October 2011 Volume 66 Supplement 2

Thorax
AN INTERNATIONAL JOURNAL OF RESPIRATORY MEDICINE

Guidelines for the management of
community acquired pneumonia in
children: update 2011

British Thoracic Society
Community Acquired Pneumonia in
Children Guideline Group

thorax.bmj.com

Michael Harris, Julia Clark, Nicky Coote, Penny Fletcher,
Anthony Harnden, Michael McKean,
Anne Thomson

Community Acquired Pneumonia in Children Guideline Group
On behalf of the British Thoracic Society
Standards of Care Committee

UK T: +44 (0)20 7383 6373 F: +44 (0)20 7383 6668 E: thorax@bmjgroup. Copyright: Ó 2011 BMJ Publishing Group Ltd and the British Thoracic Society. Statements in the Journal are there sponsibility of their authors and advertisers and not authors’ institutions. photocopying. Thorax is intended for medical professionals and is provided without warranty. the British Thoracic Society or the BMA unless otherwise specified or determined by law. UK. Readers are advised to verify any information they choose to rely on.com ISSN: 0040-6376 (print) ISSN: 1468-3296 (online) Disclaimer: Thorax is owned and published by the British Thoracic Society and BMJ Publishing Group Ltd. Chennai. tort or otherwise. stored in a retrieval system or transmitted in any form or by any means. All rights reserved. no part of this publication may be reproduced.53 ii18 9. General management in the community and BTS guidelines in hospital ii1 Abstract ii15 8. Incidence and economic consequences ii19 10. Prevention and vaccination P Cullinan (UK) C Lloyd (UK) Associate Editors R Beasley (New Zealand) A Jones (UK) ii5 3. typeset by TNQ Books & Journals. express or implied. India and printed in the UK on acid-free paper by Buxton Press. Audit criteria J Brown (UK) E Lim (UK) JC Celedón (USA) N Maskell (UK) A Custovic (UK) JL Pepin (France) A Fisher (UK) P Gibson (Australia) T Sethi (UK) M Steiner (UK) ii8 4. Aetiology ii20 11. injury or damage resulting from the use of Thorax or any information in it whether based on contract. Buxton. Periodicals postage paid at Rahway. London WC1H 9JR. Contents Volume 66 Supplement 2 | THORAX October 2011 ii14 7. USA. the BMJ Publishing Group Ltd. NJ. a wholly owned subsidiary of the British Medical Association. Introduction and methods A Bush (UK) I Pavord (UK) Deputy Editors ii3 2. recording or otherwise without the prior permission of Thorax. POSTMASTER: send address changes to Thorax. Radiological. BMA House. Complications and failure to improve Editors ii2 1. Thorax follows guidelines on editorial independence produced by the World Association of Medical Editors and the code on good publication practice of the Committee on Publication Ethics. NJ. To the fullest extent permitted by law. Avenel. 365 Blair Road. mechanical. The owners grant editorial freedom to the Editor of Thorax. . Tavistock Square. Thorax (ISSN No: 0040–6376) is published monthly by BMJ Publishing Group and distributed in the USA by Mercury International Ltd. Acceptance of advertising does not imply endorsement. Clinical features ii20 References J Grigg (UK) D Thickett (UK) D Halpin (UK) H Zar (South Africa) Statistical Editors ii9 5. Mercury International Ltd. electronic. Antibiotic management ii1 Synopsis of recommendations Journal of the British Thoracic Society Impact Factor: 6. Severity assessment Online Appendix 2 Template data collection form President. general and microbiological J Gibson (UK) investigations Online Appendix 1 Search strategy Statistical Advisor T McKeever (UK) Lung Alert Editor J Quint (UK) ii13 6. Thorax is published by BMJ Publishing Group Ltd. British Thoracic Society E Neville Editorial Office BMJ Publishing Group Ltd. the BMJ Publishing Group Ltd shall not be liable for any loss. 07001.

Mycoplasma and Chlamydia. [D] Accepted 16 June 2011 and should not be tested routinely. < Children who have oxygen saturations <92% Hammersmith Hospital. culture. [B+] – If present. Newcastle have community acquired pneumonia (CAP). [C] smallest nostril. [A+] device. Newcastle persist and/or they are not responding to upon Tyne. The John not have a chest x-ray. in 2002 and covered available evidence to early 2000. Investigations Headington.3 Penny Fletcher. [B+] children when there is persistent or repetitive 4 Pharmacy Department. University of Oxford.58C together with chest recession and College Healthcare NHS Trust. breathing air should be treated with oxygen ment of uncomplicated pneumonia and should given by nasal cannulae. UK [A] breathing or if the child is becoming distressed < Children with signs and symptoms of pneu- Correspondence to or agitated.5 Michael McKean. UK management. If use cannot be avoided. UK a raised respiratory rate.4 Anthony Harnden. UK evidence was not found. head box or face mask to maintain < Microbiological diagnosis should be attempted oxygen saturation >92%. doi:10. < A lateral x-ray should not be performed < Families of children who are well enough to be Headington. < Chest physiotherapy is not beneficial and should orescence. Oxford OX3 9DU. [C] not be performed in children with pneumonia.1 Julia Clark. London. evidence since then and consensus clinical opinion where the general practitioner with persistent fever or Oxford. Great hospital should be reassessed if symptoms North Children’s Hospital. [D] Anne Thomson.uk < Acute phase reactants are not of clinical utility on managing fever. Headington. potassium. [C] these files please visit the journal online (http://thorax. pleural fluid should be sent for Antibiotic management microscopy. [B] cared for at home should be given information UK. Royal a routine investigation in children thought to cally if there is persistence of fever 48 h after Victoria Infirmary. This document incorporates parental concern about persistent fever should 2 Department of Paediatric material from the 2002 guidelines and supersedes the prompt consideration of CAP. Severity assessment 1 These updated guidelines represent a review of new < For a child in the community. increased work of upon Tyne. [A] tory viruses. London. [D] 5 possibility of a pneumonia complicated by Department of Primary Health effusion and should trigger a referral to hospital. [A] General management Radcliffe. [C] for viral detection by PCR and/or immunoflu. [D] < Microbiological methods used should include: < Plasma sodium.66:ii1eii23. with a dull percussion note should raise the St Mary’s Hospital. Oxford monia who are not admitted to hospital should Children’s Hospital.nhs. guidelines for community acquired pneumonia in children com). Care.2 Nicky Coote. BTS guidelines British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011 Michael Harris. – Acute and convalescent serology for respira. Oxford. [D] Immunology and Infectious previous guideline document. high flow delivery not be measured routinely. UK treatment. Headley Way. < Children with CAP in the community or in Diseases. preventing dehydration and Received 10 June 2011 in distinguishing viral from bacterial infections identifying any deterioration. [B] in children with severe pneumonia sufficient to < Nasogastric tubes may compromise breathing require paediatric intensive care admission.bmj. The John Radcliffe. the considered routinely in those with milder smallest tube should be passed down the disease or those treated in the community. or and should therefore be avoided in severely ill those with complications of CAP. [C] children and especially in infants with small < Microbiological investigations should not be nasal passages. Old COPD. [C] nine should be measured at baseline and at least – Nasopharyngeal secretions and/or nasal swabs daily when on intravenous fluids. To view The British Thoracic Society first published management should not be done in young children.1136/thoraxjnl-2011-200598 ii1 . anne. pneumococcal antigen < All children with a clear clinical diagnosis of detection and/or PCR. UK [B] 6 < Chest radiography should not be considered < Department of Paediatric A child in hospital should be reassessed medi- Respiratory Medicine. re-consultation to Oxford Children’s Hospital.thomson@orh. Imperial Clinical features < Bacterial pneumonia should be considered in should be referred to hospital for assessment and College Healthcare NHS Trust. Imperial < Auscultation revealing absent breath sounds fever >38. [D] 3 SYNOPSIS OF RECOMMENDATIONS Children’s Ambulatory Unit. initiation of treatment. Royal Victoria Infirmary. routinely. urea and/or creati- – Blood culture. [C] pneumonia should receive antibiotics as bacterial Thorax 2011. [A] < Patients whose oxygen saturation is #92% while < C reactive protein is not useful in the manage.1 On behalf of the British Thoracic Society Standards of Care Committee < Additional appendices are ABSTRACT – Urinary pneumococcal antigen detection published online only.6 Anne Thomson.

They do not include neonates. This [D] we have endeavoured to do. majority of pathogens which cause CAP in this group. where pathogens are isolated. pneumonia and need not be treated with antibiotics but reflecting the difficulties in obtaining an x-ray. cefuroxime and cefotaxime Scope of guidelines or ceftriaxone. These and the results are shown in appendix 1 in the online updated guidelines represent a review of new evidence since then supplement. No external funding was obtained to support the be considered in those with a round pneumonia. [D] management based on the available evidence. because of vomiting) CAP guideline. [D] management of children with pre-existing respiratory disease or that of opportunistic pneumonias in immunosuppressed chil- dren is not addressed. which have also been updated. co-amoxiclav is tion of evidence statements and recommendations about recommended. A history of Ideally. [D] children in the UK. We have then produced a combina- < In pneumonia associated with influenza. < Macrolide antibiotics should be used if either mycoplasma or In creating guidelines it is necessary to assess all available chlamydia pneumonia is suspected or in very severe disease. BTS guidelines and viral pneumonia cannot reliably be distinguished from infection which has been acquired outside hospital. This from 2000 onwards. However. cefaclor. The Cochrane Library (DARE and Cochrane Database of As before. co-amoxiclav. These can be rationalised if a microbiological These guidelines address the management of CAP in infants and diagnosis is made. [D] paediatrician with a special interest in ambulatory paediatrics. [C] studies that a pathogen is not identified in a significant < Amoxicillin is recommended as first choice for oral antibiotic proportion of cases that otherwise meet the clinical definition therapy in all children because it is effective against the (see Section 3). persisting symptoms. INTRODUCTION AND METHODS A search strategy was developed by an information specialist The British Thoracic Society (BTS) first published management from the Centre for Reviews and Dissemination in York (part of guidelines for community acquired pneumonia (CAP) in children the National Institute for Health Research). In developed each other. evidence with consideration of the quality of that evidence. [D] < Recommended intravenous antibiotics for severe pneumonia Methods of guideline development include amoxicillin. An < Follow-up radiography is not required in those who were information specialist developed the search strategy and ran the previously healthy and who are recovering well. but should searches. These questions were pneumonia in children when the child is unable to tolerate set based upon previous guidelines and those raised in the adult oral fluids or absorb oral antibiotics (eg. a general to near normal. supplemented by < Antibiotics administered orally are safe and effective for consensus clinical opinion where no relevant evidence was children presenting with even severe CAP and are recom. a paediatrician with have recovered completely and their chest x-ray has returned a special interest in paediatric infectious diseases. [D] better diagnostic methods. Studies were limited to English symptoms of pneumonia in a previously healthy child due to an language in view of the limitations on time and resources.1136/thoraxjnl-2011-200598 . The Search strategy in 2002 and covered available evidence to early 2000. a specialist trainee in paediatrics. [B+] Identification of evidence 1. Complications < If a child remains feverish or unwell 48 h after treatment has commenced. ii2 Thorax 2011. [C] countries this can be verified by the radiological finding of < Children aged <2 years presenting with mild symptoms of consolidation. infants with < In a patient who is receiving intravenous antibiotic therapy respiratory syncytial virus bronchiolitis or children with upper for the treatment of CAP. sensitivity to detect all relevant pathogens. oral treatment should be considered respiratory tract infection. Guideline development group eration given to possible complications. the definition would include the isolation of conjugate pneumococcal vaccination gives greater confidence a responsible organism. or presents with signs of septicaemia or complicated pneumonia. As it is assumed that CAP is caused by infection. In the developing world a more practical lower respiratory tract infection do not usually have termdacute lower respiratory tract infectiondis preferred. azithromycin and clarithromycin. MEDLINE and EMBASE were searched those produced for adults. is well the presumption is that current techniques have insufficient tolerated and cheap. [B] therefore have to assume that. < Macrolide antibiotics may be added at any age if there is no they represent all likely pathogens. found. empyema and lung dards of Care Committee and comprised two paediatricians abscesses should be followed up after discharge until they with a special interest in respiratory disease. The specific if there is clear evidence of improvement. There were some technical changes made document incorporates material from the 2002 guidelines and to the original search strategies to reduce the chances of missing supersedes the previous guideline document. [D] The guideline development group was set up by the BTS Stan- < Children with severe pneumonia. should be reviewed if symptoms persist. these guidelines have been produced in parallel with Systematic Reviews).66:ii1eii23. re-evaluation should be performed with consid. mended. it is apparent from many to this decision. Alternatives are co-amoxiclav. collapse or development of the guidelines. doi:10. a general practitioner with an Follow-up interest in childhood infection and a paediatric pharmacist. There is a clear need for response to first-line empirical therapy. and consensus clinical opinion where evidence was not found. [A+] The guideline is framed in each chapter as a list of key ques- < Intravenous antibiotics should be used in the treatment of tions that are then explored and discussed. mild fever and wheeze. studies: a single search strategy was used rather than separate CAP can be defined clinically as the presence of signs and strategies for each subject. Treatment guidelines erythromycin.

