Pneumonia Caused by Chlamydia Pneumoniae in Children

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Pneumonia caused by Chlamydia pneumoniae in children

AUTHOR: Jesus G Vallejo, MD
SECTION EDITORS: Morven S Edwards, MD, Robert A Wood, MD
DEPUTY EDITOR: Diane Blake, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Nov 07, 2023.
INTRODUCTION
Pneumonia caused by Chlamydia pneumoniae in children will be discussed here. Infections

caused by other species of Chlamydia and community-acquired pneumonia in children are
discussed separately:
● (See "Chlamydia trachomatis infections in the newborn".)

● (See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)
● (See "Treatment of Chlamydia trachomatis infection".)
● (See "Psittacosis".)
● (See "Pneumonia in children: Epidemiology, pathogenesis, and etiology".)
● (See "Community-acquired pneumonia in children: Clinical features and diagnosis".)
MICROBIOLOGY
C. pneumoniae is an obligate intracellular pathogen that belongs to the Chlamydiaceae family

and Chlamydia genus [1]. Although there was a proposal to divide the Chlamydia genus into
two genera, Chlamydia and Chlamydophila [2], an international committee on the taxonomy
of Chlamydiae agreed that the Chlamydiaceae family contains a single genus, Chlamydia [3].
Chlamydia spp are unusual in several ways. Their genome is smaller than that of any other
prokaryote except Mycoplasma. Their cell wall contains very small amounts of peptidoglycan
[4]. Their growth cycle is complex and biphasic, consisting of two distinct forms [5-7]:
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/pneumonia-caused-by-chlamydia-pneumoniae-in-children/print?search=pneum… 1/19
● Elementary bodies – Elementary bodies are the infectious form. They can survive in the
extracellular environment.
● Reticulate bodies – Reticulate bodies are the form in which C. pneumoniae replicates
within a membrane-bound inclusion.
EPIDEMIOLOGY
C. pneumoniae is a common respiratory pathogen [7,8]. C. pneumoniae pneumonia occurs

worldwide [9]. Outbreaks in closed populations (eg, schools, military recruits, nursing homes)
have been described [10-13].
In case series of children with community-acquired pneumonia, the proportion of cases

associated with C. pneumoniae varies from study to study, ranging from 0.3 to 44 percent,
depending upon the diagnostic method and population studied [7,14-20]. When culture or
polymerase chain reaction (PCR)-based assays were used, the proportion ranged from 0.3 to
7.8 percent [7,17,19,20]. Epidemiologic studies that used serology for diagnosis of C.
pneumoniae must be interpreted with caution. Serology has poor correlation with culture and
PCR [7,9,21-23]. (See 'Diagnosis' below.)
The initial infection typically occurs between 5 and 15 years of age but may occur earlier in
tropical and resource-limited countries [21,24,25]. In the United States, approximately 30
percent of adolescents younger than 20 years are seropositive for C. pneumoniae [24],
although patients with culture-documented C. pneumoniae infection, particularly children
younger than five years, may not develop antibodies [9,26-31].
C. pneumoniae is thought to be transmitted from person to person via respiratory tract

secretions [25]. It is shed from the respiratory tract during acute illness and for as long as
one year after [26]. Whether symptoms increase the risk of transmission is unclear [8]. The
mean incubation period is 21 days [25].
Coinfection with other pathogens, including Streptococcus pneumoniae, Mycoplasma

pneumoniae, and viruses, is common [14,21,32].
PATHOGENESIS
At the onset of C. pneumoniae infection, elementary bodies (EBs), the infectious form of C.
pneumoniae, attach to respiratory mucosal epithelial cells and enter the cells via a
phagosome. Once inside the cell, EBs reorganize to reticulate bodies (RBs), which then
replicate, forming intracytoplasmic inclusions. RBs are unstable and revert to EBs, which are
released through cell lysis or exocytosis and go on to infect other cells [5,7]. When C.
pneumoniae is involved in coinfections, it may disrupt normal clearance mechanisms,

allowing the other pathogen to invade [7].
The host immune response is induced by chlamydial antigens, which are released onto the
host cell surface during replication [5]. Because immunity is short-lived, reinfection or
persistent infection is possible [5,7].
CLINICAL FEATURES
Clinical features of C. pneumoniae pneumonia are similar to those of other types of

community-acquired pneumonia (CAP) and include fever, cough, tachypnea, and shortness
of breath [33,34].
No clinical, laboratory, or radiographic findings reliably differentiate C. pneumoniae

pneumonia from other causes of CAP [21,28]. (See "Community-acquired pneumonia in
children: Clinical features and diagnosis".)
C. pneumoniae infection is frequently asymptomatic or only mildly symptomatic ( table 1)

