Doctor123.org

Pneumonia—Bacterial, Pediatric

Basics

Description

- Immune deficiency - Immunocompromised status - Sickle cell anemia

- Increased aspiration risk - Altered mental status - Tracheoesophageal fistula - Cerebral palsy - Seizure disorder

- Compromised lung function/anatomy - Cystic fibrosis - Congenital pulmonary malformations - Bronchopulmonary dysplasia - Asthma

- Bronchiolitis - URI - Croup (laryngotracheobronchitis) - Fungal infection (if immunodeficiency or exposure history) - Parasitic infection (if immunodeficiency or exposure history)

- Genetic: cystic fibrosis - Tumors - Lymphoma - Primary lung tumor - Metastatic tumor

- Cardiac: CHF - GI: gastroesophageal reflux disease - Miscellaneous - Foreign body aspiration - Sarcoidosis

- Patients with moderate to severe pneumonia as defined by respiratory distress and hypoxemia (<90%), infants younger than 3 " пїЅ6 months of age, children and infants with pneumonia caused by a pathogen with increased virulence (e.g., community-associated MRSA), and failed outpatient therapy should be hospitalized - Intubation and positive pressure ventilation, if clinically indicated - Empiric antibiotic treatment - All ages - Ampicillin 200 " пїЅ400 mg/kg/24 h (max 12 g/24 h) IV divided q6h (or penicillin 250,000 U/kg/24 h [max 24 million U/24 h] IV divided q6h) - Ceftriaxone 50 " пїЅ100 mg/kg/24 h (max 2 g/24 h) IV divided q12 " пїЅ24h or cefotaxime 200 mg/kg/24 h (max 12 g/24 h) IV divided q8h

Pneumonia is an infection of the lungs involving the alveoli and distal airways. пїЅ пїЅ

Epidemiology

Incidence

  • Highest incidence in children <5 years of age (annual incidence 3 " пїЅ4%)
  • Viral pneumonias still generally comprise a large proportion of pediatric pneumonia.

Risk Factors

  • Immune deficiencyImmunocompromised statusSickle cell anemia
  • Increased aspiration riskAltered mental statusTracheoesophageal fistulaCerebral palsySeizure disorder
  • Compromised lung function/anatomyCystic fibrosisCongenital pulmonary malformationsBronchopulmonary dysplasiaAsthma

Etiology

  • Etiology of bacterial pneumonia differs by age:Neonates: group B Streptococcus, enteric gram-negative rods (e.g., Escherichia coli), Listeria monocytogenes, Haemophilus influenzae, Bordetella pertussis1 " пїЅ3 months: neonate organisms + Staphylococcus aureus, Streptococcus pneumoniae, Chlamydia trachomatis4 months to 4 years: Streptococcus pneumoniae, Staphylococcus aureus, H. influenzae>5 years of age: Streptococcus pneumoniae, H. influenza, Staphylococcus aureus, Mycoplasma pneumoniae, Mycobacterium tuberculosis
  • Etiology can also differ based on risk factors:Aspiration as etiology increases the risk for oral flora including anaerobes such as Bacteroides and Peptostreptococcus.Ventilator-dependent patients are at increased risk for Pseudomonas or Klebsiella infections and infection with other gram-negative rods.Cystic fibrosis increases the risk for Pseudomonas and other more unusual organisms.

Diagnosis

History

  • Fever and/or chills
  • Rapid breathing is a sensitive but nonspecific finding in bacterial pneumonia.
  • Difficulty breathing or shortness of breath is common (can be associated with difficulty feeding in infants).
  • Poor feeding or apnea in young infants
  • Cough is often seen in bacterial pneumonia. B. pertussis pneumonia often presents after a catarrhal phase with a paroxysmal cough and posttussive vomiting.
  • Pleuritic chest pain
  • Abdominal pain and/or vomiting: most often seen with lower lobe pneumonia.
  • Irritability, lethargy, and/or malaise
  • Birth history, including maternal infections (e.g., C. trachomatis can be transmitted to an infant through a mother 's genital tract at delivery)
  • Immunization status: In a fully immunized child, H. influenzae type b, B. pertussis, and S. pneumoniae infections are less common.
  • Recent history of upper respiratory tract infection (URI) or RSV can predispose to bacterial pneumonia.
  • History of repeated bacterial infections may suggest immunodeficiency or cystic fibrosis (both are risk factors for bacterial pneumonia).
  • Exposure to contacts with pertussis, tuberculosis, or history of recent travel
  • Travelers, health care workers, and persons working in prisons or institutional settings are at greater risk for tuberculosis.

