pneumonitis due to inhalation of food or vomitus
- 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
- 480.1 Pneumonia due to respiratory syncytial virus
- 480.9 Viral pneumonia, unspecified
- 482.40 Pneumonia due to Staphylococcus, unspecified
- 483.1 Pneumonia due to chlamydia
- 484.3 Pneumonia in whooping cough
ICD10
- J15.7 Pneumonia due to Mycoplasma pneumoniae
- J18.9 Pneumonia, unspecified organism
- J69.0 Pneumonitis due to inhalation of food and vomit
- J13 Pneumonia due to Streptococcus pneumoniae
- J12.1 Respiratory syncytial virus pneumonia
- J12.9 Viral pneumonia, unspecified
- J15.211 Pneumonia due to methicillin suscep staph
- J16.0 Chlamydial pneumonia
- J17 Pneumonia in diseases classified elsewhere
SNOMED
- 233604007 Pneumonia (disorder)
- 422588002 aspiration pneumonia (disorder)
- 46970008 Pneumonia due to Mycoplasma pneumoniae (disorder)
- 34020007 pneumonia due to Streptococcus (disorder)
- 195881003 Pneumonia due to respiratory syncytial virus
- 233609002 Chlamydial pneumonia
- 441658007 pneumonia due to Staphylococcus aureus (disorder)
- 59475000 Pneumonia in pertussis (disorder)
- 75570004 Viral pneumonia (disorder)