2) in children aged 0e16 years and 28. BTS guidelines Two thousand and seventy-six studies were identified by the (temperature.8[III] In the UK. This was repeated after the findings and chest x-ray) in 2001e2 (n¼750) from a prospective second search by another reviewer. 10 000 in children aged 0e16 years per annum and 33. 32. The draft guideline was 10 000 population. 2.2 Are there pathogen-specific incidence rates? guideline statement grades used As discussed in Section 3. bronchiolitis and Provenance and peer review croup) presenting to primary or secondary care from 1999 to The draft guideline was made available online for public 2001.8 for those Two reviewers then assessed the studies for inclusion.7 very different from the UK were excluded unless they addressed (26. and 150. included children with lower respiratory tract infection (including pneumonia.9[III] Thorax 2011. the question examined. The studies were appraised using the Cochrane data pneumonia (clinical assessment plus chest x-ray in 96.DE (Paediatric Respiratory Infection in Germany) Review of the guideline study. admission reported previously from the 1980s in Finland. determining the aetiology of pneu- Guideline monia is critically dependent on the thoroughness of the search Evidence statement and the methods used. a summative the same Schleswig-Holstein area of Germany conducted in evidence level was attached to each statement depending on the 1999e2001 from parental interviews at school entry permitted level of evidence underpinning that statement. IVb) by the authors of each chapter. Data from Ia A good recent systematic review of studies A+ an enhanced surveillance system for laboratory-confirmed inva- designed to answer the question of interest sive pneumococcal disease (IPD) in England and Wales from Ib One or more rigorous studies designed to answer A 1996 to 2000. bronchitis. Then.1 First.1%) extraction template (see appendix 2 in online supplement).3 in those aged 0e1 year.2e31. Finally.79/10 000 following the introduction of conju- children aged <16 years seen in hospital with pneumonia gate pneumococcal vaccine (PCV7) to the national childhood immunisation programme.7[II] This prospective cohort study was designed to repre- The guideline is due for review in 3 years from the date of sent the German population of children aged <3 years and publication.9[III] Table 1 Brief description of the generic levels of evidence and 2.1 How common is CAP in children in the community and in The incidence of all-cause and pneumococcal pneumonia in hospital? children aged <2 years and pneumococcal pneumonia in chil- Two recent European papers give incidence rates for CAP in dren aged 2e4 years decreased in the USA after pneumococcal children seen in hospital (table 2) which are lower than those vaccination (PCV) became universal. each the calculation of population-based incidence of all CAP diag- recommendation was graded (A to D) based upon a considered nosed by physician as 181. doi:10. In addition. The relevant titles and population-based study in 13 hospitals in the north of England abstracts were grouped by subject matter with many papers are remarkably similar with overall incidence rates of 14. INCIDENCE AND ECONOMIC CONSEQUENCES pneumonia (101/10 000). but not formally combined related to pneumonia or pneumococcal disease and data from II One or more prospective clinical studies B+ which illuminate.1 in those aged 0e2 Assessing the literature years.8%) and almost Any guideline statements made were graded using the same certainly what in the UK would be called bronchiolitis. inpatients (294/10 000 population. Recently there have been attempts to level Definition grade estimate the contribution of pneumococcal disease. wheeze. but do not rigorously answer. clinical signs and chest x-ray infiltrate in previ- searches.66:ii1eii23. included children with comorbidities (22. incidence rates per 10 000 of 14. from 59.8 in children aged the question 10e14 years (table 3).5/10 000 in those aged 0e5 years. each paper was given an evidence level (Ia to 65.3e13. hospitalised) party. The updated search ously well child) from 2003 to 2005 in Oslo gave population identified a further 511 titles.7 in children aged 0e16 years.2 (11. These rates are lower than the pre- IVa Formal combination of expert views C conjugate vaccine data on hospital admissions coded for pneu- IVb Other information D monia with pneumococcal disease from the USA.5[II] The table as that used by the group developing the adult guidelines overall incidence per 10 000 was 30 in children aged 0e16 years.1/10 000 in children aged 0e1 year judgement of the body of evidence. which were rerun in July 2010. 95% CI 2770 to 2970) and 114 were given reviewed by the BTS Standards of Care Committee (July 2010/ a clinical diagnosis of pneumonia (137/10 000).8 in those aged 0e5 years and 111. Rates of those admitted to hospital were less at from countries where the populations or clinical practices were 12. at the end of each A series of retrospective population-based cohort studies from chapter when evidence statements were collated.4) in those aged 0e5 years. but do not rigorously weekly Royal College of General Practitioner returns. together with hospital episode statistics for codes the question.4[II] questions that could be generalised to the UK (such as clinical A population-based study performed in Kiel. were answer.3[III] Initial review of the 2076 titles and abstracts was undertaken by UK data for children seen at hospital with pneumonia (clinical one reviewer. Studies aged <5 years. 2924 March 2011).2[Ib] rates for childhood pneumonia decreased by 19% between 2006 A prospective population-based study of 278 Norwegian and 2008 to 10.1136/thoraxjnl-2011-200598 ii3 .7 in infants aged <1 month to 0. 95% CI 284 to 304) were included in the study with 1004 given a clinical diagnosis of 2. Germany from assessment). (table 1).7[II] Age-specific incidence rates per 100 000 population III One or more retrospective clinical studies B were calculated for non-meningitis confirmed IPD and ranged which illuminate. A total of 2386 children were seen as outpatients (2870/ consultation (January/February 2011).6[III] Further estimates of pneumonia incidence can be obtained from the PRI. screening for relevance.4 per being relevant for more than one subject area. Any differences of opinion were settled by a third 1996 to 2000 of children (n¼514) with severe (ie.8 in those aged 0e5 years and 42.

3 Are there any known risk factors? Mycoplasma infection occurs in clusters but has no clear In the UK study. Severe disease as assessed by the BTS management guidelines published in 2002 was significantly more likely in children aged 2. prescribed in the community and in hospital.7 days).7 to 25. The average cost per admitted patient (n¼636) was £2857.16 monia in 199912[III] calculated the costs of hospital management.7/10 000.7 50.9/10 000 and 0.13[II] A total of 1329 cases in primary care of all cases.8 to 64. ii4 Thorax 2011.4) Germany (PRI.14[III] also reported a low incidence of hospital CAP in summer and Resource use data were routinely collected in the North of a peak in January.8 1. Standard NHS list cost data were applied and inflated to 2005/6 levels. of age with lower respiratory tract infection. 2.1) UK Pneumonia Signs and CXR 33.5 days). 0.4) 12.4 21. patchy pneumonic otics. lobar and In the PRI. demonstrating cost savings of 10e14 years 0.85).DE) Pneumonia Clinical including 137 comorbidity Germany Pneumonia Clinical by parental 181.66:ii1eii23.7 to 1 £473e518 per child when oral amoxicillin was used.6 pneumonia comorbidity CXR. seasonality.7)/10 000 per year.07 to 2.11[III]12[III]13[II] Parainfluenza 3. Parental costs suggested this may also be true in children.4 to 21. personal communication.7/ switched to the oral route after 24e48 h and to V1066 (£958) in 10 000) than lobar (5. to 13. Cost anal- 1e11 months 23.6/10 000) and perihilar changes (7. BTS guidelines Table 2 Incidence per 10 000 population Definition of Age 0e1 year Age 0e2 years Age 0e3 years Age 0e5 years Age 0e16 years Country Disease pneumonia (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Whole population data Norway Pneumonia Signs and CXR 42.6 to 2 the health service were lower at £1410 for intravenous treat- 5e17 years 3.11[III] Senstad et al for those seen in primary care.5. For those classified as The use of gastric acid inhibitors is associated with an pneumonia.3.4 (95% CI 17. Overall. Hospitalisation Age group pneumonia (UK) CI pneumonia (USA) (non-intensive care) costs accounted for 70% of the total with >1 month 59. the rates of patchy.4 to 10. A number of recent studies have examined the economic costs of 95% CI 1. lobar pneumonia accounted for only 17.DE study of infants and children up to 36 months perihilar changes were 2.2 cillin in children admitted to hospital.5/10 000.7 (12.8) 14.7 days) sepsis and Pneumococcal and £909 in mild cases (hospital stay 1.3) 32.1 (Schleswig-Holstein) interview Admitted to hospital UK Pneumonia Signs and CXR 28.11) and in those born at 24e28 weeks gestation CAP. In an Israeli study. while.8 (31. doi:10.2 to 31.1136/thoraxjnl-2011-200598 .8 (26. An Italian study of 99 children hospitalised with pneu- compared with those born at >37 weeks (OR 4. and number of is found throughout the year.8 a further 25% accounted for by intensive care stays.1 What is the effect of seasonality? mation on indirect family costs for a child with CAPdsuch as A marked seasonal pattern with winter preponderance was seen days of work missed.2/10 000) those treated exclusively with oral antibiotics. chest x-ray.8 to 38.2 to 17.2 ysis has also been performed on the PIVOT trial.02. The mean Table 3 Incidence rate per 100 000 population cost for severe pneumonia was £3513 (mean hospital stay Pneumococcal 5. influenza 2009[IVb]). falling to £2325 in moderate (hospital stay 4.3[III] There is marked seasonal variation in viral England CAP study 2001e2 (J Clark.9 9.DE) Pneumonia Clinical including 107 comorbidity USA All-cause Coding including 129.8 0.7 (26. direct medical costs were V85 (£76) per office-based increased risk of pneumonia in adults. in those aged 5e15 years.4 equivalence for oral amoxicillin and intravenous benzyl peni- 2e4 years 27.5 ment and £937 for oral treatment.15[III] The average costs to 5e9 years 1. This included preadmission GP visits.8 30 bronchiolitis including comorbidity Germany (PRI.6% data were collected.4 What are the economic consequences of CAP in children? <5 years (19. The costs were reduced to V1218 (£1094) in those changes were more common in those aged <5 years (18.2 controlled equivalence trial that demonstrated therapeutic 1e4 years 9. travel costs to primary/secondary cared for laboratory-reported IPD and hospital admissions due to amounted to 976 Israeli shekels (£161) for hospitalised patients.1 (32 to 52. December and January 747 (£123) for those seen at emergency facilities and 448 (£73) showed a peak 3e5 times higher than August. economic resource respectively.4 to 15. A single study has case and V2306 (£2072) per hospitalised case.3 to 13.10[III] amounted to a further V53 (£47) per office-based case and V118 (£106) per hospitalised case.1 to 36. however.2 (11. OR 1. The mean cost per patient was V1435 (£1289). antibiotics and parainfluenza 1+2. a randomised 0e2 years 26. increasing to When based on the pattern of changes on the chest x-ray V2553 (£2294) in those treated solely with intravenous antibi- (defined as patchy.4[II] boys had higher incidence rates at all ages. infections such as respiratory syncytial virus (RSV).7) 14. 95% CI 1. and 2039 hospitalised cases were analysed.4 (13. further infor- 2. confirmed pneumococcal infection.7[II] days of hospital care including any intensive care.2) Germany (Kiel) Pneumonia and Signs and CXR 111.3 65. lobar or perihilar).1 150.