[35]. However, severe and life-threatening infections can occur [36,37]. Coinfection with other
pathogens may affect the clinical presentation [38].
In small case series, common features of C. pneumoniae pneumonia include gradual onset of
symptoms, associated pharyngitis, and often hoarseness ( table 2) [21,39,40]. Sinusitis
frequently accompanies C. pneumoniae pneumonia or develops as a complication.
Pneumonia caused by Mycoplasma spp and respiratory viruses can present in a similar
fashion.
The white blood cell count is usually normal or mildly elevated [33]. Chest radiograph
findings generally are nonspecific and include patchy subsegmental infiltration, bilateral
infiltrates, and pleural effusion [21,33,36].
Although there are rare reports of extrapulmonary manifestations (eg, meningoencephalitis

[41-43], Guillain-Barré syndrome [44], and myocarditis [45-49]), a causal role for C.
pneumoniae has not been definitively established.
DIAGNOSIS
● Indications for laboratory evaluation – We individualize decisions about laboratory

testing for C. pneumoniae based upon severity of illness, test availability, and whether
the results would affect management (eg, to provide specific therapy in critically ill
children). General indications for microbiologic testing in children with community-
acquired pneumonia (CAP) are discussed separately (See "Community-acquired

pneumonia in children: Clinical features and diagnosis", section on 'Indications for
microbiologic testing'.)
We usually perform laboratory evaluation for C. pneumoniae only in hospitalized

children who are critically ill and require mechanical ventilation; the sample is obtained
from a tracheal aspirate or bronchoalveolar lavage. Our institution does not have an in-
house multiplex respiratory panel that includes C. pneumoniae.
Testing is rarely necessary in the outpatient setting, where empiric therapy with activity
against C. pneumoniae typically is initiated in children ≥5 years with CAP and clinical
features suggestive of atypical pneumonia ( table 2). (See "Community-acquired
pneumonia in children: Outpatient treatment" and "Community-acquired pneumonia in
children: Outpatient treatment", section on 'Factors influencing choice of regimen'.)
● Microbiologic confirmation – When confirmation of C. pneumoniae is necessary,

polymerase chain reaction (PCR)-based assays are preferred if available [23,50]. Cell
culture is an alternative, but results will not be available to guide initial treatment.
Serology is not helpful in the diagnosis of acute C. pneumoniae infection. (See
'Antimicrobial therapy' below.)
• PCR-based assays – PCR-based assays have high sensitivity and specificity and
provide rapid results [9,23]. However, positive results for C. pneumoniae should be
correlated with clinical findings because PCR-based assays do not differentiate
between acute symptomatic infection and asymptomatic infection or persistent C.
pneumoniae following resolution of symptoms [21,26,51]. Identification of C.
pneumoniae does not exclude coinfection.
PCR-based assays can be performed on a variety of respiratory specimens (eg,

nasopharyngeal swab or aspirate, oropharyngeal swab, bronchial lavage fluid).
However, the sensitivity and specificity of most PCR-based assays, including
multiplex assays, when used on different clinical samples and in the clinical setting
are unknown. Pending additional information, results of PCR-based assays should
be used in conjunction with clinical and epidemiologic information to make
treatment decisions.
Availability of PCR-based assays for C. pneumoniae vary from laboratory to

laboratory. Clinicians should check with their laboratory for details about
appropriate specimen types, specimen collection, and transport [23].
Commercially available multiplex panels for respiratory infection that include C.

pneumoniae are used by some institutions and general practitioners in the
evaluation of patients with respiratory tract infections [52-56]. If the panel is sent to
an outside laboratory, turnaround time is usually one to three days; if it is

performed on site, turnaround time is usually three to four hours.
• Cell culture – Although cell culture permits genotyping and antimicrobial

susceptibility testing, it is rarely used for routine clinical testing because it requires
specialized techniques with variable sensitivity and specificity depending on the
expertise of the laboratory and can take weeks to obtain results [7,9,23]. It is not
widely available and is costly.
• Serology – Serology is not helpful in the diagnosis of acute C. pneumoniae infection.

