Pediatric Community-Acquired

Pneumonia

Sources: Nelson Textbook of Pediatrics and 3rd PAPP Update [2016] in

the Evaluation and Management of
Pediatric Community-acquired Pneumonia
 EPIDEMIOLOGY

Pneumonia
• Inflammation of the
lung parenchyma
• leading infectious cause
of death globally
among children
younger than 5 year old
ETIOLOGY
• Noninfectious causes: include aspiration (of food or gastric acid,
foreign bodies, hydrocarbons, and lipoid substances)
• Microorganisms
• Hypersensitivity reactions,
• Drug- or radiation-induced pneumonitis
ETIOLOGY: Infectious Causes
• Streptococcus pneumoniae
• most common bacterial pathogen in children 3 weeks to 4 years of age
• Mycoplasma pneumoniae and Chlamydophila pneumoniae
• Most frequent bacterial pathogens in children age 5 years and older
• Group A streptococcus
• Staphylococcus aureus
• Often complicates an illness caused by influenza viruses.
ETIOLOGY
• Viral pathogens are the most common causes of lower respiratory
tract infections in infants and children older than 1 month but
younger than 5 years of age.
• Respiratory syncytial virus and rhinoviruses
• - Most Common identified especially in children younger than 2 yr of age.
PATHOGENESIS: Viral pneumonia

• Spread of infection along the airways

• Direct injury of the respiratory epithelium
• Airway obstruction from swelling, abnormal secretions, and cellular
debris.
• Atelectasis, interstitial edema, and hypoxemia from ventilation–
perfusion mismatch often accompany airway obstruction.

• Viral infection of the respiratory tract can also predispose to secondary

bacterial infection by disturbing normal host defense mechanisms, altering
secretions, and through disruptions in the respiratory microbiota.
PATHOGENESIS: Bacterial pneumonia
• Respiratory tract organisms colonize the trachea and subsequently
gain access to the lungs
• pneumonia may also result from direct seeding of lung tissue after
bacteremia
• Bacterial infection is established in the lung parenchyma, the
pathologic process varies according to the invading organism.
PATHOGENESIS: Bacterial pneumonia
M. pneumoniae
• Attaches to the respiratory epithelium, inhibits ciliary action, and
leads to cellular destruction and an inflammatory response in the
submucosa.
• As the infection progresses, sloughed cellular debris, inflammatory
cells, and mucus cause airway obstruction, with spread of infection
occurring along the bronchial tree, as is seen in viral pneumonia.
S. pneumoniae
PATHOGENESIS: Bacterial pneumonia
S. pneumoniae
• produces local edema that aids in the proliferation of organisms and their
spread into adjacent portions of lung resulting in the characteristic focal
lobar involvement