Physical Exam

  • Most common findings: oxygen saturation <95%, elevated respiratory rate, nasal flaring, fever, and ill appearance
  • General examination can range from mildly ill appearing to toxic in appearance.
  • Infants may have a paucity of exam findings disproportionate to their appearance and tachypnea.
  • Patients may be dehydrated or in shock.
  • Most children with bacterial pneumonia have fever.
  • Patients with atypical bacterial pneumonia and pertussis are sometimes afebrile.
  • Tachypnea or increased work of breathing: nasal flaring, grunting, and/or retracting
  • Decreased oxygen saturation; therefore, oxygen saturation should be obtained by pulse oximetry in children with tachypnea or other signs of distress.
  • Localized rales, crackles, rhonchi, decreased breath sounds, or wheezing
  • With increasing consolidation, dullness to percussion and decreased breath sounds may be noted.
  • In patients who are actively wheezing, it may be difficult to distinguish rales from other auscultated sounds.

Diagnostic Tests & Interpretation

  • Not indicated for patients with uncomplicated pneumonia
  • In toxic-appearing infants, blood, urine, and CSF cultures (i.e., a sepsis workup) should be considered.
  • Viral testing for RSV, influenza, and other respiratory viruses if readily available can help exclude viral diagnoses in children who are candidates for outpatient therapy.

Lab

  • Blood cultureNot indicated in healthy, immunized children with uncomplicated pneumoniaRarely leads to identification of pathogen causing pneumoniaShould be obtained in children not responding to antibiotic therapy or moderate to severe pneumonia requiring hospitalizationBacteremia has been noted in up to 30% of patients with pneumococcal pneumonia.
  • Elevated peripheral WBC or range 15,000 " пїЅ40,000/mm3 is associated with bacterial pneumonia or even higher WBC in pertussis but should not be relied upon to distinguish etiology of pneumonia.
  • Testing for M. pneumoniae may be considered to guide antibiotic therapy if with signs or symptoms of atypical bacteria.
  • Acute-phase reactants such as ESR, CRP, or others may provide useful information for clinical management in serious disease but cannot distinguish between viral and bacterial etiologies
  • Purified protein derivative (PPD) test or an interferon-gamma release assay (e.g., quantiFERON) should be obtained in all patients in whom M. tuberculosis is suspected.

Imaging

  • Chest radiograph (CXR), uprightA CXR is not required for diagnosis if clinical symptoms and examination findings are consistent with uncomplicated pneumonia.A CXR (PA and lateral) is recommended if pneumonia is suspected but clinical findings are unclear, if the patient has hypoxemia or significant respiratory distress, if a pleural effusion is suspected, or if the patient is not responding to treatment.Characteristic CXR patterns include "alveolar or lobar infiltrate " пїЅ with air bronchograms. "Round " пїЅ infiltrates may be seen with S. pneumococcus. "Diffuse " пїЅ interstitial infiltrates and hyperinflation may be seen with atypical pneumonia such as M. pneumoniae or chlamydial pneumonias.More commonly, CXR cannot be reliably used to distinguish between viral and bacterial disease.An infiltrate may not be seen (negative CXR) if the disease is diagnosed early or if the patient is dehydrated.
  • CXR, lateral decubitus: more sensitive than an upright radiograph in detecting pleural effusions or foreign body aspiration
  • CT scan: not recommended as 1st-line imaging for suspected pneumonia. CT is mainly used as adjunct imaging for patients who are worsening (not improving) despite treatment or have complications.

Diagnostic Procedures/Other

If diagnosis is unclear, consider the following: пїЅ пїЅ

  • Tracheal aspirates for Gram stain and culture if intubation necessary
  • In immunocompetent children, bronchoscopy, bronchoalveolar lavage, percutaneous lung aspiration, or lung biopsy should be reserved for severe pneumonia if initial tests are not diagnostic.