It is not standardized, has poor correlation with culture and PCR, and requires
collection of both acute and convalescent sera for diagnosis [7,9,21-23,57].
ANTIMICROBIAL THERAPY
Empiric therapy for community-acquired pneumonia — Treatment for community-

acquired pneumonia (CAP) in children usually is initiated empirically, based upon the age of
the child and the clinical presentation. Among children who are treated as outpatients,
microbiologic testing generally is not obtained. Empiric therapy may or may not include
coverage for atypical pathogens, including C. pneumoniae. If C. pneumoniae is suspected (eg,
outbreak setting, clinical features suggestive of atypical pathogens ( table 2)), empiric
therapy should include activity against C. pneumoniae (eg, a macrolide antibiotic with or
without additional coverage for typical bacterial pathogens). Empiric therapy for CAP in
children is discussed separately. (See "Community-acquired pneumonia in children:
Outpatient treatment", section on 'Empiric therapy' and "Pneumonia in children: Inpatient
treatment", section on 'Empiric therapy' and "Community-acquired pneumonia in children:
Outpatient treatment".)
Therapy for C. pneumoniae
● Outpatient setting
• Preferred regimen – For children with microbiologically confirmed C. pneumoniae

pneumonia in the outpatient setting, we suggest treatment with azithromycin 10
mg/kg per day orally (maximum daily dose 500 mg) on day 1 followed by 5 mg/kg
per day orally (maximum daily dose 250 mg) on days 2 through 5.
• Alternative regimen – Doxycycline 2 to 4 mg/kg per day orally divided into two doses
(maximum daily dose 200 mg) for seven days is an alternative for children of all ages
[58-60].
We prefer azithromycin because its treatment course is shorter and it is associated with
fewer adverse effects than other oral agents with activity against C. pneumoniae (eg,
other macrolides, doxycycline, levofloxacin, moxifloxacin) [61-64]. Fluoroquinolones
generally are reserved for children in whom there is no safe and effective alternative or
an oral fluoroquinolone is the only alternative to parenteral therapy [65]. (See
"Fluoroquinolones", section on 'Children'.)
● Hospitalized children
• Preferred regimen – For children who require hospitalization for severe

microbiologically confirmed C. pneumoniae pneumonia ( table 1), we suggest
initial treatment with azithromycin 10 mg/kg intravenously (IV) once per day on day
1 and day 2, followed by transition to oral therapy (if possible) with azithromycin 5
mg/kg orally once per day to complete a five-day course [58].
• Alternative regimens – Alternative initial IV regimens include [58]:
- Erythromycin 20 mg/kg per day IV divided in four doses, or
- Levofloxacin – Age 6 months to 5 years: 16 to 20 mg/kg per day IV divided in two

doses; age 5 to 16 years: 8 to 10 mg/kg per day IV once per day (maximum daily
dose 750 mg)
When the child is ready to transition to oral therapy, one of the following regimens
can be used to complete a 7- to 10-day course of therapy:
- Clarithromycin 15 mg/kg per day orally divided in two doses
- Erythromycin 50 mg/kg per day orally divided in four doses
- Doxycycline 2 to 4 mg/kg per day orally divided in two doses (maximum daily
dose 200 mg)
- Levofloxacin 500 mg orally once daily (for skeletally mature adolescents)
- Moxifloxacin 400 mg orally once daily (for skeletally mature adolescents)
Clinical trials directly evaluating the efficacy of antibiotics on clinical outcomes in children
with C. pneumoniae pneumonia are lacking. However, in randomized trials and observational
studies of children with radiographically confirmed CAP, azithromycin and clarithromycin
appear to have clinical efficacy similar to that of erythromycin [14,63,66,67].
Although it is not known whether microbiologic eradication is necessary for clinical cure, in
subgroup analysis of patients with culture-confirmed C. pneumoniae from several clinical
trials, the efficacy of microbiologic eradication was approximately 80 percent with a 5-day
course of azithromycin [63,68] and 70 to 100 percent with a 10-day course of clarithromycin,
erythromycin, or moxifloxacin or a 7- to 10-day course of levofloxacin [28,69,70]. Failures are
thought to be due to lack of eradication of the pathogen in its persistent state and not due to
drug resistance [71].
RESPONSE TO THERAPY
Children with community-acquired pneumonia who receive appropriate antimicrobial