Group A streptococcus
• typically results in more diffuse lung involvement with interstitial
pneumonia.
• necrosis of tracheobronchial mucosa; formation of large amounts of
exudate, edema, and local hemorrhage, with extension into the
interalveolar septa; and involvement of lymphatic vessels with frequent
pleural involvement
PATHOGENESIS: Bacterial pneumonia
S. aureus
• confluent bronchopneumonia unilateral and characterized by the
presence of extensive areas of hemorrhagic necrosis and irregular
areas of cavitation of the lung parenchyma
• resulting in pneumatoceles, empyema, and, at times,
bronchopulmonary fistulas
PATHOGENESIS: Recurrent Pneumonia
• Defined as 2 or
more episodes in a
single year or 3 or
more episodes
ever, with
radiographic
clearing between
occurrences
• An underlying
disorder should be
considered if a
child experiences
recurrent
pneumonia
Clinical Manifestation
• Pneumonia is frequently preceded by several days of symptoms of an
upper respiratory tract infection, typically rhinitis and cough.
• In viral pneumonia fever is present but lower than bacterial
pneumonia
• Tachypnea is the most consistent clinical manifestation of pneumonia.
• Increased work of breathing accompanied by intercostal, subcostal,
and suprasternal retractions, nasal flaring, and use of accessory
muscles is common.
Clinical Manifestation
• Severe infection may be accompanied by cyanosis and lethargy,
especially in infants.
• Auscultation of the chest may reveal crackles and wheezing, but it is
often difficult to localize the source of these adventitious sounds in
very young children with hyperresonant chests.
• In many children, splinting on the affected side to minimize pleuritic
pain and improve ventilation is noted; such children may lie on one
side with the knees drawn up to the chest.
Clinical Manifestation
• Early in the course of illness, diminished breath sounds, scattered crackles,
and rhonchi are commonly heard over the affected lung field
• With the development of increasing consolidation or complications of
pneumonia such as pleural effusion or empyema, dullness on percussion is
noted and breath sounds may be diminished
• A lag in respiratory excursion often occurs on the affected side
• Abdominal distention may be prominent because of gastric dilation from
swallowed air or ileus
• The liver may seem enlarged because of downward displacement of the
diaphragm secondary to hyperinflation of the lungs or superimposed
congestive heart failure
Clinical Manifestation
• In infants, there may be a prodrome of upper respiratory tract
infection and poor feeding, leading to the abrupt onset of fever,
restlessness, apprehension, and respiratory distress.
• These infants typically appear ill, with respiratory distress manifested
as grunting; nasal flaring; retractions of the supraclavicular,
intercostal, and subcostal areas; tachypnea; tachycardia; air hunger;
and often cyanosis
• Some infants with bacterial pneumonia may have associated
gastrointestinal disturbances characterized by vomiting, anorexia,
diarrhea, and abdominal distention secondary to a paralytic ileus.
1. A patient may be classified as pCAP A, B, C or D within 48 hours
after consultation based on the following risk classification for
pneumonia-related mortality
2. A patient initially classifed as pCAP A or B but is not responding to
current treatment after 48 hours may be admitted
3. A patient classified as pCAP C
1. May be admitted to the regular ward
2. Managed initially on an outpatient basis if all of the following are not
present at initial site-of-care
• Age less than 2 years old.
• Convulsion.
• Chest x-ray with effusion, lung abscess, air leak or multilobar consolidation.
• Oxygen saturation < 95% at room air.
4. A patient classified as pCAP D may be admitted to a critical care unit
DIAGNOSIS
1. CXR-PAL
• An infiltrate supports the diagnosis of pneumonia

• may also indicate a complication such as a pleural effusion or

empyema.
1. CXR-PAL
• Viral pneumonia:
• hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing

• Pnuemococcal pneumonia:
• Confluent lobar consolidation is typically seen
VIRAL PNEUMONIA
hyperexpansion
of the lungs with
bilateral fine air
space disease and
streaks of
density, indicating
the presence of
both pneumonia
and atelectasis.
VIRAL PNEUMONIA
Increased
bilateral
pneumonia
PNEUMOCOCCAL PNEUMONIA
1. CXR-PAL
• Repeat CXR are not required for proof of cure for patients with
uncomplicated pneumonia.

• May not be necessary for older children with suspected pneumonia

(cough, fever, localized crackles, or decreased breath sounds) who are
well enough to be managed as outpatients.
2. UTZ
• Point-of-care use of portable or handheld ultrasonography

• Highly sensitive and specific in diagnosing pneumonia in children by

determining lung consolidations and air bronchograms or effusions.
3. WBC
• Viral pneumonia:

• normal or elevated but is usually not higher than

• 20,000/mm3, with a lymphocyte predominance.
3. WBC
• Bacterial pneumonia:
• elevated WBC count, in the range of 15,000- 40,000/mm3, and a
predominance of granulocytes.
• A large pleural effusion, lobar consolidation, and a high fever at the onset of
the illness are also suggestive of a bacterial etiology.
3. WBC
• Atypical pneumonia
• caused by C. pneumoniae or M. pneumoniae is difficult to distinguish from
pneumococcal pneumonia on the basis of radiographic and laboratory
findings,
• associated with a higher WBC count, erythrocyte sedimentation rate,
procalcitonin, and C-reactive protein level, there is considerable overlap,
particularly with adenoviruses and enteroviruses.
4. DNA/RNA test
• the definitive diagnosis of a viral infection
• isolation of a virus or detection of the viral genome or antigen in
respiratory tract secretions.
• Reliable DNA or RNA tests for the rapid detection of many respiratory
pathogens are available and accurate.
5. CULTURE
• The definitive diagnosis of a bacterial infection requires isolation of
an organism from the blood, pleural fluid, or lung

• Culture of sputum
• is of little value in the diagnosis of pneumonia in young children

• Percutaneous lung aspiration

• is invasive and not routinely performed.
5. CULTURE
• Blood culture
• positive in only 10% of children with pneumococcal pneumonia and are not
recommended for nontoxic appearing children treated as an outpatient.
• recommended for those who fail to improve or have clinical deterioration, in
those with complicated pneumonia and those requiring hospitalization.
WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP A or pCAP B BEING MANAGED IN AN
AMBULATORY SETTING?