30[II] However.2% reduction. cover years 2000e10. 3.28[Ib]32[Ib]24[Ib] In the UK during a 6-month winter influenza season. Most studies are designed to indirect evidence of vaccine efficacy for the prevention of investigate specific pathogens.9% of cases24[Ib]33[Ib]34[Ib]35[Ib] and human age and those born between 24 and 28 weeks gestation have bocavirus has recently been isolated from 4.40[Ib] There are no UK data on the detected.16[II]17[Ib]18[II]19[II]20[II]24[II]37[II] It is commonly found in a certain pathogen. and also to blood.36[Ib] a higher incidence of severe disease.29[Ib] case definition includes clinical findings compatible with pneu.1 What are the causes of CAP? bacteria. All constitute levels of 19F and 23F being implicated more frequently in IPD and sero- evidence of Ib or II (indicated). Overall.26[II]28[Ib]32[Ib]29[Ib] It is also apparent that a significant with PCV943[Ib] and 23. although serotype column. monia together with radiological changes. Streptococcus pneumoniae is assumed to be the season of the year in which the study was done. with serotypes 14. In some studies it was not possible to determine 1 has been predominantly responsible for empyema. the potential annual direct medical costs of 3. as well as of S pneumoniae is positive in 4e10% of cases of whether or not the study period coincides with an epidemic of CAP. Bacterial data on serotypes identified in bacteraemic pneumonia in chil- isolates are not included if isolated from a sputum or upper dren from Italy since the introduction of PCV7 found serotypes respiratory tract specimen in the absence of other evidence of 1 and 19A to be the most common.21[II]22[Ib] with the conjugate PCV have detected S pneumoniae in around 44%. there are direct costs to families and indirect costs to immunofluorescence.509 million. studies found 39% identified S pneumoniae.4% in California with PCV7.2% in Korea.44[Ib] A recent study of 23e33% of cases. RSV. In these. varicella zoster and chest radiograph infiltrate in a previously well child is virus.1 Which viruses are associated with CAP? children aged 0e16 years admitted to hospital in the UK with A number of viruses appear to be associated with CAP. the diagnostic yield has improved shown a decrease in radiologically-confirmed pneumonia from since 2000. including the UK. pneumoniae in 90% either by culture or PCR. viruses 3. 19A.2 Which bacteria are associated with CAP? Other factors which also limit the ability to extrapolate the Quantifying the proportion of CAP caused by bacteria is results of published studies to other populations include the more difficult. defined as fever. the age of those most common bacterial cause of CAP but is infrequently studied. thus increasing respiratory based PCR is increasingly used and validated. with a pathogen identified in 65e86% of 23% in the Philippines using PCV1142[Ib] to 37% in the Gambia cases.7[II] Influenza virus was annum is spent on children with CAP admitted to hospital. A review of lung tap techniques that include relatively small sample sizes. However.5/ Several new viruses have been identified and are regularly 10 000 in those aged 0e16 years. In detected relatively infrequently in paediatric pneumonia using addition. the pneumonia are £12e18 000/10 000 per annum.44[Ib] The number of cases of CAP represent a mixed infection. were sero- was detected. Children <5 years of identified in 8e11.17[Ib]28[Ib]29[Ib] PCV11 found that. Human metapneumovirus has been < Boys have a higher incidence at all ages. £13e20 million per in the community and in hospital.66:ii1eii23. blood or pleural fluid culture to hospital and the local criteria for admission. 16% of children with pneu- Evidence statements monia had influenza A.2% in Spain24[Ib] and 15.29[Ib]24[Ib] Overall.5% of cases. all trials have consistently widely at aetiology. either viruses or Mycoplasma/ pneumonia can be used to assess the contribution of S pneumo- Chlamydia. whether or not the children were admitted found in blood cultures.1. although 34% of radiologically-confirmed Thorax 2011. therefore. herpes simplex virus and enteroviruses.22[Ib] Both these serotypes are significancedfor example. increasing pneumococcal incorporating this into diagnosis in children not immunised detection.41[Ib] Recent whether infections were single or mixed (as indicated). The most effect is most striking in the first year with a 32. Pneumococcal serotypes are important. [Ib] associated with pneumonia.4% reduction in the first 2 years.1.28[Ib] often as a co-pathogen with either viruses or other 3.31[II] Other viruses isolated in children < The European incidence of CAP.1136/thoraxjnl-2011-200598 ii5 .5% in Thailand.5%33[Ib] to 6. [III] 14. In the columns the percentage type 1 in empyema. approximately 33/10 000 in those aged 0e5 years and 14.39[II] Pneumolysin- pharyngeal aspirates or secretions. 3. influ- the economy from parental time off work.38[III] A recent study over the last 10 years PCR techniques have developed of 34 children in Finland who had a lung aspirate identified S considerably and have been applied to viral detection on naso. Where both viral and bacterial isolates were types 1. BTS guidelines Overall. AETIOLOGY appear to account for 30e67% of CAP cases in childhood and are Studies of the aetiology of CAP are complicated by the low yield more frequently identified in children aged <1 year than in those of blood cultures.21[II]22[Ib] Studies viral identification. parainfluenza and influenza are Office for National Statistics (2007) the UK population aged detected in similar proportions of children with pneumonia both 0e16 years is 11. doi:10. Only two come from a UK population With the introduction of conjugate pneumococcal vaccines.16[II]17[Ib]18[II]19[II]20[II] the difficulty in aged >2 years (77% vs 59%). enza is found in 7e22% of cases. The most common isolates in IPD since the indicates the percentage of all CAP cases in which that organism introduction of PCV7 in Europe.28[Ib]24[Ib] obtaining adequate sputum specimens and the reluctance to perform lung aspiration and bronchoalveolar lavage in children. It is now further complicated by the routine cultures of upper respiratory tract specimens. included in PCV13. introduced into the UK immunisation The studies are updated from the previous guidelines and schedule in 2010. yet is increasing numbers of studies using specific serological or PCR known to be a commensal in this setting. it was classified as mixed and indicated in a separate most frequent serotypes found in pneumonia. 6A and 7F. 6B. rhinovirus. a rise in antibody concentrations. cytomegalovirus.29[Ib] Mixed summarised in table 4. comprehensive studies found a mixed viral-bacterial infection in and a 23. clinical signs with pneumonia include adenovirus. the setting. The proportion of CAP due to S pneumoniae increases Studies of specific pathogens in developed countries are up to 41% in cases where serological testing is used. According to the predominant one being RSV.33[Ib] Coronavirus is identified in 1. with PCR techniques. In children under 2 years. All of these are prospective studies in pneumococcal and viral infections appear important and are which the pneumonia was community acquired and where the found in 62% of pneumococcal pneumonias. although several are from Europe. with only a few studies designed to look more niae to CAP. Therefore.

BC. Spn BPCR. UK.1% multiple) y 14. hMPV PCR.5 (17) 2 (3) 11 (15) 51 (70) Spn.9 [Ib] Cilla24 1e35 months 2004e6. BC. ii6 Table 4 Prospective studies of specific pathogens from developed countries Reference Total [evidence Total Bacteria. CP. CP. 154 45 (65) 60 (93) 14 (21) 9 (14) 23 79 (122) serology viral. IP NPIA.2 NAy RV 14.9 hMPV 13. diagnosed. Mixed. IP+OP NPIA + PCR.8 (6) * NA NA Binax pleural fluid infection) RSV 19. 338 67 (18 viral co.2 RV 13. 136 37 (50) 12.8 (45) y 37.9 (2. serology viral. RSV 25 GAS 7 (9) Infl A 5 Spn 4 (5) CMV 3 Adeno 1. MP. Japan NPA PCR 1700 27. MP.8 (251) 1. NPVC. Switzerland: NPIA + PCR. BC.4 Laundy31[II] 0e5 years 2001e2. NPIA 1296 RSV 23. level] Age Year and setting Tests episodes Viral (n) % (n) % (n) % (n) % (n) % (n) 23 [Ib] Wolf <5 years ED NPA hMPV PCR. IP NPIA. Taiwan. specifically 51 43 (22) 12 (6) 4 (2) NA NA 49 (25) viral testing RSV 18 (9) Spn 6 Infl A 16 (8) Adeno 6 (3) PIV 6 (3) Continued Thorax 2011. CP RSV 13 Spn 44 (68) Infl 22 GAS 1 (2) PIV 13 SA 1 (2) Adeno 7 [Ib] Macherel29 2 monthse5 years 2003e5.5 [II] Haman25 0e19 years 2005e6.9 [II] Don26 0. MP.8 HboV 14.6 HMPV 11.3 Michelow28 [Ib] 6 weekse18 years 1999e2000. Spain.1 hMPV 8. doi:10.3 Infl 13.9 (8) 20 65 (66) RSV 17 Spn18 <2 years: 1 PIV 12 HI 3 2e5 years: 8 Infl 9 Mcat 1 >5 years: 18 hMPV 5 p<0. USA.4 Infl A 2. urine Spn ag.3 (5) NA NAy urine Spn ag.4 hMPV 7.0001 [II] Lin27 3 monthse18 years 2001e2. Spn 2.3e16 years 2001e2.BC. IP+OP Serology (viral and bacterial) 101 42 (3 dual) 44 26.4 (24) 15. 116 38. Chlamydia. Spn BPCR.3 Adeno 3.1 (7) 1. serology MP+CP RSV 28.9 Adeno 28.9 (44) 4. Mycoplasma.7 (27) 7.2 HboV 2. IP+OP NPIA+PCR.5 RSV 9. NPVC. UK. BC.5 Corona 6.66:ii1eii23.1136/thoraxjnl-2011-200598 . NPVC. RV 20h Spn 46 (45) MPV 13 GAS 1 (1) RSV 13 Infl 14 Paraflu 13 Adeno 7 Corona 7 Drummond30[II] 0e16 years 1996e8.9 BTS guidelines PIV 2. serology. Spn. 99 67 53 (52) 11 7 33 (33) 86 (85) IP serology viral. Spn. IP NPIA. Italy.

uk/web/HPAwebFile/HPAweb_ C/1245581527892). In the same study. with rates of detection from 27% to 36% (see table 5). blood PCR.26[II]28[Ib]24[Ib] Michelow et al28[Ib] detected level] Tsolia a pathogen in 92% of children aged <6 months but in only 75% Thorax 2011. coronavirus. Moraxella catarrhalis. diagnosed. Other bacterial pathogens appear to be less frequent causes of CAP. With improved diagnostic tests including serology and PCR. BTS guidelines pneumonias were prevented in children under 1 year. it may be found in 1%28[Ib]29[Ib] to 7% of cases. whether children with mycoplasmal (or chlamydial) pneumonia are over-represented in hospital-based studies because of failure of penicillin-related antibiotic treatment in the community.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/12030088 63939/). so that the total IPD rate due to all serotypes is climbing back to similar rates before the introduction of PCV7 (http://www. HI. HI. BC. NPVC. ED.58[III]59[III] Age Continued 3.66:ii1eii23. New bacteria are also being described. when present. This trend is expected to reverse with the introduction 35 (26) % (n) of PCV13 (http://www. group A streptococcus. NA. but a steady increase in vaccine serotype replacement (ie. Infl.57[II] Year and setting 2004. org. a Chlamydia-like organism.52e56 Where Chla- mydia pneumoniae is sought.1136/thoraxjnl-2011-200598 ii7 . blood culture. Spn. NPA PCR. nasopharyngeal PCR. it appears to be responsible for 5e14% of cases. CP.42[Ib] In 77 (58) % (n) children aged >2 years there was only a 9. Mycoplasma pneumoniae previously yAll bacterial cases identified by NPA PCR so difficult to distinguish carriage from pathogen. serology MP. Recent reports indicate a fivefold increase Adeno 12 (9) hMPV 1 (1) RV 45 (34) in influenza and S aureus mortality in children in the USA from RSV 3 (2) PIV 8 (6) Infl 7 (5) Viral (n) 2004 to 2007. nasopharyngeal immunoassay. NPIA. rhinovirus. Streptococcus pneumoniae. NPA PCR. ag. episodes significant increase in IgG or IgM was shown in 16 (5% of all Total 75 CAP). Greece. Spn 7 (5) severity as. Haemophilus influenzae.44[Ib] A Total Adeno. Spn.47[Ib] 65 (49) Claesson et al48[II] assessed the antibody responses to non- capsulated Haemophilus influenzae and isolated it as the only pathogen from the nasopharynx of 43 of 336 children.5% of cases of CAP. but a single US study detected it in 27%. RSV.org. or are over-represented in community studies because they are less sick and therefore less likely to be referred to hospital. nasopharyngeal viral culture. mycoplasma. influenza A and B virus. RV. CP. Mcat. those studies published where M pneumoniae is specifically sought in children Tests admitted to hospital show remarkable consistency. PIV. OP. only a 2. as is Staphylococcus aureus. HboV. human Cochrane systematic review found a pooled vaccine efficacy for PCV11 of 27% for reduction of radiographically-confirmed pneumonia in children <2 years and 6% for clinical 28 (21) Mixed. % (n) pneumonia. Chlamydia pneumoniae. adenovirus. human bocavirus. MP.hpa.8[Ib] S aureus has also long been associated with increased mortality in influenza. emergency department. Mycoplasma. PC. outpatients. Mcat.45[Ia] The introduction of PCV7 has dramatically decreased IPD due to vaccine serotypes in those countries where it has been Chlamydia.30[II] It is increasingly associated with pneumonia complicated by empyema. IP Biases which need to be considered in these reports include *No serological tests were performed for Chlamydia pneumoniae. A parainfluenza virus 1e3.49[II] This was supported by another study by Korppi et al50[II] in which seroconversion to M catarrhalis was documented in only 1. pharyngeal culture. suggesting that it too is an uncommon cause of CAP in children. respiratory syncytial virus.hpa.3 What is the contribution of atypical organisms? In aetiology studies. Group A streptococcal infection is important in terms of Bacteria. natural selection of pneumococcal serotypes not % (n) 3 (2) present in the vaccine) has been evident in the UK to 2010. Corona.1. it is more likely to progress to 40 (30) % (n) paediatric ICU admission or empyema. universally introduced. 3% also had a significant increase in antibodies to Moraxella catarrhalis. is detected frequently by PCR in respiratory samples although antibody studies suggest it may be 5e14 years rarely implicated in pneumonia. doi:10. Simkania negevensis. BPCR.1% reduction.2 Does the aetiology differ by age? Several generalisations are possible with respect to age. hMPV. 3. not available. IP. there was metapneumovirus. GAS.51 Since 2000. evidence Reference [evidence 32[Ib] of specific aetiology tends to be more commonly found in Table 4 younger children. inpatients. accounted for 4e39% of isolates. antigen.30[II]46[III] When looked for.7% decrease in those aged 12e23 months.