therapy generally are clinically improved within 48 to 72 hours of treatment. Management of
those who do not improve as expected is discussed separately. (See "Community-acquired
pneumonia in children: Outpatient treatment", section on 'Treatment failure' and
"Pneumonia in children: Inpatient treatment", section on 'Treatment failure'.)
PROGNOSIS
C. pneumoniae pneumonia is usually mild and most patients recover without complications
[8]. In some children, C. pneumoniae may be associated with prolonged cough (mean
duration 25 to 30 days) [8,72-75]. Although C. pneumoniae has been associated with asthma
[76-79] and reactive arthritis [80-82], a causal relationship has not been established.
PREVENTION
C. pneumoniae is thought to be transmitted from person to person via respiratory tract

secretions or fomites. Frequent hand washing and respiratory hygiene/cough etiquette are
suggested to prevent transmission [12,25,83].
For patients hospitalized with C. pneumoniae pneumonia or community-acquired pneumonia

of unknown etiology, standard precautions are recommended [25,84]. (See "Infection
prevention: Precautions for preventing transmission of infection".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pediatric
pneumonia".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
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and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
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comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or email these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Pneumonia in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Chlamydia pneumoniae is an obligate intracellular pathogen that causes a minority of

cases of community-acquired pneumonia (CAP) in children. Outbreaks have been
reported in closed populations. Coinfection with other pathogens is common. The initial
infection usually occurs between 5 and 15 years of age but may occur earlier. (See
'Epidemiology' above.)
● Clinical features of C. pneumoniae are similar to those of other types of CAP and include
fever, cough, tachypnea, and shortness of breath. Common features include gradual
onset of symptoms, associated pharyngitis, and often hoarseness ( table 2). However,
no clinical, laboratory, or radiographic findings reliably differentiate C. pneumoniae
pneumonia from other causes of CAP. (See 'Clinical features' above.)
● We individualize decisions about laboratory testing for C. pneumoniae based upon

severity of illness, test availability, and whether the results would affect management
(eg, to provide specific therapy in critically ill children). Testing is rarely necessary in the
outpatient setting. When confirmation of C. pneumoniae is necessary, polymerase chain
reaction-based assays are preferred if available. (See 'Diagnosis' above.)
● For children with microbiologically confirmed C. pneumoniae pneumonia and clinical