The following may be requested at initial site-of-care

• Oxygen saturation using pulse oximetry
• Gram stain and/or aerobic culture and sensitivity of sputum
• Chest x-ray PA-lateral
• Chest ultrasound
The following may not be requested
• Blood culture and sensitivity
• White blood cell [WBC] count
• C-reactive protein [CRP]
• Procalcitonin [PCT)
WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP C or pCAP D BEING MANAGED IN A
HOSPITAL SETTING?

1. For pCAP C and pCAP D, the following diagnostic aids may be requested at initial site-of-care.
• Oxygen saturation using pulse oximetry
• Arterial blood gas
• C-reactive protein
• Procalcitonin [PCT]
• Chest x-ray PA-lateral
• White blood cell [WBC]
• Chest x-ray PA-lateral
• Chest ultrasound
• Gram stain and/or aerobic culture and sensitivity of sputum, nasopharyngeal aspirate and/or pleural fluid,
and/or blood for pCAP C with lung abscess, empyema or pneumothorax
• Gram stain and/or aerobic culture and sensitivity of sputum, tracheal aspirate and/or pleural fluid, for
pCAP D Anaerobic culture and sensitivity of sputum, nasopharyngeal aspirate, pleural fluid, and/or blood
culture and sensitivity for pCAP C with lung abscess, empyema or pneumothorax pCAP D
WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP C or pCAP D BEING MANAGED IN A
HOSPITAL SETTING?

1. For pCAP C and pCAP D, the following diagnostic aids may be requested at initial site-of-care.
• pH in arterial blood gas for metabolic acidosis
• Serum sodium for hyponatremia
• Serum potassium for hypokalemia
• Predictive marker for mortality: pH in arterial blood gas for metabolic acidosis
• Predictive marker for initial treatment failure: Pulse oximetry for oxygen saturation less than 90% at room
air, chest x-ray PA-lateral for pleural effusion or consolidation, or WBC for leukocytosis or leukopenia
• Blood culture for bacteremia, serum hemoglobin for anemia, or serum glucose for hypoglycemia
• Predictive marker for prolonged hospitalization or pneumatocoele formation: Lung ultrasound showing
impaired perfusion and hypoechoic lesions
2. For pCAP D, a referral to a specialist may be done for additional diagnostic tests
3. For uncomplicated pCAP C, the following may not be requested.
• Blood culture
• CRP as marker for risk of treatment failure or prolonged hospitalization
TREATMENT
TX – bacterial pneumonia
• Amoxicillin
• For mildly ill children who do not require hospitalization
• With the emergence of penicillin-resistant pneumococci, high doses of
amoxicillin (80-90 mg/kg/24 hr) should be prescribed unless local data
indicate a low prevalence of resistance.
• Therapeutic alternatives include: cefuroxime axetil and
amoxicillin/clavulanate.
TX – bacterial pneumonia
• Macrolide antibiotic (ex: azithromycin)
• For school-age children and in children in whom infection with M.
pneumoniae or C. pneumoniae
• alternative is fluoroquinolone (levofloxacin, moxifloxacin) in adolescents
TX – bacterial pneumonia
• ampicillin or penicillin G.
• In areas without substantial high-level penicillin resistance among S.
pneumoniae, children who are fully immunized against H. influenzae type b
and S. pneumoniae and are not severely ill
TX – bacterial pneumonia
• ceftriaxone or cefotaxime
• For children who do not meet these criteria
• vancomycin or clindamycin
• If clinical features suggest staphylococcal pneumonia (pneumatoceles,
empyema)
TX – viral pneumonia
• it is reasonable to withhold antibiotic therapy, especially for those
patients who are mildly ill, have clinical evidence suggesting viral
infection, and are in no respiratory distress.
TX – viral pneumonia
• 30% of patients with known viral infection, particularly influenza
viruses, may have coexisting bacterial pathogens.
• deterioration in clinical status should signal the possibility of
superimposed bacterial infection, and antibiotic therapy should be
initiated.
TX – viral pneumonia
• antibiotics should generally be continued until the patient has been
afebrile for 72 hr

• the total duration should not be less than 10 days (or 5 days if
azithromycin is used).