pain. IP Serology NPA PCR 418 35. [II] influenza should raise the possibility of pneumonia due to < Mycoplasma is not unusual in children aged 1e5 years. IP Serology 140 27 (38) 5 (7) ?0 Korppi56 [II] <15 years 1981e2. hospitals in the north-east of England with a history or signs of moniae infection in children aged 3e4 years is high. This raises questions about appropriate treatment in this age This study confirms the importance of respiratory rate as group. Austria.28[Ib] However.001). Italy. wheeze or chest half of these. of those aged >5 years. Although viral infections (especially 4. Switzerland. [Ib] <5 years. [II] secondary bacterial infection. Studies on pneumonia are often difficult to collate as the and C pneumoniae infections to be comparable in all age clinical settings and criteria for diagnosis can vary widely. In particular. IP NPA culture PCR serology 112 6. >50 breaths/min in confirmed pneumonia in children aged <2 years. nasopharyngeal PCR. doi:10. tachypnoea.8 (150) 11 (46) 6 (26) Baer54 [II] 1e18 years 1999e2000.7 (4 of 60 tested) Principi53 [Ib] 2e14 years 1998e9. the vaccine serotype replacement is evident in the UK. although young children may have milder M pneumoniae a valuable sign. [III] (p<0. Palafox et al69[II] found that. the WHO definitions for tachypneoa (respiratory rate < S pneumoniae causes about one-third of radiologically.66:ii1eii23. Interestingly. < One-third of cases of CAP (8e40%) represent a mixed It is worth noting that prolonged fever associated with infection. The clinical features of CAP vary with the age of the child (see cating at least 20% have a pneumococcal aetiology across all table 6 and Section 6). but work of breathing is more aged <1 year than in those aged >2 years. cough.001). [evidence level] Age Year and Setting Tests episodes % (n) % (n) % (n) Kurz52 [II] 2 monthse18 years 2006e7.54[II] pneumonia were studied. Block et al57[II] found the incidence of M pneumoniae ology.68[II] < S pneumoniae is the most common bacterial cause of Previously. as there was a significant correlation between infection65[IVb] and many recover without specific antibiotic respiratory rate and oxygen saturation (r¼28. radiological changes of pneumonia? – In older children. This treatment. inpatients. [Ia] children aged 2e12 months and >40 breaths/min in children < The introduction of PCV7 has dramatically decreased IPD due >12 months) had the highest sensitivity (74%) and specificity to vaccine serotypes in the UK. pneumococcal pneumonia. CLINICAL FEATURES RSV) are more commonly found in younger 4.16[II]19[II]26[II]52[II]54[II]60[II]62[II]63[II]64[II] referral for hospital assessment in areas without access to radi- However. They may also present with abdominal pain and/or tified with increasing age.1 How do children with CAP present? children. to 50% of children aged <2 years. IP+OP Serology (updated from 201 30 (61) 14 (29) 5 (10) previous study) 0e4 years: 9% 6% 5e9 years: 40% 13% 10e14 years: 67% 35% IP. Respira- childhood and are more frequently identified in children tory rate is of some value. Turkey. Chlamydia. Finland. IP Serology NPA PCR 50 32 (16) 8 (4) 6 (3) 1e3 years: 22% >3e7 years: 35% >7 years: 40% Somer55 [II] 2 monthse15 years 1996e8. when a bacterial cause is found. Children with upper respi- less frequent with age. [II] of 45% for radiological consolidation and a negative predictive ii8 Thorax 2011. Criteria for diagnosis based on signs and ages. in children aged pneumonia in childhood. p<0. bacteria are more frequently iden. features was mainly undertaken in developing countries to assist Chlamydia and Mycoplasma species have been more commonly non-healthcare workers in identifying the need for antibiotics or found in older children.2 Are there clinical features that are associated with to 50%. chest indrawing and/or a respira- commonly S pneumoniae followed by mycoplasma and tory rate of >50 breaths/min gave a positive predictive value chlamydial pneumonia.2[II]16[II]17[II]19[II]24[II]60[II] bacteria are also isolated in up Children with CAP may present with fever. Recent lower respiratory tract infection. viruses account for 30e67% of CAP cases in children of all ages with increased work of breathing. [II] indicative of the likelihood of pneumonia.1136/thoraxjnl-2011-200598 . The respiratory rate was also significantly more likely than pneumococcal to progress to the paediatric higher in patients with breathlessness or difficulty breathing ICU or empyema. but a steady increase in (67%) for radiographically-defined pneumonia.28[Ib] hence mixed infections become vomiting and may have headache.70[II] < Age is a good predictor of the likely pathogens: – Viruses alone are found as a cause in younger children in up 4. BTS guidelines Table 5 Aetiology studies looking for atypical organisms Reference Total Mycoplasma.26[II] This has implications for the way in which we symptoms tend not be very specific. Mixed. [II] respiratory rate was less sensitive and less specific in the first < Pneumonia caused by group A streptococci and S aureus are 3 days of illness. Significantly lower oxygen saturation was seen in < Overall. In infants aged <1 year. a respiratory rate of 70 breaths/min had a sensitivity of 63% and specificity of Evidence statements 89% for hypoxaemia. outpatients. with Baer also noting a 22% a hospital paediatrician with radiographically-confirmed incidence of M pneumoniae in children aged 1e3 years. the finding of Clark et al20[II] recently studied 711 children presenting to a 23% incidence of M pneumoniae infection and 23% of C pneu. together with a virus in up to breathlessness or difficulty in breathing.26[II]61[II] Vaccine probe studies indicate ratory tract infection and generalised wheeze with low-grade that one-third of young children with radiological changes have fever do not have pneumonia. NPA PCR. Only children seen by studies have supported this. Early work on diagnostic consider antibiotic choices.66[II] supports previous findings. OP. >60 breaths/min for infants <2 months. it is most In previous studies in infants. groups between 3 and 12 years.45[Ia] with serological studies indi.

1 to 1. a history of difficulty breathing wide variability in what is considered radiographic pneumonia. The National Institute for Health and Clinical Excellence (NICE) < respiratory rate $50 breaths/min (adjusted OR 3. might also suggest mycoplasma difficulty breathing. 96% had fever.2 to 4. of pneumonia. Eighty- Mycoplasma pneumonia can present with cough. Of those without radiographic evidence of infection.68[II] An emergency room prospective study of 510 children aged 5.72[II] Crackles and bronchial breathing have been reported to chest recession and a raised respiratory rate. tachypnoea and Recommendation chest recession or indrawing were not sensitive signs. as difficulty breathing. It is not until lysis occurs and debris irritates cough in Pakistan in which children were diagnosed with non-severe receptors in the airways that cough begins. chest pain and two per cent of x-rays were classified as normal and 4% were be accompanied by wheezing. BTS guidelines value of 83%.58C together with min. Forty-four of 510 cases (8.83[III] frontal and lateral chest x-rays of patients enza in infants and older children. Classically.3 to radiographs should and should not be done in febrile children. is an additional valuable symptom.2.71[II] In children aged >3 years. [IVb] admit that some of the loss of sensitivity may be due to the < In children older than 3 years. relevant to pneumonia is: 95% CI 1. The authors the child and tend not be very specific for diagnosis.79 9.9).4. [D] have a sensitivity of 75% and specificity of 57%. bacterial between radiographic findings and clinical pneumonia. The incidence is increasing.4.74[II]75[II]76[IVb]77[III] This is complicated by mixed infections.1 Pneumococcal pneumonia evidence of pneumonia have been discussed in Section 4. It can complicate influ.78[IVb] pneumonia.6. The clinical features individual causative agents? thought to be more significantly associated with radiographic 4. The sensitivity Evidence statements and specificity of the frontal x-ray alone for lobar consolidation < Children with CAP may present with fever. Other studies81[II] have drawn similar conclusions. confirmed previous evidence that there is no way of reliably Radiographic pneumonia was defined as confluent opacification distinguishing clinically (or radiologically) between aetiological without volume loss. 95% CI has recently produced a guideline for the assessment of febrile 1.3. Pneumococcal pneumonia starts with fever and tachypnoea. preschool children are just as there is poor agreement between clinical signs and chest likely as those of school age to have atypical pneumonia. [II] diagnosed pneumonias are not evident from the study.2.1. a radiological diagnosis of pneumonia was present in 14% indrawing and ‘toxic’ or ‘unwell’ appearance. There radiography.2 Mycoplasma pneumonia classified as having ‘interstitial parenchymal changes’. referred from an emergency department in the USA were reviewed by three radiologists independently.5). In an ambulatory setting. These studies have spare unnecessary radiography in children without pneumonia. Non-respiratory symptoms. wheeze or the specificity 98%.1136/thoraxjnl-2011-200598 ii9 . pretations). and pleural effusion. was 100%. cough. and atypical pneumonias? A prospective cohort study73[Ib] of 510 patients in the USA Many studiesdlargely retrospective reviews and one small sought to elucidate clinical variables that could be used to iden- prospective studydhave sought clinical features which might tify children likely to have radiographic pneumonia in an effort to help to direct treatment options.4. RADIOLOGICAL. Children < Bacterial pneumonia should be considered in children when can have pneumonia with respiratory rates of <40 breaths/ there is persistent or repetitive fever >38. 95% CI 2. Can clinical features distinguish between viral. suggesting that these types of radiographic chest pain. pneumonia (and treated with antibiotics) based on the WHO Many studies therefore emphasise the importance of the criteria of tachypnoea without ‘danger symptoms’. 95% CI 1. From this study it would appear that has been proposed more recently. Are there specific clinical features associated with had radiographic evidence of pneumonia. Several other studies have also examined the relationship 4. chest x-rays did not improve outcome.5.4.3 Staphylococcal pneumonia This is indistinguishable from pneumococcal pneumonia at the 5. and The recommendation of the guideline development group < in infants aged #12 months. Thorax 2011. It remains rare in developed countries In a retrospective study of 1268 cases (7608 x-ray inter- where it is usually a disease of infants. Two hundred and twenty-three were 4. For non-lobar infiltrates the sensitivity was 85% and breathlessness or difficulty in breathing. peripheral rather than central opacification agents. Of those with radiographic evidence worse than the signs would suggest. [II] The clinical implications of these radiographically under- < A raised respiratory rate is associated with hypoxaemia.1 Should a lateral x-ray be performed? beginning of the illness.0). are likely to be geographical variations in these findings. 99% had cough and 91% had A study of 154 children by Michelow et al28[Ib] found that. doi:10.66:ii1eii23. the symptoms are classified as ‘bronchiolitis’. showed that history of fever and breathlessness and the signs of tachypnoea. These clinical features of CAP vary with the age of changes may be underdiagnosed in 15% of cases. illness in children which gives comprehensive advice on when < oxygen saturation #96% (adjusted OR 4. GENERAL AND MICROBIOLOGICAL 2e59 months identified similar clinical findings significantly INVESTIGATIONS associated with chest radiographic infiltrates as follows: 5. increased peribronchial the reported incidence of which varies from 8.73[Ib] < Children with symptoms and signs suggesting pneumonia It must be noted that these features are also likely to be who are not admitted to hospital should not routinely have associated with children with viral-induced wheeze where a chest x-ray. Hyperinflation.6%) 4. radiographic changes do not represent pneumonia. tachypnoea. nasal flaring (adjusted OR 2. 94% had fever.82 4.2% to 23%.28[Ib] markings or subsegmental (band-like) atelectasis were not considered evidence of pneumonia.2).6 to 7.4.1 When should a chest x-ray be performed? < age >12 months (adjusted OR 1. (263/1848) with 26 (approximately 1%) of these constituting lobar pneumonia. 99% had cough and 89% had such as arthralgia and headache. Evidence from 1848 x-rays taken as part of a double-blind Cough is not a feature initially as alveoli have few cough prospective randomised controlled trial80[Ib] based at six centres receptors.

up x-rays. 10 developed minor alveolar infiltrations.3 Can chest radiography be used to distinguish aetiology? management was instituted on the basis of these radiographic It is common in clinical practice that alveolar infiltration is findings. Of the groups by three radiologists unaware of the clinical diagnoses 27 patients with abnormal x-rays. The authors established that a follow-up x-ray infiltrations. 106 of which were normal and 27 of which were Toikka et al86[II] studied 126 patients. Of 196 follow-up x-rays. < Follow-up radiography is not required in those who were 72% of 134 cases with bacterial pneumonia had alveolar infil.1 Pulse oximetry between radiographic appearances and aetiology. abnormal. producing is of viral or bacterial aetiology.72. < a good pulse signal should be obtained. increased perihilar and peribronchial markings.49 and suspected CAP in the community? specificity 0. They also followed the children scheme. x-rays are unnecessary. some viral infections are severe. pneumonitis and effusion). CAP who comes to hospital? defined pneumonia. To obtain a reliable reading: aetiology and 70% in each of those with atypical bacterial and < the child should be still and quiet. The oximeter is easy to use and requires alveolar infiltrates were present in 68%. Of 137 children (64%) < A lateral x-ray should not be performed routinely.1136/thoraxjnl-2011-200598 . all of whom had x-rays.2 What general investigations should be done in a child with with interstitial infiltrates the sensitivity was 0. These modest benefits those in group 1. Radio.1. 5. hyperaeration. atelectasis 47%. Oxygen saturation measurements provide a non-invasive estimate trates were present in 44 children (62%). For viral pneumonia 5. Alveolar infiltrates were present in and is susceptible to motion artefacts. 69% had bacterial pneumonia and 18% viral pneumonia.3 What general investigations should be done in a child with In a study of 101 Italian children with radiographically. Suren et al89[III] published the results of a retrospective study Chest radiography is generally unhelpful for deciding on of 245 children recovering from CAP.66:ii1eii23. [B+] The sensitivity for bacterial infection in those with alveolar infiltrates was 0. 20% were new abnormalities. major alveolar infiltrations.and inter-observer variation in radiographic Two recent studies have examined the utility of follow-up x-rays features used for diagnosing CAP. Of might have been helpful in 5/245 cases. patchy consolidation. Of the 106 patients with normal follow-up x-rays. with an uneventful recovery. were abnormalities in 30% (infiltrates 67%. There is no indication for any tests in a child with suspected In a prospective study of 136 children. the concordance rate between two trained reviewers up at 8e10 years after diagnosis. but should trates and 49% with viral pneumonia had alveolar infiltrates. perihilar pneumonia) subsequent clinical problems. pleural fluid. 133 had follow- a potential causative agent.1). be considered in those with a round pneumonia.4 Are follow-up x-rays necessary? There is great intra. In those aged >5 years of arterial oxygenation.1. viral in 32% and 14% two went on to develop further clinical problems (both recur- had unknown aetiology. atelectasis. pleural not admitted to hospital should not have a chest x-ray. Bacterial aetiology was established in 54%. Again. 71% had evidence of bacterial infection. lobar alveolar follow-up x-ray. unknown aetiologies. there was only 48% (250/521). The emitting and receiving 46% of those with viral aetiology. No change in 5. [B] with alveolar infiltrates. even using this study of 196 children with CAP.3. Adequate sensitivity is lacking for either of these assignations. [II] marked changes on the x-ray. hilar enlargement. BTS guidelines Lateral x-rays are not routinely performed in paediatric CAP Chest x-rays are often done in research studies of CAP. Follow-up at 8e10 years of 194 patients showed no thought to be secondary to a bacterial cause and bilateral diffuse new illnesses associated with the previous pneumonia. before the regular scheduling of the covering a whole lung. Of those in group 2. but and the recommendation is that they are not necessary84[II] and these studies do not support the routine use of chest x-rays in would mean exposing the child to further radiation. Alveolar infil. hyperaeration. In those interstitial infiltrates to atypical bacterial or viral infections. Aetiology is therefore difficult to assign on the basis of the x-ray.1. Clearly. patients (see Section 5. Korppi et al77[II] found no association 5. [A] fluid and location in one or both lungs. 5. persisting symptoms. [A] graphic findings were classified as alveolar and/or interstitial < Children with signs and symptoms of pneumonia who are pneumonia. some bacterial infections are Evidence statements only mild. previously healthy and who are recovering well. the recent guidance showed that there was no significant difference in aetiology published by NICE regarding the management of feverish illness among the five radiographic groups into which their cases in children provides a useful framework for assessing these were divided (lobar consolidation. Drummond et al30[II] pneumonia in the community.2 How good is agreement on interpretation of x-rays? 5. The x-rays were divided into two rent pneumonias with no established underlying cause). atelectasis). lymph nodes 28%). Recommendations Virkki et al87[II] studied 254 children with radiographically < Chest radiography should not be considered a routine diagnosed CAP. Most of these occurred within the and group 2 (n¼61) had marked changes (interstitial changes first 4 weeks after discharge. Of 112 who did not have follow-up x-rays. changes (interstitial infiltrations not covering a whole lung. It does require a pulsatile signal from the patient were negative in all cases. although blood cultures no calibration. doi:10. three developed further clin- and characteristics: group 1 (n¼61) had mild or moderate ical problems that could be related to the previous pneumonia. 67% with pneumococcal diodes need to be carefully opposed. The WHO85 produced in previously healthy children with CAP. assigning aetiology in 215/254 patients. Of these. conversely. pneumonia. producing less marked changes on the chest x-rays < Chest radiography is too insensitive to establish whether CAP and. the investigation and management of CAP. collapse or Half of those with interstitial infiltrates had bacterial infection.72 and specificity was 0. a method for standardising the interpretation of chest x-rays in Virkki et al88[II] published the results of a 3-year prospective children for epidemiological purposes but. abscess formation.51. investigation in children thought to have CAP. 39% had bacterial pneumonia and 45% viral should be balanced against the exposure of children to radiation. ii10 Thorax 2011.