findings compatible with CAP, we suggest treatment with azithromycin rather than
other macrolides, tetracyclines, or fluoroquinolones (Grade 2C). Azithromycin has a
shorter treatment course and is associated with fewer adverse effects than other
available agents. We use 10 mg/kg per day orally (maximum daily dose 500 mg) on day
1 followed by 5 mg/kg per day orally (maximum daily dose 250 mg) on days 2 through
5. Doxycycline is an alternative for children of all ages. (See 'Therapy for C. pneumoniae'
above.)
● Children with CAP who receive appropriate antimicrobial therapy generally are clinically
improved within 48 to 72 hours of treatment. Most patients recover without
complications. (See 'Response to therapy' above and 'Prognosis' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Dori Zaleznik, MD, who contributed to an earlier
version of this topic review.
Use of UpToDate is subject to the Terms of Use.
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62. Kohlhoff SA, Huerta N, Hammerschlag MR. In Vitro Activity of Omadacycline against
Chlamydia pneumoniae. Antimicrob Agents Chemother 2019; 63.
63. Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the
treatment of community-acquired pneumonia in children. Pediatr Infect Dis J 1998;
17:865.
64. Langley JM, Halperin SA, Boucher FD, et al. Azithromycin is as effective as and better
tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics 2004;
114:e96.
65. Jackson MA, Schutze GE, COMMITTEE ON INFECTIOUS DISEASES. The Use of Systemic
and Topical Fluoroquinolones. Pediatrics 2016; 138.
66. Numazaki K, Sakamoto Y, Umetsu M, et al. Therapeutic effect of clarithromycin for
respiratory-tract infections in children caused by Chlamydia pneumoniae. Research
Group of Sapporo for Pediatric Chlamydial Infections. Int J Antimicrob Agents 2000;
13:219.
67. Lee PI, Wu MH, Huang LM, et al. An open, randomized, comparative study of
clarithromycin and erythromycin in the treatment of children with community-acquired
pneumonia. J Microbiol Immunol Infect 2008; 41:54.
68. Roblin PM, Hammerschlag MR. Microbiologic efficacy of azithromycin and
susceptibilities to azithromycin of isolates of Chlamydia pneumoniae from adults and
children with community-acquired pneumonia. Antimicrob Agents Chemother 1998;
42:194.
69. Hammerschlag MR, Roblin PM. Microbiologic efficacy of moxifloxacin for the treatment
of community-acquired pneumonia due to Chlamydia pneumoniae. Int J Antimicrob
Agents 2000; 15:149.
70. Hammerschlag MR, Roblin PM. Microbiological efficacy of levofloxacin for treatment of
community-acquired pneumonia due to Chlamydia pneumoniae. Antimicrob Agents
Chemother 2000; 44:1409.
71. Panzetta ME, Valdivia RH, Saka HA. Chlamydia Persistence: A Survival Strategy to Evade
Antimicrobial Effects in-vitro and in-vivo. Front Microbiol 2018; 9:3101.
72. Hallander HO, Gnarpe J, Gnarpe H, Olin P. Bordetella pertussis, Bordetella parapertussis,
Mycoplasma pneumoniae, Chlamydia pneumoniae and persistent cough in children.
Scand J Infect Dis 1999; 31:281.
73. Jama-Kmiecik A, Frej-Madrzak M, Gosciniak G, et al. Detection of Chlamydophila

Pneumoniae and Typical Bacteria in Patients with Chronic Cough. Adv Exp Med Biol
2015; 857:75.
74. Hagiwara K, Ouchi K, Tashiro N, et al. An epidemic of a pertussis-like illness caused by
Chlamydia pneumoniae. Pediatr Infect Dis J 1999; 18:271.
75. Wright SW, Edwards KM, Decker MD, et al. Prevalence of positive serology for acute
Chlamydia pneumoniae infection in emergency department patients with persistent
cough. Acad Emerg Med 1997; 4:179.
76. Juvonen R, Bloigu A, Paldanius M, et al. Acute Chlamydia pneumoniae infections in

asthmatic and non-asthmatic military conscripts during a non-epidemic period. Clin
Microbiol Infect 2008; 14:207.
77. Asner SA, Jaton K, Kyprianidou S, et al. Chlamydia pneumoniae: possible association with
asthma in children. Clin Infect Dis 2014; 58:1198.
78. Smith-Norowitz TA, Chotikanatis K, Weaver D, et al. Chlamydia pneumoniae-induced
tumour necrosis factor alpha responses are lower in children with asthma compared
with non-asthma. BMJ Open Respir Res 2018; 5:e000239.
79. Dzhindzhikhashvili MS, Joks R, Smith-Norowitz T, et al. Doxycycline suppresses

Chlamydia pneumoniae-mediated increases in ongoing immunoglobulin E and
interleukin-4 responses by peripheral blood mononuclear cells of patients with allergic
asthma. J Antimicrob Chemother 2013; 68:2363.
80. Rizzo A, Domenico MD, Carratelli CR, Paolillo R. The role of Chlamydia and
Chlamydophila infections in reactive arthritis. Intern Med 2012; 51:113.
81. Melby KK, Kvien TK, Glennås A, Anestad G. Chlamydia pneumoniae as a trigger of
reactive arthritis. Scand J Infect Dis 1999; 31:327.
82. Carter JD, Hudson AP. The evolving story of Chlamydia-induced reactive arthritis. Curr
Opin Rheumatol 2010; 22:424.
83. Falsey AR, Walsh EE. Transmission of Chlamydia pneumoniae. J Infect Dis 1993; 168:493.
84. Siegel JD, Rhinehart E, Jackson M, et al. Healthcare Infection Control Practices Advisory C
ommittee 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectiou
s Agents in Healthcare Settings, June 2007. Updated July 2019. https://www.cdc.gov/infe
ctioncontrol/guidelines/isolation/index.html (Accessed on October 27, 2021).
Topic 5957 Version 23.0
GRAPHICS
Severity of community-acquired pneumonia in infants and children
Clinical features of mild pneumonia Clinical features of severe pneumonia
Temperature <38.5°C (101.3°F) Temperature ≥38.5°C (101.3°F)
Mild or absent respiratory distress: Moderate to severe respiratory distress:
Increased RR, but less than the age-specific RR RR >70 breaths/minute for infants; RR >50
that defines moderate to severe respiratory breaths/minute for older children
distress Moderate/severe suprasternal, intercostal,
Mild or absent retractions or subcostal retractions (<12 months)
No grunting Severe difficulty breathing (≥12 months)
No nasal flaring Grunting
No apnea Nasal flaring
Mild shortness of breath Apnea
Significant shortness of breath
Normal color Cyanosis
Normal mental status Altered mental status
Normoxemia (oxygen saturation ≥92 percent in Hypoxemia (sustained oxygen saturation <90
room air) percent in room air at sea level)
Normal feeding (infants); no vomiting Not feeding (infants) or signs of dehydration