Differential Diagnosis

  • InfectiousSepsisViral pneumoniaInfants: cytomegalovirus (CMV), metapneumovirus, herpes simplex virus (HSV)From 1 to 3 months: CMV, respiratory syncytial virus (RSV), metapneumovirusFrom 4 months to 4 years: RSV, adenovirus, influenza, metapneumovirusBronchiolitisURICroup (laryngotracheobronchitis)Fungal infection (if immunodeficiency or exposure history)Parasitic infection (if immunodeficiency or exposure history)
  • PulmonaryAsthmaAtelectasisPneumonitis (i.e., chemical)PneumothoraxPulmonary edemaPulmonary hemorrhagePulmonary embolism
  • CongenitalPulmonary sequestrationCongenital pulmonary airway malformation
  • Genetic: cystic fibrosis
  • TumorsLymphomaPrimary lung tumorMetastatic tumor
  • Cardiac: CHF
  • GI: gastroesophageal reflux disease
  • MiscellaneousForeign body aspirationSarcoidosis

Treatment

Medications

Outpatient: empiric treatment пїЅ пїЅ

  • Nontoxic, uncomplicated pneumonias in patients older than 3 " пїЅ6 months of age and anticipated to comply with antibiotic therapy may be managed as outpatients.
  • Infants and preschool children (<5 years old)Amoxicillin 80 " пїЅ100 mg/kg/24 h (max 3 g/24 h) PO divided q8 " пїЅ12h
  • School-aged children ( ≥5 years old)Amoxicillin 80 " пїЅ100 mg/kg/24 h (max 3 g/24 h) PO divided q8 " пїЅ12h
  • Consider for additional coverage of atypical bacterial pathogensAzithromycin 10 mg/kg/dose (max 500 mg) PO пїЅ пїЅ 1 day then 5 mg/kg/dose (max 250 mg) PO once daily пїЅ пїЅ 4 daysMay consider clarithromycin 15 mg/kg/24 h (max 1 g/24 h) PO divided q12h or doxycycline 4.4 mg/kg/24 h (max 200 mg/24 h) PO divided by 2 doses in patients 7 years of age or older.
  • If specific pathogen is known or suspected, use appropriate antibiotic therapy.
  • For patients with more severe disease, may consider combining пїЅ пїЅ-lactam antibiotic and macrolide

Inpatient Considerations

  • Patients with moderate to severe pneumonia as defined by respiratory distress and hypoxemia (<90%), infants younger than 3 " пїЅ6 months of age, children and infants with pneumonia caused by a pathogen with increased virulence (e.g., community-associated MRSA), and failed outpatient therapy should be hospitalized
  • Intubation and positive pressure ventilation, if clinically indicated
  • Empiric antibiotic treatment
  • All agesAmpicillin 200 " пїЅ400 mg/kg/24 h (max 12 g/24 h) IV divided q6h (or penicillin 250,000 U/kg/24 h [max 24 million U/24 h] IV divided q6h)Ceftriaxone 50 " пїЅ100 mg/kg/24 h (max 2 g/24 h) IV divided q12 " пїЅ24h or cefotaxime 200 mg/kg/24 h (max 12 g/24 h) IV divided q8h
  • If atypical pathogens suspected, may add macrolide or use as alternative: azithromycin IV or PO using the same initial empiric dosage regimen from above
  • For seriously ill patients, add vancomycin 15 mg/kg/dose IV q6 " пїЅ8h.
  • For antistaphylococcal coverage, add vancomycin 15 mg/kg/dose IV q6 " пїЅ8h or clindamycin 30 mg/kg/24 h IV/PO divided q8h.
  • May also consider macrolides or clindamycin as alternative for cephalosporin-allergic patients

Ongoing Care

Follow-up Recommendations

Patient Monitoring

  • Children on appropriate therapy should show improvement within 48 " пїЅ72 hours.
  • If worsening or not responding to treatment, consider repeated or additional diagnostic studies. For example, persistent fever may be due to loculated pleural fluid or an empyema.
  • For additional antibiotic guidance for children not improving, consider pediatric infectious disease consultation.
  • CXR may be abnormal for up to 10 weeks after successful treatment. Consider follow-up CXR only if indicated for severe disease, clinical progression, or suspected complications (e.g., effusion, empyema).
  • For children with recurrent bacterial pneumonia, consider an underlying anatomic or immunologic disorder (e.g., abnormal antibody production, cystic fibrosis, tracheoesophageal fistula, pulmonary sequestration).