2 Acute phase reactants PCT.42 microscopy. doi:10. as defined by of 99 patients using a variety of microbiological. defined by admission to hospital and the presence of alveolar infiltrates on the chest x-ray. aetiology. if present. [A+] diagnosis. the positive predictive value for l.20 to 5. bacterial CAP of 2. but the evidence is still lacking for the biochemical means. generally. WBC >173109/l. clinical utility. alveolar infiltrates on the x-ray were included. PCT >0. There was no significant association feasibility of performing PCR analysis for viruses in nasopha- between PCT levels and aetiological group. association between severity of CAP (as defined by inpatient Microbiological methods that may be used are several and versus outpatient management) and PCT or between aetiology include: blood culture.68[II] values. then bacterial pneu- Several studies have looked at using various acute phase reac.66:ii1eii23. as infections. the saturation reading should be Toikka et al86[II] studied 126 children with CAP. The median values for each of the four aetio.1136/thoraxjnl-2011-200598 ii11 . there was no correlation with aetiology. they have little value in tants as a means of differentiating the aetiology and/or severity differentiating viral from bacterial CAP. including several revealed in our recent search. Forty-three children had an aetiological pneumonia.45 mg/l. the risk of death from and 14% unknown. Median PCT values (25the75th 5.8 mg/l and ESR >63 mm/h. producing an OR for bacterial versus non- combinations of markers that would differentiate a pneumo. viral acute and convalescent serology for respiratory viruses. but there was marked overlapping of present. They found that no disease. of CAP. 54% had bacterial infection. they CRP values of 40e60 mg/l was 64%. CRP and IL-6 levels are very high. M and unknown) were not significantly different (p¼0.97[II] but this is not currently practical in the UK. logical groups (pneumococcal. (PCT). PCT levels and unequivocal consolidation on would be a sample directly from the infected region of lung (lung the x-ray. BTS guidelines < once a signal is obtained.4. 19% were of bacterial aetiology alone.083).72. The cases were assigned into four aetiological groups: There is no indication for microbiological investigations to be pneumococcal (n¼18). PCT levels were ryngeal secretions in the context of pandemic respiratory virus found to be significantly associated with severity of CAP. 33% ability of PCT to discriminate between viral and bacterial causes of viral aetiology alone and 33% of mixed viral and bacterial of CAP.4. mycoplasma/chlamydial. For a combination of CRP >80 mg/ of bacterial pneumonia of 41%. 17 had M pneumoniae. CRP. [A] Michelow et al93[II] investigated a panel of 15 cytokines in 55 < CRP is not useful in the management of uncomplicated patients with CAP. None of Recommendations these combinations of parameters was sufficiently sensitive or < Acute phase reactants are not of clinical utility in distin- specific to differentiate bacterial (specifically pneumococcal) guishing viral from bacterial infections and should not from viral pneumonia. pleural fluid for inpatient versus outpatient management. 41% had bacterial CAP. A Korppi et al64[II] examined WBC. respectively. ESR and PCT levels and CRP range of 35e60 mg/l was significantly associated with chest radiographic findings in 132 cases in an effort to find bacterial pneumonia.89. were 17. Thorax 2011. In the developed world. The sensitivity and specificity of CRP and PCT levels were low. It is important to attempt microbiological diagnosis in patients Korppi et al90[II] published a prospective population-based admitted to hospital with pneumonia severe enough to require study of 190 children in an ambulatory primary care setting admission to the paediatric ICU or with complications of CAP. The individually and in combination has been assessed. PCR. respectively (p¼0.74 with a sensitivity of 61% and specificity of 65%. There were no significant differences for IL-6 levels. Don et al91[II] evaluated the usefulness of PCT for assessing 5. interleukin 6 (IL-6) Determining the causative agent in acute lower respiratory tract was the only one significantly associated with a rise in white infection can be frustrating and difficult.4 What microbiological investigations should be performed? and bacterial infections. one had S aureus and eight had viruses identified. 11 had influenza A. nasopharyngeal secretions and nasal of CAP and PCT.2 Which microbiological investigations should be performed on centiles) for inpatients and outpatients.3.58 (95% CI 1.81 a child admitted to hospital? and 0. If 5.55). atypical bacterial (n¼25). with radiologically-diagnosed pneumonia and aetiological diag.87[II]95[II]96[II] that mentation rate (ESR) and white blood cell (WBC) count examined the use of CRP in establishing aetiology in CAP. They should not be considered routinely in those with milder noses for five bacteria and seven viruses. the likelihood ratio was 1. specificity 82% and sensitivity 34%. If bacterial pneumonia. measuring watched over at least 30 s and a value recorded once an PCT. PCT levels were 0. serological and admission to hospital. Eleven had mixed viral 5. pooled study population was 1230. viral (n¼23) done in the community. pneumococcal antigen detection and/or and 0. The gold standard cell band forms. However. Of the cytokines. Aetiology was established for six adequate stable trace is obtained. erythrocyte sedi. there may be some Cevey-Macherel et al29[Ib] identified a causative agent in 86% alignment between PCT levels and severity. According to these two studies. puncture). monia is more likely but. Median PCT and CRP levels were found to pneumonia was significantly increased when hypoxaemia was be significantly different. cytokines. C reactive protein (CRP). 32% viral In a prospective study from Zambia. Given the prevalence coccal from a viral aetiology.1 Are there any microbiological investigations that should be both the severity and aetiology of CAP in a study of 100 performed in the community? patients. swabs for viral detection (by PCR or immunofluorescence). three had C pneumoniae. Some workers have investigated the and unknown (n¼34). CRP and IL-6 levels. The conclusion of the found the likelihood ratio of the pneumonia being pneumococcal meta-analysis was that CRP was only weakly predictive for was 1.64[II]86[II]90[II]91[II]92[II]93[II] The utility of procalcitonin Flood et al94[Ia] performed a meta-analysis of eight studies. routinely be tested. For pneumoniae and C pneumoniae and. bacteria and 11 viruses.77). Twenty-one children had S pneumoniae. less invasive sampling There remains little evidence that cytokine profiles have any methods are usually used to achieve a diagnosis. culture.

5%.100[Ib] serum and sputum or throat swabs. specificity was include viral culture.7 (range received antibiotics for some time before aspiration of pleural 5. Of interest.3% for CPS. One hundred and pneumolysin was 77. As well as cases in this study were diagnosed by clinical and radiological viral culture and PCR. two studies have investigated in the blood in <5% of cases of pneumococcal CAP cases.98[IVb] the use of PCR in identifying atypical bacterial infections. The authors argue that coccal DNA by PCR. 9 of Normal bacterial flora.6% of cases and was not DFA in this study was 84%. BTS guidelines 5. they used viral antigen detection and evidence with blood culture positivity in 29.5 Which investigations are useful in identifying viral pneumonia? antigen of S pneumoniae has shown promise for excluding Viruses are significant causes of paediatric CAP.101[Ib] In the previously mentioned study undertaken by Cevey- Rajalakshmi et al102[Ib] studied the efficacy of antigen detec. 29[Ib] Pneumococcal tests) remains the mainstay for diagnosing M pneumoniae and C pneumonia is seldom a bacteraemic illness. doi:10.3%). specificity of 97. positive predictive detected in any controls. of CPS and pneumolysin in urine when compared with blood Shetty et al107[Ib] subjected 1069 nasopharyngeal swabs to culture were identical (52.78 days.2% for pneumolysin and 67. Rapid detection of the capsular polysaccharide (CPS) 5.9e1279.3). The negative predictive value of value 96% and negative predictive value 96%. 190 61. whereas pneumococcal latex agglutination PCR positivity for M pneumoniae in the upper respiratory tract is antigen testing was positive in 12. The infection could not be detected by any other method.1136/thoraxjnl-2011-200598 .104[II] PCR analysis for eight common respiratory viruses. Eleven of the 18 were diagnosed in the Serum. acute phase and nine (50%) of those serologically diagnosed were ratory infections98 concluded that pneumococcal antibody and positive for M pneumoniae by PCR of sputum. In those with a negative PCR. In their study. studies have found good sensitivity (100%) and specificity (95%) Lambert97[II] collected nose-throat swabs and nasopharyngeal in children with pneumonia. PCR had a sensitivity fluid. One Pleural fluid cultures often show no growth. which may explain why culture is so often uninformative.4. The pharyngeal aspirates to be very sensitive. children with serologically-proven M pneumoniae infections with pharynx is not indicative of lower respiratory tract infection. with just 9% of 47 of the controls was PCR positive.1e42. twenty of 140 hospitalised patients (86%) had viral cultures that reported positive only after the children had been discharged.29[Ib] they found viral PCR of naso- tion assays of pneumolysin versus CPS antigen in urine. six on both. specificity 99%.7%. identifying 27/ tion of oxygen therapy (1. whereas infection with bacteria). The sensitivity of PCR too complex for routine clinical use. p¼0.2% and of CPS was 76. and negative predictive value of 82. However.106[II] Paired serology seems to have the best yield. viral pneumolysin is a protein produced only by S pneumoniae. as well as bacteria known to cause CAP. whereas the specificities were viral culture and direct fluorescent antibody (DFA) staining. of 57. the 12 each positive on nasopharyngeal and oropharyngeal are often identified.41[Ib] Most children will have pneumoniae by PCR in serologically-proven cases was 54.21[Ib]103[II] but others have been aspirates in 295 patients (303 illnesses) and subjected them to concerned about its specificity. were diagnosed by convalescent serology. Taken together. However.5%) for M pneumoniae and in Biochemical and immunological methods one (1.3 Which investigations are helpful in identifying a bacterial 5. 42 controls. antigen detection. in for by PCR. Michelow et al103[II] used PCR to diagnose M pneumoniae from Nasopharyngeal bacterial culture nasopharyngeal and oropharyngeal swabs. 66/99 rationale behind this study is that there is cross reactivity children had evidence of acute viral infection (33/99 as co- between antigens of Viridans streptococci and CPS. The presence of bacteria in the naso. Macherel and colleagues.1%.66:ii1eii23.7 vs 0.6%. 32 of the 47 cultures were positive for pneumo. especially in young children. CPS was detected in 38. 29 empyemas in one study. pneumoniae infection up to 7 months after disease onset. They compared 21 This is uninformative. all of which were accounted suggestive of lower respiratory tract infection. Other studies have confirmed some utility for their study PCR-positive cases had a significantly longer dura- pneumococcal antigen detection in pleural fluid. 3/18 were for the detection of pneumococcal infections in children. Several studies have looked at the both a sensitivity and negative predictive value of 100% for an various techniques available for identifying viruses.045).29[Ib] samples. pleural fluid and secretions. Some any utility in making clinical management decisions.5%) for Legionella. too low to be clinically useful. 12 of the 21 children (57%) were PCR positive. immune complex assays. The OR for detecting M cultures positive in a UK study.0%.4. S pneumoniae is cultured pneumoniae infections. When compared with ELISA. In ii12 Thorax 2011. These immunochromatographic test for CPS. Of 65 children. The sensitivity for controls. Pneumolysin-based PCR is increasingly used to detect The authors make the point that the viral cultures were not of pneumococcus in blood.4 Which investigations are helpful for identifying atypical cause? bacteria? Blood culture Paired serology (rising titres in antibody complement fixation Positivity is often quoted as <10% in CAP. Several other serological versus IgM EIA in this study was 50%. serology (IgM EIA) was positive in 18 (27. either on their pneumococcal infection. Pneumolysin was were DFA and viral culture positive (true positive) and 837 were detected in urine in 37. A review of pneumococcal serology in childhood respi. PCR.4.3% In this study. Nose-throat The laboratory techniques in this area are rapidly evolving and swabs are thought to be ‘less invasive’ samples that are more improving and show promise in helping to make microbiological easily collected by parents and therefore of possible benefit in diagnoses. A study undertaken in France identified own or in mixed infections.99[II] and with an apparently useful Maltezou et al105[II] used PCR to diagnose Legionella and sensitivity of 90% and specificity of 95% compared with culture Mycoplasma lower respiratory tract infections by collecting and/or PCR in another study. serology and PCR. while sufficiently sensitive and specific 15/18 were diagnosed by PCR and IgM serology.9% of cases compared with 2. This is consistent with techniques exist and have been used in combinations with other recent observations that PCR can detect persistent M culture and non-culture techniques to increase diagnostic yield.29[Ib]30[II] Urine. The sensitivities serum complement fixation tests.1% of DFA and culture negative (true negative). The greatest diagnostic yield was therefore Pleural fluid when samples from both sites were combined and analysed. rapid diagnosis in the context of a respiratory virus pandemic. positive predictive value of 97.