(older children)
Normal heart rate Tachycardia
Capillary refill <2 seconds Capillary refill ≥2 seconds
RR: respiratory rate.
Data from:
1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children
older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious
Diseases Society of America. Clin Infect Dis 2011; 53:e25.
2. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired
pneumonia in children: Update 2011. Thorax 2011; 66:ii1.
Graphic 72015 Version 4.0
Clinical and radiographic clues to the etiology of pneumonia in children*
Etiology Clinical features Radiographic features
Bacteria Children of all ages Alveolar infiltrates

(most commonly Abrupt onset Segmental consolidation
Streptococcus
Ill-appearance Lobar consolidation
pneumoniae)
Chills "Round" pneumonia
Moderate to severe respiratory Complications:
distress
Pleural effusion/empyema
Focal auscultatory findings
Lung abscess
Localized chest pain
Necrotizing pneumonia
WBC count >15,000/microL (if
Pneumatocele
obtained)
Elevated acute phase reactants (if
obtained)
Atypical bacterial Children of all ages (most common M. pneumoniae:

(Mycoplasma in children >5 years) Lobar or segmental
pneumoniae, Abrupt onset with constitutional consolidation (37%)
Chlamydia findings (malaise, myalgia, Parahilar or peribronchial
pneumoniae) headache, rash, conjunctivitis, infiltrates (27%)
photophobia, sore throat) Localized reticulonodular
Gradually worsening nonproductive infiltrates (21%)
cough Patchy infiltrates (15%)
Wheezing
Extrapulmonary manifestations or
complications (eg, polymorphous
mucocutaneous eruptions,
hemolytic anemia, hepatitis,
pancreatitis, myopericarditis, aseptic
meningitis)
Viral Usually children <5 years Interstitial infiltrates

Gradual onset Associated bronchiolitis:
Preceding upper airway symptoms Patchy atelectasis
Nontoxic appearing Peribronchial infiltrations with
Diffuse, bilateral auscultatory air bronchograms
findings Hyperinflation with flattening of
Wheezing the diaphragms
May have associated rash (eg,
measles, varicella)
Afebrile Usually in infants 2 weeks to 4 Hyperinflation with interstitial

pneumonia of months infiltrates
infancy Insidious onset
(most commonly
Tachypnea, diffuse crackles
Chlamydia Rhinorrhea
trachomatis) Staccato cough pattern
Peripheral eosinophilia (if CBC
obtained)
Fungal Appropriate geographic or Mediastinal or hilar adenopathy

environmental exposure
Mycobacterium Children of any age Mediastinal or hilar adenopathy

tuberculosis Chronic cough
Constitutional symptoms
Exposure history
WBC: white blood cell; CBC: complete blood count.
* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypical
bacterial, and viral etiologies; up to one-half of community-acquired pneumonias in children may be
mixed bacterial/viral infections. Chest radiography generally is not helpful in determining the
potential causative agent of pneumonia. Nonetheless, these features may facilitate decisions
regarding empiric therapy.
Data from:
1. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6 th ed, Feigin RD, Cherry JD,
Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.
3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.
4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
5. Cho YJ, Han MS, Kim WS, et al. Correlation between chest radiographic findings and clinical features in hospitalized
children with Mycoplasma pneumoniae pneumonia. PLoS One 2019; 14:e0219463.
6. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health 1990;
26:209.
Graphic 52021 Version 14.0

Pneumonia Caused by Chlamydia Pneumoniae in Children

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21/2/24, 20:12 Pneumonia caused by Chlamydia pneumoniae in children - UpToDate

Official reprint from UpToDate®

Pneumonia caused by Chlamydia pneumoniae in children

Literature review current through: Jan 2024.