Complications

  • Pleural effusion
  • Empyema
  • Lung abscess
  • Pneumatoceles
  • Pneumothorax
  • Bacteremia/sepsis

Additional Reading

  • Bradley пїЅ пїЅJS, Byington пїЅ пїЅCL, Shah пїЅ пїЅSS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25 " пїЅe76. пїЅ пїЅ[View Abstract]
  • Kabra пїЅ пїЅSK, Lodha пїЅ пїЅR, Pandey пїЅ пїЅRM. Antibiotics for community acquired pneumonia in children. Cochrane Database Syst Rev. 2006;(3):CD004874. пїЅ пїЅ[View Abstract]
  • Lee пїЅ пїЅGE, Lorch пїЅ пїЅSA, Sheffler-Collins пїЅ пїЅS, et al. National hospitalization trends for pediatric pneumonia and associated complications. Pediatrics. 2010;126(2):204 " пїЅ213. пїЅ пїЅ[View Abstract]
  • McIntosh пїЅ пїЅK. Community-acquired pneumonia in children. N Engl J Med. 2002;346(6):427 " пїЅ437. пїЅ пїЅ[View Abstract]
  • Ranganathan пїЅ пїЅSC, Sonnappa пїЅ пїЅS. Pneumonia and other respiratory infections. Pediatr Clin North Am. 2009;56(1):135 " пїЅ156. пїЅ пїЅ[View Abstract]

Codes

ICD09

  • 482.9 Bacterial pneumonia, unspecified
  • 482.32 Pneumonia due to Streptococcus, group B
  • 482.82 Pneumonia due to escherichia coli [E. coli]
  • 482.2 Pneumonia due to Hemophilus influenzae [H. influenzae]
  • 482.0 Pneumonia due to Klebsiella pneumoniae
  • 482.1 Pneumonia due to Pseudomonas
  • 482.89 Pneumonia due to other specified bacteria
  • 482.49 Other Staphylococcus pneumonia
  • 484.3 Pneumonia in whooping cough

ICD10

  • J15.9 Unspecified bacterial pneumonia
  • J15.3 Pneumonia due to streptococcus, group B
  • J15.5 Pneumonia due to Escherichia coli
  • J14 Pneumonia due to Hemophilus influenzae
  • J15.0 Pneumonia due to Klebsiella pneumoniae
  • J15.8 Pneumonia due to other specified bacteria
  • J15.7 Pneumonia due to Mycoplasma pneumoniae
  • J15.1 Pneumonia due to Pseudomonas
  • A37.11 Whooping cough due to Bordetella parapertussis w pneumonia

SNOMED

  • 53084003 Bacterial pneumonia (disorder)
  • 195886008 Group B streptococcal pneumonia (disorder)
  • 51530003 Pneumonia due to Escherichia coli
  • 70036007 Haemophilus influenzae pneumonia
  • 59475000 Pneumonia in pertussis (disorder)
  • 41381004 Pneumonia due to Pseudomonas (disorder)
  • 233607000 Pneumococcal pneumonia (disorder)
  • 64479007 Pneumonia due to Klebsiella pneumoniae
  • 22754005 Staphylococcal pneumonia (disorder)

FAQ

  • Q: What are the indications for admission and inpatient treatment of pneumonia in children?
  • A: Failure of outpatient therapy, moderate to severe pneumonia as defined by respiratory distress and hypoxemia, infants younger than 3 " пїЅ6 months of age, children and infants with pneumonia caused by a pathogen with increased virulence (e.g., community-associated MRSA)
  • Q: What is the appropriate duration of therapy for bacterial pneumonia?
  • A: Empiric treatment courses of 10 days have been studied the most, although shorter courses may be effective in uncomplicated disease. Pneumonias caused by some pathogens (e.g., CA-MRSA) may require longer duration.
  • Q: What is the most common causative organism of pulmonary abscess, and what is the appropriate treatment?
  • A: S. aureus is the most common causative organism. Treatment includes IV vancomycin, IV or PO clindamycin, or PO linezolid. If MSSA is confirmed cefazolin, nafcillin, or cefuroxime may be used.
  • Q: Which children are most likely to have systemic complications from community-acquired pneumonia? Local complications?
  • A: An analysis of inpatient data from pediatric hospitals from 1997 to 2006 suggests that children <1 year of age are more likely to have systemic complications (e.g., sepsis, acute respiratory failure), whereas patients aged 1 " пїЅ5 years are more likely to have local complications (e.g., empyema, abscess).
  • Q: What are risk factors for invasive pneumococcal disease?
  • A: Conditions associated with invasive pneumococcal disease include congenital immune deficiency (e.g., B- or T-lymphocyte deficiencies) asplenia/functional hyposplenism, complement deficiency, diseases associated with immunosuppressive therapy or radiation therapy (including malignancies), and solid organ transplantation and chronic cardiac disease.