68[II] signs: fever. In a study carried out in the developing 6. [C] department. wheeze. parents/carers bring the child directly to a hospital emergency culture. The spectrum of severity of CAP can be mild to severe hypoxaemia. [C] *Values to define tachycardia vary with age and with temperature.58C For adenovirus. present with other worrying features. [C] community.1% to 79. [C] community. hospital? Features of severe disease in an infant include: A referral to hospital will usually take place when a general < oxygen saturation <92%.58C Temperature >38. BTS guidelines 186/303 (61%) paired nose-throat swabs/nasopharyngeal aspi. Taking full feeds Nasal flaring The authors argue that the combination of PCR and the less Cyanosis invasive nose-throat swabs provides adequate sensitivity for the Intermittent apnoea detection of respiratory viruses. initial antimicrobial therapy. [C] underlying risk factors the child may have together with the – Nasopharyngeal secretions and/or nasal swabs for viral ability of the parents/carers to manage the illness in the detection by PCR and/or immunofluorescence. Some with severe disease will require hospital admission for treatment. A global assessment of clinical severity and risk factors is crucial in identifying the child likely to require hospital 6. There is no single validated severity scoring system to guide ratory symptoms can be managed safely in the community. This decision may be influenced by the level of – Acute and convalescent serology for respiratory viruses. Infants and children with mild to moderate respi.5%) compared with 93. abdominal pain and chest pain (see min in infants aged <1 year was a significant predictor of Section 4). For nose-throat swabs the Mild to moderate Severe sensitivity was 91.[IVb] the decision on when to refer for hospital care. saturations <94%. The same study showed that a respiratory rate of $70 breaths/ cough. Table 6 Severity assessment rates.58C Temperature >38. Respiratory rate Respiratory rate [Ib] <50 breaths/min >50 breaths/min < Molecular methods have shown promise but are currently Mild breathlessness Severe difficulty in breathing most useful in identifying viral pathogens. Thorax 2011. the decision < Microbiological methods used should include: whether to refer to hospital or not should take account of any – Blood culture. cyanosis.67[II] < Microbiological investigations should not be considered routinely in those with milder disease or those treated in the community. at least one virus was detected. pleural fluid should be sent for microscopy. Features including for hospital-based care. headache.1136/thoraxjnl-2011-200598 ii13 .9% Respiratory rate Respiratory rate (95% CI 50. [B+] Children with CAP may also access hospital services when the – If present. difficulty in breathing.2. Infants Temperature <38. Grunting respiration Not feeding Evidence statements Tachycardia* < Blood culture positivity is uncommon.109[III]110[III] There is some evidence that an additional useful Management in these environments is dependent on an assessment is the quality of a child’s cry and response to their assessment of severity. if these are felt to be abnormal and microbiological investigations. Mycoplasma and Chlamydia. tachycardia and capil- accurate assessment of severity of illness at presentation and an lary refill time >2 s were more likely to occur in severe infec- assessment of likely prognosis. In these circumstances hospital doctors may come < Urinary pneumococcal antigen detection should not be done across children with mild disease that can be managed in the in young children. Severity assessment will influence parent’s stimulation111[II].3% <50 breaths/min >70 breaths/min to 98. [Ib] No vomiting Nasal flaring Cyanosis Recommendations Grunting respiration < Microbiological diagnosis should be attempted in children Signs of dehydration with severe pneumonia sufficient to require paediatric Tachycardia* intensive care admission or those with complications of Capillary refill time $2 s CAP.1% for influenza A. This has the potential to reduce inappropriate complication by effusion and should trigger a referral to hospi- hospital admissions and the associated morbidity and costs. parental anxiety. This decision is best informed by an a temperature >398C. tachypnoea. Older children Temperature <38. tal. doi:10. In previously well children there tions. One key indication for admission to 6. duration of treatment and level of the case for referral for admission to hospital. the sensitivity of nose-throat swabs was 65. children with low oxygen saturations were shown to be Children with CAP may present with a range of symptoms and at greater risk of death than adequately oxygenated children. practitioner assesses a child and feels the clinical severity < respiratory rate >70 breaths/min.6%) for nasopharyngeal aspirates. they may also strengthen route of administration.9% for RSV was and 93. pneumococcal antigen detection and/or PCR. SEVERITY ASSESSMENT hospital is hypoxaemia.1 Why is severity assessment important? world.58C Positive tests are too non-specific and may represent carriage.66:ii1eii23.2% (95% CI 81. What are the indications for referral and admission to admission. [Ib] Capillary refill time $2 s < Urinary antigen detection may be helpful as negative predictors of pneumococcal infection in older children. Concordance between Mild recession Moderate to severe recession nasopharyngeal aspirates and nose-throat swabs was 89. In addition to assessing severity. [C] requires admission. nursing and medical care.1%.108[II] Auscultation revealing absent breath sounds with is a low risk of complications and treatment in the community a dull percussion note should raise the possibility of a pneumonia is preferable. breathlessness. An emergency The most important decision in the management of CAP is care-based study assessed vital signs as a tool for identifying whether to treat the child in the community or refer and admit children at risk from a severe infection. (see table 6).

2. parents/carers should be advised on what symptoms and signs providers. all the above should be assessed in addition to 7. head box considered (see Section 9). referred to hospital for assessment and management. [B+] < prolonged central capillary refill time >2 s. grunting. immune increased work of breathing or if the child is becoming deficiency). bronchiectasis.68[II] ii14 Thorax 2011. In the community. chronic lung Recommendations disease of prematurity. hospital. with or without < identifying signs of other serious illness a raised arterial carbon dioxide tension. < Auscultation revealing absent breath sounds with a dull < difficulty in breathing. Looking for the features a further assessment for their child. in the following three areas may be useful in identifying cases where the infection is not being adequately treated and Recommendation < Families of children who are well enough to be cared for at reassessment by a doctor is required: < Fever: a high swinging or persistent fever (the temperature home should be given information on managing fever.2 What is the general management for children cared for in vital signs. 7. should start to settle 48 h after treatment starts). Agita- dehydration. admission. GENERAL MANAGEMENT IN THE COMMUNITY AND IN admission to an intensive care unit: (1) when the pneumonia is HOSPITAL so severe that the child is developing severe respiratory failure 7. < chronic conditions (eg. distressed or agitated.113 Less common complications should also be should be treated with oxygen given by nasal cannulae. or face mask to maintain oxygen saturation >92%. developing.6. after treatment for CAP has been initiated < liaise with other healthcare professionals. A global assessment of clinical severity and risk factors < difficulty in breathing. Key features that suggest a child requires The general management of a child who does not require transfer include: hospital referral comprises advising parents and carers about: < failure to maintain oxygen saturation >92% in fractional < management of fever inspired oxygen of >0. be reassessed if symptoms persist and/or they are not < respiratory rate >50 breaths/min. complication by effusion and should trigger a referral to < signs of dehydration. BTS guidelines < significant tachycardia for level of fever (values to define Evidence statements tachycardia vary with age and with temperature67[II]). chronic lung < A child in hospital should be reassessed medically if there is disease of prematurity. fever should prompt consideration of CAP.1 What general management strategy should be provided for requiring assisted ventilation.114[Ia] but is agitated and distressed.66:ii1eii23.1. immune practitioner with persistent fever or parental concern about deficiency). to ensure the parent/carer has direct access to to look for when reassessing their child. re-consultation to the general to infection such as cystic fibrosis. [D] Features of severe disease in an older child include: < Children with CAP in the community or in hospital should < oxygen saturation <92%. [B] < chronic conditions (eg. doi:10. [D] 6. A prolonged fever is a useful pointer to empyema tion may be an indicator of hypoxia. signs. whether in information on warning symptoms and how further health- the community or in hospital. chronic respiratory conditions leading persistence of fever 48 h after initiation of treatment.1136/thoraxjnl-2011-200598 . [IVb] < recurrent apnoea or slow irregular breathing. < arrange a follow-up appointment at a certain time and place. for pleural collections 7. oral antibiotics plus advice on antipyretics and hydration).112[III] and this may require drainage for successful Patients whose oxygen saturation is <92% while breathing air treatment. < Children with CAP present with a range of symptoms and < prolonged central capillary refill time >2 s.3 What are the indications for transfer to intensive care? There are two main scenarios when a child is likely to need 7. cyanosis. [D] < Effort of breathing: the child seems to be working harder to breathe with a fast breathing rate and chest recession. and (2) a pneumonia complicated a child treated in the community? by septicaemia. [IVb] In hospital.1 Over-the-counter remedies [IVb] No over-the-counter cough medicines have been found to be < Effect of breathing: the child is not comfortable and relaxed effective in pneumonia. [IVb] – use of antipyretics < shock. including out-of-hours (eg. The ‘safety net’ should be one or more of the following: < provide the parent or carer with verbal and/or written 6. is crucial in identifying the child likely to require hospital < intermittent apnoea. congenital heart disease. congenital heart disease. Medical assessment should always look for signs of hospital? overwhelming infection and septicaemia. chronic respiratory conditions leading < For a child in the community. [IVb] preventing dehydration and identifying any deterioration. responding to treatment.1 Oxygen therapy that may develop into empyema thoracis110[III] and for signs of Hypoxic infants and children may not appear cyanosed. to infection such as cystic fibrosis. [IVb] < not feeding. percussion note should raise the possibility of a pneumonia < grunting. bronchiectasis. [IVb] – avoidance of tepid sponging < rising respiratory and pulse rate with clinical evidence of < preventing dehydration < identifying signs of deterioration severe respiratory distress and exhaustion.4 When should the child be reassessed? For children with CAP. [D] < significant tachycardia for level of fever (values to define < Children who have oxygen saturations <92% should be tachycardia vary with age and with temperature67[II]). reassessment is important. [IVb] < how to access further healthcare (providing a ‘safety net’). care can be accessed.

with 84% RSV positive. although 15 of the 64 in the physiotherapy did not have any effect on the length of hospital placebo group did eventually receive antibiotics. drawn to the 2007 National Patient Safety Agency alert ‘Reducing the risk of hyponatraemia when administering 8. either with pneumonia or bronchiolitis. effectiveness of nasopharyngeal suction were identified. Recommendation Evidence statement < Chest physiotherapy is not beneficial and should not be < Agitation may be an indicator that a child is hypoxic. potassium. Resistance to Recommendations antibiotics among bacterial pathogens is increasing and is of < Nasogastric tubes may compromise breathing and should concern. [D] with a group not treated with antibiotics. [C] trial of 136 young Danish children aged 1 month to 6 years. the smallest tube should be passed down the respiratory infections treated with antibiotics were compared smallest nostril. issues. fever or chest radiographic findings in patients with methods of oxygen delivery is more effective than any other.2 Fluid therapy < when to change to oral treatment if intravenous treatment Children who are unable to maintain their fluid intake due to initiated. gentle distress.119[Ib]120[II]122[IVb] There is a suggestion equally effective. would have measured at baseline and at least daily when on intravenous bronchiolitis not pneumonia. the smallest evidence to inform parenteral to oral switch or duration of tube should be passed down the smaller nostril. comparing various different antibiotic combinations found although potentially to a lesser extent because of their larger little differences in efficacy. No studies assessing the There were no new studies identified.118 Serum levels of sodium can be One of the major problems in deciding whether to treat low in children with pneumonia and there is debate as to a child with CAP with antibiotics is the difficulty in distin- whether this is related to inappropriate antidiuretic hormone guishing bacterial pneumonia (which would benefit from secretion or overall sodium depletion. doi:10. [IVb] performed in children with pneumonia. Trials status.2. some difficulties in assessing their however. in infants with small nasal passages. One was a randomised controlled fluids. head box or face mask to maintain The management of a child with CAP involves a number of oxygen saturation >92%. an important factor in this increase is the overuse of therefore be avoided in severely ill children and especially antibiotics. pneumonia.115[II] but the numbers studied were small that physiotherapy is counterproductive. urea and/or creatinine should be both enrolled many children who.2 Which children should be treated with antibiotics? intravenous fluids to children’. suctioning of the nostrils may help. There were no differences in the Two randomised controlled trials119[Ib]120[II] and an observa. Higher concentrations of resolving stage of pneumonia. [B] decisions regarding treatment with antibiotics: < whether to treat with antibiotics. percussion of the chest or <5 years concluded that the head box and nasal cannulae are deep breathing exercises. If use cannot be Two studies were identified in which children with diagnosed avoided. including postural drainage. oping and developed countries with different criteria used as Patients who are vomiting or who are severely ill may require definitions for pneumonia and with different immunisation intravenous fluids and electrolyte monitoring. in the UK. in theory.124[II]126[II] However.117[IVb] There is antibiotics. lacking.66:ii1eii23. BTS guidelines There is no strong evidence to indicate that any one of these stay. circulating bacteria and resistance patterns. < which antibiotic and by which route.123[Ib] and no children.1136/thoraxjnl-2011-200598 ii15 . ANTIBIOTIC MANAGEMENT air should be treated with oxygen given by nasal cannulae. This difficulty has been described in Section 3. < Plasma sodium. Studies on preterm < duration of treatment. smaller more frequent feeds are less likely to relevance to the UK as children have been enrolled from devel- cause stress to the respiratory system. 7. 8. course of the illness between the two groups (ampicillin or tional study121[Ib] conducted on adults and children showed that penicillin treated or placebo). [A] Recommendation < Patients whose oxygen saturation is #92% while breathing 8.2. and improve respiratory symptoms in children with respiratory Where the child’s nose is blocked with secretions. there is no methods of delivering high-flow humidified nasal oxygen are evidence to show that physiotherapy is beneficial in the available and increasingly used.124[II] The other Thorax 2011. identified in the update searches.116[II]117[IVb] Older children may be similarly affected. breathlessness or fatigue need fluid therapy. they should be avoided in severely ill pneumonia treated in the emergency department. It is easier to feed with nasal cannulae. There is no evidence to support the use of physio- A study comparing the different methods in children aged therapy.119[Ib] In addition. Alternative fever than the control group. Attention is backgrounds. infants or infants weighing <2000 g have shown that the The British Thoracic Society guidelines of 200251 found presence of a nasogastric tube compromises respiratory scanty evidence with which to address these questions. one trial indicating equivalence of nasal passages so. 7. A summary article121[Ib] summarised the studies discussed No new published studies about oxygen therapy were above.1 Introduction high-flow delivery device. with patients who and definitive recommendations cannot be drawn from this receive physiotherapy being at risk of having a longer duration of study. although tube feeds offer nutritional benefits intramuscular penicillin and oral amoxicillin in children with over intravenous fluids. however. There are.3 Physiotherapy Severe disease was excluded. Where nasogastric tube feeds are used. humidified oxygen can also be delivered via face mask or head A supported sitting position may help to expand the lungs box if necessary. Good quality evidence is antibiotics) from non-bacterial pneumonia (which would not). a number of large studies from many no evidence that nasogastric feeds given continuously are any different countries have attempted to address some of these better tolerated than bolus feeds (no studies were identified). Since then.