Pneumonia caused by Chlamydia pneumoniae in children will be discussed here. Infections

● (See "Chlamydia trachomatis infections in the newborn".)

C. pneumoniae is an obligate intracellular pathogen that belongs to the Chlamydiaceae family

C. pneumoniae is a common respiratory pathogen [7,8]. C. pneumoniae pneumonia occurs

In case series of children with community-acquired pneumonia, the proportion of cases

C. pneumoniae is thought to be transmitted from person to person via respiratory tract

Coinfection with other pathogens, including Streptococcus pneumoniae, Mycoplasma

pneumoniae is involved in coinfections, it may disrupt normal clearance mechanisms,

Clinical features of C. pneumoniae pneumonia are similar to those of other types of

No clinical, laboratory, or radiographic findings reliably differentiate C. pneumoniae

C. pneumoniae infection is frequently asymptomatic or only mildly symptomatic ( table 1)

Although there are rare reports of extrapulmonary manifestations (eg, meningoencephalitis

● Indications for laboratory evaluation – We individualize decisions about laboratory

acquired pneumonia (CAP) are discussed separately (See "Community-acquired

We usually perform laboratory evaluation for C. pneumoniae only in hospitalized

● Microbiologic confirmation – When confirmation of C. pneumoniae is necessary,

PCR-based assays can be performed on a variety of respiratory specimens (eg,

Availability of PCR-based assays for C. pneumoniae vary from laboratory to

Commercially available multiplex panels for respiratory infection that include C.

an outside laboratory, turnaround time is usually one to three days; if it is

• Cell culture – Although cell culture permits genotyping and antimicrobial

• Serology – Serology is not helpful in the diagnosis of acute C. pneumoniae infection.

Empiric therapy for community-acquired pneumonia — Treatment for community-

Therapy for C. pneumoniae

• Preferred regimen – For children with microbiologically confirmed C. pneumoniae

• Preferred regimen – For children who require hospitalization for severe

• Alternative regimens – Alternative initial IV regimens include [58]:

- Erythromycin 20 mg/kg per day IV divided in four doses, or

- Levofloxacin – Age 6 months to 5 years: 16 to 20 mg/kg per day IV divided in two

- Clarithromycin 15 mg/kg per day orally divided in two doses

- Erythromycin 50 mg/kg per day orally divided in four doses

- Levofloxacin 500 mg orally once daily (for skeletally mature adolescents)

- Moxifloxacin 400 mg orally once daily (for skeletally mature adolescents)

Children with community-acquired pneumonia who receive appropriate antimicrobial

C. pneumoniae is thought to be transmitted from person to person via respiratory tract

For patients hospitalized with C. pneumoniae pneumonia or community-acquired pneumonia

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Chlamydia pneumoniae is an obligate intracellular pathogen that causes a minority of

● We individualize decisions about laboratory testing for C. pneumoniae based upon

● For children with microbiologically confirmed C. pneumoniae pneumonia and clinical

Use of UpToDate is subject to the Terms of Use.

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6. Roulis E, Polkinghorne A, Timms P. Chlamydia pneumoniae: modern insights into an

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42. Guglielminotti J, Lellouche N, Maury E, et al. Severe meningoencephalitis: an unusual

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73. Jama-Kmiecik A, Frej-Madrzak M, Gosciniak G, et al. Detection of Chlamydophila

76. Juvonen R, Bloigu A, Paldanius M, et al. Acute Chlamydia pneumoniae infections in

79. Dzhindzhikhashvili MS, Joks R, Smith-Norowitz T, et al. Doxycycline suppresses

Severity of community-acquired pneumonia in infants and children

Clinical features of mild pneumonia Clinical features of severe pneumonia