• Shorter courses (5-7 days) may also be effective, particularly for

children managed on an outpatient basis
TX – viral pneumonia
 
• oral zinc
• (10 mg/day for <12 mo, 20 mg/day for ≥12 mo)
• reduces mortality among children with clinically defined severe pneumonia
Management
Class Management
Oral Amoxicillin 40-50mKD in 3 doses for 7 days
For those without previous antibiotic (Max 1500mg/day may be given for a minimum
regardless of immunization status against
of 3 days or in 2 divided dose for a minimum of
HiB or S. Pneumoniae
5 days)
PCAP A & B Azithromycin 10mg/kg/day OD for 3 days (max
If with known Hypersensitivity to amoxicillin 500mg/day) or 10mg/kg/day on day 1 then
or suspicion of atypical organisms especially 5mg/kg/day on days 2-5 (max 500mg/day)
Mycoplasma pneumoniae Clarithromycin 15 mg/kg/day in 2 doses for 7
days (max 100mg/day)
No previous antibiotic use requiring Penicillin G 100,000 units/kg/day every 6 hours
hospitalization and with complete HiB
vaccination
With incomplete or unknown status of HiB Ampicillin 100mg/kg/day every 6 hours
PCAP C vaccination
If >15 years old can be treated as adult IV non-antipseudomonal beta-lactam
(Cephalosporin or Carbapenem) plus extended
macrolide or fluoroquinolone
PCAP D Refer to a Specialist
PROGNOSIS
PROGNOSIS
• response to therapy, with improvement in clinical symptoms (fever,
cough, tachypnea, chest pain)

• within 48-96 hr of initiation of antibiotics.

• Radiographic evidence of improvement lags substantially behind

clinical improvement.
PROGNOSIS
patient does not improve with appropriate antibiotic therapy:
(1) complications, such as empyema
(2) bacterial resistance;
(3) nonbacterial etiologies such as viruses or fungi and aspiration of foreign
bodies or food;
(4) bronchial obstruction from endobronchial lesions, foreign body, or mucous
plugs;
PROGNOSIS
(5) preexisting diseases such as immunodeficiencies, ciliary dyskinesia,
cystic fibrosis, pulmonary sequestration, or congenital pulmonary
airway malformation, formerly called cystic adenomatoid malformation

(6) other noninfectious causes (including bronchiolitis obliterans,

hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, and
granulomatosis with polyangiitis, formerly called Wegener
granulomatosis).
PROGNOSIS
• A repeat chest radiograph is the first step in determining the reason
for delay in response to treatment.

• Bronchoalveolar lavage may be indicated in children with respiratory

failure

• high-resolution CT scans may better identify complications or an

anatomic reason for a poor response to therapy.
COMPLICATIONS
• are usually the result of direct spread of bacterial infection within the
thoracic cavity (pleural effusion, empyema, and pericarditis) or
bacteremia and hematologic spread.

• Meningitis, suppurative arthritis, and osteomyelitis

• rare complications of hematologic spread of pneumococcal or H. influenzae
type b infection.
COMPLICATIONS
Parapneumonic effusions and empyema
• S. aureus, S. pneumoniae, and S. pyogenes are the most common causes

• Imaging studies including ultrasonography and CT are helpful in determining

the stage of empyema.

• The mainstays of therapy include antibiotic therapy and drainage with tube
thoracostomy.
COMPLICATIONS
PREVENTION

• 7-valent pneumococcal conjugate vaccine (PCV7)

• 13-valent pneumococcal conjugate vaccine (PCV13)

PREVENTION
• The expansion of influenza vaccine recommendations to include all
children >6 mo of age in 2010 might be expected to affect pneumonia
hospitalization rates in a similar fashion, and ongoing surveillance is
warranted.
THANK YOU!