3.130[III] isolates indicate a stable 30% are macrolide resistant.3. because outcomes for children.134[Ib] should be reviewed if symptoms persist. Geographical variation appeared to have bronchiolitis rather than pneumonia.9% with amoxicillin for causing bacteraemia rose in the 1990s to 6. monia from the USA139[III] and South Africa140[II] found no reductions in intermediate penicillin-resistant strains have not difference in outcome between penicillin-resistant or sensitive followed. in Recommendations some areas up to 40%.133[Ib] wheeze. Serotype 19A.135[Ib] the UK primary immunisation schedule of PCV7 in 2006 and of PCV13 in April 2010. Increased macrolide use is associated with pneumococcal and although an increasing proportion has high-level macrolide group A streptococcal resistance133[Ib] and bacteria may acquire resistance. mostly low-level resistance in the USA but high-level resistance other b lactams and many other agents continue to be effica- in Europe.3.3 How much of a problem is antibiotic resistance? empyemas seen. erythromycin resistance was found in pneumonia. penicillin resistance children in 2000.1 Streptococcus pneumoniae unexpected spread of resistant clones of serotypes such as 19A Despite the rapid reduction in PCV7 serotypes following the following the introduction of a conjugate PCV for use in introduction of conjugate vaccine in 2000. Despite the increasingly wide literature on antibiotic resis- 51% of isolates were non-susceptible to penicillin. [C] Methicillin-resistant S aureus (MRSA) is of increasing concern in the USA and has been implicated in the increase in pleural 8. need PCV7. which is both antibiotic resistant and pneumococal pneumonias.143[Ib] A study from Portugal significantly associated macrolide use However. macrolides.142[III] resistance. Outcomes in pneumococcal meningitis have not been shown S pneumoniae macrolide resistance is also increasing. it is not ranges from 1. There is also varying prevalence of macrolide resistance in Streptococcus pyogenes (group A streptococcus) worldwide. is not covered by PCV7 and is now dren with pleural empyema and sensitive or resistant pneumo- increasing worldwide.132[Ib] macrolide resistance very fast if used indiscriminately. However.2 Group A streptococcus a fully vaccinated young child is therefore very small. and to differ significantly between susceptible and resistant different mechanisms of resistance drive different levels of isolates. Penicillin resistance has lower respiratory tract infection do not usually have not been seen to date and penicillin remains the therapeutic drug pneumonia and need not be treated with antibiotics but of choice. bacteraemia incidence.5% in the East Midlands to 8.6% and 14. nor were differences noted in chil- a common cause of disease. This possible to draw conclusions from them regarding whether is in contrast to much of mainland Europe where rates are young children with pneumonia benefit from antibiotics.136[Ib] and b-lactamase production in H < All children with a clear clinical diagnosis of pneumonia influenzae is widespread. there is less evidence of the impact of this on clinical PCVs have reduced drug-resistant S pneumoniae but. the likelihood of bacterial pneumonia in 8. graphic changes. including in countries without coccal disease in terms of duration of fever and tachypnoea. There was a non-significant difference in failure Pneumococcal penicillin non-susceptibility in pneumococci rate of 24% with placebo and 19. in those with a clinical diagnosis 12% of invasive isolates from children. A history of conjugate pneumococcal vaccination gives greater confidence 8. BTS guidelines in India enrolled children aged 2e59 months with cough. erythro- cannot be reliably distinguished from each other. as most children in these studies since declined to around 4% in 2007. Overall. increased steadily in Cleveland. penicillin resistance is far less prevalent. the 8. Resistance mechanisms vary geographically with as recommended in the British National Formulary for Children).2% in north-east effective. in the UK the reported resis- should receive antibiotics as bacterial and viral pneumonia tance rates for group A streptococcus to clindamycin.134[Ib] In 2006e7.4% resistant to all three. non-response to bronchodilator without chest radio. At this time. 5. it is included within PCV 13.134[Ib] it has not yet been a signif- choices and there is worldwide concern about increasing anti. however.0% respectively < Children aged <2 years presenting with mild symptoms of in 2007.126[II] Unfortunately. [C] mycin and tetracycline were 5. audible or auscultatory isolates among children (p¼0.30[II]41[II]138[II] biotic resistance among pneumococci and its potential impact on the treatment of pneumonia and invasive pneumococcal 8.45[Ia] With the introduction into very uncommon. the clinical impact of macrolide resistance is unclear. It is much higher in mainland with vaccine probe studies suggesting that one-third of children Europe with 25e50% macrolide resistance in France and aged <2 years with radiological signs have pneumococcal Italy. in severe infection double the normal dose.66:ii1eii23.1136/thoraxjnl-2011-200598 . with serotype 19A still of pneumonia.128[Ia]129[Ia]130[Ia] However. In the UK.006). whereas low-level resistance only involves dose penicillin G (ie.0% in London.127[Ib] tance.7% in 2000 and has 3 days.7% in London. mean duration of the introduction of which would potentially prevent a further therapy or length of hospital stay.131[Ia] US surveillance data for 2000e4 of respiratory cious parenterally for pneumonia and bacteraemia. doi:10. series of children with pneu- of increased intermediate resistance among non-PCV7 serotypes. but has decreased since 2004 aetiology in specific ages to the likelihood that these will be and also varies across the country from 5.3.01) and erythromycin non-susceptible breathing or difficulty breathing.3% in 2007.44[Ib]45[Ia] However. more recently. this falls to 6%. 25e50% in France and Spain.141[III] 50% of continuing IPD in children. rapid isolates from adults (p<0. for surgical treatment. high- resistance.4 What is the clinical impact of antibiotic resistance? disease. USA until 2003e4. The management of pneumococcal infections has been chal- lenged by the development of resistance and.1%. with the increase of penicillin and erythromycin non-susceptible with case reports describing clinical failure in adults with ii16 Thorax 2011. with 4.134[Ib] Erythromycin resistance in The other way of approaching this is relating knowledge of the UK is higher at 9. Both viruses and bacteria are found in young children. icant factor in either empyema or pneumonia. England to 14.3 Staphylococcus aureus to this decision.137[III] Although MRSA contributes to 31% of S Antibiotic resistance has the potential to impact on therapeutic aureus bacteraemia in the UK. High-level resistance also involves clindamycin In the face of no widespread failure of antibiotic therapy.

[III] cephalosporins (cefaclor has an association with skin reactions but. resistant S pneumoniae. on that evidence. they suggested that the study by Esposito et al indicated that mendations based. The antibiotics compared with penicillin or no antibiotic treatment. cefpodoxime. [D] 2006 was updated in 2010. procaine penicillin and cefuroxime.138[II] expected pathogens circulating within the community and the Information on the antibiotics recommended for treatment of immunisation status of the child. < Although there appears to be no difference in response to cefixime. with pneumoniae assessed as ‘clinical failures’. groups. where possible. Randomised controlled trials comparing different antibiotics have shown similar or equivalent efficacy variously for Evidence statement macrolides. the data are limited and the majority otics such as levofloxacin153[II] have shown efficacy in similar of children in these studies were not treated with oral b- studies in the USA. [D] identified clinically who fulfil the WHO criteria for pneumonia have normal chest x-rays. [B] erythromycin.158[Ib]165[Ib]166[Ib] The PIVOT trial166[Ib] randomised with non-severe outpatient-treated clinical pneumonia were the UK children over the age of 6 months admitted to hospital with same with standard and double dose amoxicillin.53[II] Children with M pneumoniae nia. azithromycin and clarithromycin. the nature of the infecting organism is almost never intravenous benzylpenicillin or oral penicillin V) with the known at the initiation of treatment and the choice of antibiotic introduction of a local management protocol. length and severity of pneumonia caused by M pneumoniae shock. cefaclor. In pneumonia in can be rationalised to simple narrow spectrum antibiotics (eg.5 How should antibiotics be given? income developed countries and less than a quarter enrolled One large adequately-powered trial compared the efficacy of using chest radiographic definitions. A large multicentre randomised open-label equivalency study tion. no differences in therapy in all children because it is effective against the clinical efficacy have been identified.66:ii1eii23. is well little difference between different macrolides. although reviewed the relevant scientific evidence and provide recom. with 19% treatment failure. On the basis of treated in the emergency department.158[Ib] Five studies were from high 8. In adults. doi:10. co-amoxiclav was comparable to azithromycin 24e36 h did not show any differences in outcome between the and cefpodoxime but superior to amoxicillin. treated with macrolides.164[IVa] frequently recommendations are based on judgements about A recent report of a closed audit loop showed that prescribing what constitutes safe and effective treatment. encompassing 11 928 children. amoxicillin given for 24e36 h to children with pneumonia thromycin). compared with cefalexin.4 Which antibiotic should be used? respiratory tract infections did not find enough evidence to It is clear that there is variation in medical prescribing that indicate whether antibiotics improved outcomes in children largely reflects custom. defined pneumonia and randomised them to oral amoxicillin or Improved short. We have with M pneumoniae lower respiratory tract infections.161 In an produced equivalent outcomes.163[II] However. knowledge of resistance patterns of developing. amoxicillin.19[II] conventional antibiotic treatment in children with penicillin- 63[II]147[II]148[II]149[II]150[II]151[II]152[II] Additionally.165[Ib] and lower by clinical diagnosis) treated with macrolides In a randomised control trial a group in Pakistan also studied compared with those not treated. cefuroxime and ceftriaxone.158[Ib] Thorax 2011.157[Ia] Twenty-seven studies were < Macrolide antibiotics should be used if either mycoplasma or reviewed. It is recognised that 82% of children recommended. BTS guidelines bacteraemic infection144[III] but not in those with pneumo. newer antibi. cefixime is poorly active against S aureus and < Amoxicillin is recommended as first choice for oral antibiotic cefuroxime axetil has poor oral absorption). Asia and South America and cytokines compared with placebo. Alternatives are co-amoxiclav. erythromycin. comparing multiple chlamydia pneumonia is suspected or in very severe disease. in the UK. most of these were enrolled on the basis of [D] WHO-defined clinical criteria for pneumonia and were from < In pneumonia associated with influenza.162[II] There is little enrolled 1702 infants aged 3e59 months with severe clinically- evidence for specific antibiotics in children. experimental mouse model of respiratory M pneumoniae infec. There also appears to be majority of pathogens which cause CAP in this group. in Pakistan. 83% had not been equivalent results in both groups. antibiotics.123[Ib] Evaluation at single studies. a Cochrane review of specific mycoplasma treatment in children with lower 8. cefaclor. Despite pharmacological differences in oral lactam agents alone. co-amoxiclav. if treated with macrolides. This has the is therefore determined by the reported prevalence of different potential to reduce the likelihood of antibiotic resistance pathogens at different ages.57[II]154[II]155[II] tolerated and cheap.156[II] < Macrolide antibiotics may be added at any age if there is no A Cochrane review of antibiotics in childhood pneumonia in response to first-line empirical therapy. but more some children may benefit. even in severe pneumonia. local practice and availability.145[II]146[II] To date. co-amoxiclav is developing countries. clarithromycin significantly decreased M pneumoniae levels in eight developing countries in Africa.and long-term outcomes have been described parenteral penicillin. High-dose amoxicillin twice daily is a pharmacokinetically Oral amoxicillin has been shown to be as effective as paren- satisfactory dosing regime and may aid compliance159[Ib] teral penicillin. Africa/Asia although. good activity against S pyogenes Recommendations and S pneumoniae.160[Ib] pneumonia to either oral amoxicillin or intravenous penicillin. Findings included equiva.1136/thoraxjnl-2011-200598 ii17 . outcomes for infants aged 2e59 months and Pakistan. children. Identical outcomes were obtained in each in children with respiratory tract infections (a mixture of upper group. treatment with intramuscular penicillin (one dose) and oral lence for amoxicillin and macrolides (azithromycin and clari.66[II] Of those children with severe pneumonia and compared home treatment using twice lower respiratory tract infections due to M pneumoniae and/or C daily oral high-dose amoxicillin with parenteral ampicillin. although clarithromycin may be better tolerated than erythromycin. CAP is available in the British National Formulary for Children. pleural effusion requiring drainage). no association with resistance and pneumonia in Taiwan had significantly shorter duration of fever treatment failure has been demonstrated in children. However. macrolide antibiotics have been shown to reduce the Only the most severe were excluded (oxygen saturation <85%.

1 Pleural effusions and empyema the issue of when it is safe and effective to transfer from Parapneumonic effusions are thought to develop in 1% of intravenous to oral antibiotic therapy. even in severe disease in hospitalised improve? children. Answers to the the UK.6 When should antibiotics be switched from parenteral to oral? 9. with no difference in outcome.173[III]174[III] A persisting fever despite adequate Recommendation antibiotic treatment should always lead the clinician to be < In a patient who is receiving intravenous antibiotic therapy suspicious of the development of empyema. Lung abscess with an associated antibiotic treatment in the UK. the pleural space should be drained. minimum inhibitory concentration for most penicillin-resistant and cefotaxime or ceftriaxone. which had a bacterial cause) to either 4 or 7 days of parenteral More details on the diagnosis and management of empyema are penicillin or cefuroxime.2 What are the common complications of CAP? No randomised controlled trials were identified that addressed 9.169[II] Most of these children the chest x-ray and diagnosis can be confirmed by CT scannin- may not have needed antibiotics at all and.177[III] There are also emerging data that with wheeze and 23% RSV-positive in the paper by Agarwal certain serotypes of pneumococcal disease are more likely to lead et al125[II]. No difference was seen in acute cure or some children are predisposed to this more severe form of lung relapse rates between the groups. Ultrasound.2 Necrotising pneumonias a Cochrane review by Haider et al.172[III] It has this is an area for further investigation. There can thus be no rigid patients with CAP171[III] but.150[Ib] given in the BTS guidelines on pleural disease in children. only 38% had difficulty toxin can lead to severe lung necrosis with a high risk of breathing and 80% had <10 breaths excess respiratory rate. neurological disorders and who would be defined as having bronchiolitis with wheeze (13% immunodeficiency. ideally in from developing countries. in the severely ill child. in commenced.168[II] All are feverish.179[IVb] Prolonged intravenous antibiotic courses may be the group that.125[II]169[II] were reviewed in 9. Only mortality. [A+] cillin-resistant S pneumoniae would lead to failure of treatment. doi:10.178[III] Suspicion of abscess/necrosis is often raised on 14% had chest radiographic changes.2. although 99% had a cough. only two of which are published. Where an effusion is present and the patient is persistently comparing the duration of antibiotic treatments.or CT-guided with a bacterial pneumonia.168[II] These studies enrolled Lung abscess. There are some difficulties in infection. oral treatment should be considered pleural space is revealed on the chest x-ray and the amount of if there is clear evidence of improvement. bronchiectasis. [D] 8. It is therefore still not known empyema may be drained at decortication if the abscess is close whether a 3-day antibiotic course is sufficient to treat a child to the parietal pleura and is large.175[III] and that S aureus with PantoneValentine leukocidin infections as. recently been reported that empyema thoracis may be increasing in incidence. < Intravenous antibiotics should be used in the treatment of However. The authors noted that the pneumonia. one study170[III] has shown that there is no difference pneumonia in children when the child is unable to tolerate in the percentage of children in hospital treated successfully oral fluids or absorb oral antibiotics (eg. is believed to be an increasing and important criteria of non-severe pneumonia to either 3 or 5 days treatment complication. re-evaluation is necessary.113 Three randomised trials of short-course oral antibiotics. [D] fluid is best estimated by ultrasound examination. The predisposing factors include: congenital cysts. because of vomiting) with penicillin or ampicillin when the organism was penicillin- or presents with signs of septicaemia or complicated susceptible or penicillin-resistant. co-amoxiclav. A clinician should consider empyema when a child has a persistent fever 8. If a child remains feverish or unwell 48 h after treatment has Parenteral administration of antibiotics in children (which.174[III] Fluid in the for the treatment of CAP. [D] serum concentration of penicillin or ampicillin achieved with < Recommended intravenous antibiotics for severe standard intravenous dosages was much greater than the pneumonia include amoxicillin.180[III] ii18 Thorax 2011.2. indeed. a microbiological diagnosis is made. drug costs are much greater than with < Is the patient having appropriate drug treatment at an oral regimens and admission to hospital is generally required.7 What is the optimal duration of antibiotic treatment? beyond 7 days174[III] or a fever not settling after 48 h of antibi- Since 2000 there have been a few trials and a Cochrane review otics. if vaccinated.1 What factors should be considered in children who fail to to parenteral treatment. These can be rationalised if strains. < Is the patient not responding because of a complication in the host such as immunosuppression or coexistent disease such Recommendations as cystic fibrosis? < Antibiotics administered orally are safe and effective for There has been concern that the increased incidence of peni- children presenting with even severe CAP. although a rare complication of CAP in child- infants in developing countries with WHO-defined clinical ren. Some had simple upper respiratory tract s. parenteral administration < Is there a lung complication of pneumonia such as a collection ensures that high concentrations are achieved rapidly in the of pleural fluid with the development of an empyema or lung. cefuroxime. in those admitted to hospital. randomised children with pneumonia (a high proportion of There is debate as to the best method of draining effusions.175[III]176[III] There are some data suggesting that with oral amoxicillin.66:ii1eii23. COMPLICATIONS AND FAILURE TO IMPROVE concluded that oral therapy was a safe and effective alternative 9. except for a trial from Finland which a specialist centre. translating these data as the cohorts of infants included many sequestrations. adequate dosage? However. The parenteral route should also be used if there are evidence of a lung abscess? concerns about oral absorption. percutaneous drainage can be used. BTS guidelines Two of these were reviewed in a Cochrane review167[Ia] which 9. 23% with wheeze and 18% RSV-positive in the paper to necrotising pneumonia and abscess formation than other- by Qazi et al169[II]).1136/thoraxjnl-2011-200598 . statement about the timing of transfer to oral treatment and effusions may be found in as many as 40% of cases. is generally intravenous) is traumatic as it requires the following questions should be sought: insertion of a cannula. fall into g. it is suggested do not require required until the fever settles.

3.5 million/ 9. but a number of clinical trials and caseecontrol myocarditis and neurological complications including encepha. The rare complication Children can present with symptoms and signs of pneumonia of haemolytic uraemic syndrome is described with pneumo- but also have features of systemic infection. home on $1 day/week. there is still more to be done in improving housing. Smoking cessa- Pneumatoceles occasionally leading to pneumothorax are more tion would decrease respiratory illness in children but there are commonly seen with S aureus pneumonia.3 Septicaemia and metastatic infection shift in serotype prevalence are ongoing.6%). However.5 Long-term sequelae crowding. The long-term no specific data for pneumonia. PREVENTION AND VACCINATION cation. of 43 cases of pneumococcal haemolytic uraemic syndrome. < Children with severe pneumonia.2.2 Mycoplasma pneumonia annum prior to 1980 to 345 000 in 2005. with infants that is believed to be associated with certain serotypes.1 Staphylococcus aureus pneumonia for respiratory conditions of US$117 per child.2. aseptic meningitis. A near normal. doi:10. reducing 9. but it is advised to counsel home had an increased likelihood of hospital admission (4. term respiratory symptoms secondary to areas of fibrosis or bronchiectasis. pancreatitis. no smoking) especially if they have a pre-existing diagnosis of asthma. healthcare service use and expenditure for respiratory conditions There are also prospective data to suggest that children who in children linked to exposure to smoking in the home. have contributed greatly to the prevention of CAP. 35 presented with pneumonia and 23 presented with empyema.2 Bordetella pertussis being found to cause necrotic pneumonia and abscess formation Whooping cough continues to be seen in the UK.178[III] In the than 2 million deaths were averted by immunisation.5% vs 3. Thorax 2011. this General improvements in public health over the last century should be considered.3 Complications of specific infections smoking was associated with additional healthcare expenditure 9. particularly with S aureus infections. empyema and lung abscess can lead to long.2. The WHO estimates that. reducing smoking and improving the uptake of Severe pneumonia. transverse myelitis and acute psychosis introduction of this vaccine reduced radiologically-confirmed have all been reported. The introduction of measles vaccination resulted in a decrease of deaths from measles worldwide from 2. sufficiently unusual to warrant investigation of the child’s Pneumonia contributes to 56e86% of all deaths attributed to immune system. in 2003.2. empyema and lung abscess should be followed up after discharge until they have 9. Children exposed to smoking in the reasons for this are as yet unclear.181[II] Although a rare compli.4 Haemolytic uraemic syndrome recovered completely and their chest x-ray has returned to S pneumoniae is a rare cause of haemolytic uraemic syndrome.175[III] aged <6 months having the highest morbidity and mortal- Vaccination programmes against pneumoccocus do not protect ity. Metastatic infection can < If a child remains feverish or unwell 48 h after hospital rarely occur as a result of the septicaemia associated with admission with pneumonia. hepatitis. in cases with pallor. outlook is good with normal lung function.1 Would smoking cessation help? be followed up after discharge until they have recovered A recent paper from the USA estimated the annual excess completely and their chest x-ray has returned to near normal. Children with coccal pneumonia. lihood of an emergency unit visit for respiratory illness (8. the 10.190[III] In the USA. routine vaccines. The using multivariant analysis. BTS guidelines 9.66:ii1eii23. pneumonia by 20e30%. Osteomyelitis or septic arthritis should be consid- consideration given to possible complications.186[III] Complications in almost every body system have been reported in association with M pneumoniae. not known.3 Streptococcus pneumoniae pneumonia vaccination was 1304/100 000 children aged <5 years. profound anaemia and anuria.1 Haemophilus influenzae StevenseJohnson syndrome occurs rarely. septicaemia and pneumonia are likely to require high depen- Recommendations dency or intensive care management.1136/thoraxjnl-2011-200598 ii19 . [D] ered. S aureus pneumonia is 607 000 were prevented by the use of pertussis vaccination. re-evaluation is necessary with pneumonia.187[Ib]188[II] The WHO estimated that the global incidence of H influenzae pneumonia in the absence of 9. smoking outside the home.184[III] Vaccination has made a real impact on pneumonia and child PantoneValentine leukocidin toxin-producing S aureus can lead survival worldwide.41[Ib] The survey that has self-reported data on smoking inside the home. pericarditis. polyarthritis.185[III] have had an episode of CAP are more likely to suffer from They linked data from the nationally representative Medical prolonged cough (19% vs 8%). 29 134 cases of against all serotypes and surveillance studies monitoring for pertussis were reported of whom 7203 were aged <6 months. this study does suggest respiratory health assessed in three groups (smoking inside the that some children do develop persistent expiratory symptoms. Children with empyema and lung abscess should 10.3. from 1997 to 2000. majority of children with CAP have no long-term sequelae and Data were obtained on 2759 children aged 0e4 years and make a complete recovery.2.3% vs parents and carers at discharge to consult their doctor if these 1. and haemolytic The impact of Hib conjugate vaccine on pneumonia in the UK is anaemia. [D] recent case series found that. studies from the developing world have established that the litis. It is increasingly 10. However. measles.1% had at least one hospital stay/year) and an increased like- symptoms occur. Indoor 9.3.2 What is the influence of vaccination? requiring extracorporeal membrane oxygenation. chest wall shape abnormality (9% Expenditure Panel survey with the National Health Interview vs 2%) and also doctor-diagnosed asthma (23% vs 11%). The data were not specific for pneumonia.189[Ib] Pneumococcus is the most common bacterium to cause CAP and the major complication of empyema thoracis.182[III]183[III] There has been an increase in MRSA and some severe cases reported 10. more to severe lung necrosis with a high risk of mortality. of which UK and other developed countries. 10. Rashes are common.

Nuorti JP. Evidence statements monia. Trollfors B.35.117:e817e20. internally peer reviewed. than in other provinces. Jalonen E.34:E1e11. Koshy E. Senstad AC.2. Clin Infect Dis <1 year. 22. et al. Clark JE.8:856e62.83) from 2006 to children: quantifying the burden on patients and their families including decrease in 2008.199[III] In Ontario. Edmunds WJ. Ahmed A. data of effectiveness in relation to childhood pneumonia in the 17. et al. Eur J Pediatr 2003. polymerase chain reaction using blood samples.8:341e8. Germany. The several studies of the effectiveness in decreasing respiratory audit tool will be updated to reflect the content of the current morbidity. J Infect 2006. Weigl JA. Population-based burden of pneumonia children per year). et al. 52%). Klin Padiatr 2005.190[III] 11. (1997e2008) recently published results on the impact of the 13. Community-acquired pneumonia in a 19% decrease (RR 0. et al.4 Influenza J 2010. et al. Mertsola J. et al. Atkinson M. Attanasio E. 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