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Apr.24.2020View related content

Community-acquired pneumonia in children (aged older than 3 months)

Synopsis

Key Points

  • Community-acquired pneumonia is an acute infection of the pulmonary parenchyma that occurs in a child who has not resided in a hospital or health care facility in the preceding 14 days
  • Patient presents with fever, cough, and tachypnea. In the setting of fever, tachypnea is the most sensitive finding suggesting pneumonia in young children
  • Majority of pediatric pneumonia cases are viral; most common bacterial cause is Streptococcus pneumoniae
  • Chest radiography, cultures, and other diagnostic testing are not routinely recommended, but are indicated when the child is sick enough to require admission
  • For outpatient treatment, amoxicillin is the first line therapy for a previously well, appropriately immunized child with pneumonia. Macrolide antibiotics are first line therapy for a child with probable atypical pneumonia
  • For inpatient treatment, ampicillin or penicillin G is recommended for fully immunized children unless there is evidence of local high-level penicillin resistance. Otherwise, give a third-generation parenteral cephalosporin (eg, ceftriaxone, cefotaxime)
  • Empiric combination therapy with a macrolide (oral or parenteral) and a β-lactam antibiotic are indicated when Mycoplasma pneumoniae and Chlamydophila pneumoniae are significant considerations for a hospitalized child
  • Treat children with community-acquired pneumonia and probable influenza with influenza antiviral therapy
  • Supportive care includes oxygen for a pulse oximetry reading less than 90%, IV fluids for dehydration, and antipyretics for a fever r1

Urgent Action

  • Administer supplemental oxygen for oxygen saturation less than 90% r1
  • Consider noninvasive positive pressure ventilation for patients with greater than 50% FiO₂ requirement or other signs of significant respiratory distress
  • Give fluid boluses of 20 mL/kg isotonic saline for tachycardia and poor perfusion
  • Administer antibiotics as soon as possible to any ill-appearing patient or patients suspected of having bacterial pneumonia
  • Obtain CBC, blood culture, and chest radiographs for any patients requiring admission

Pitfalls

  • Not obtaining a pulse oximetry reading in a child with community-acquired pneumonia and delaying oxygen administration
  • Not considering a foreign body in a child with recurrent pneumonia
  • Forgetting to add antiviral therapy in a child with moderate to severe community-acquired pneumonia and possible influenza

Terminology

Clinical Clarification

  • Community-acquired pneumonia is an acute infection of the pulmonary parenchyma that occurs in a child who has not resided in a hospital or health care facility in the preceding 14 days

Classification

  • By cause
    • Typical
      • Caused by Streptococcus pneumoniae
    • Atypical
      • Caused by Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella species, and respiratory viruses
  • By severity level (and site of care)
    • Pneumonia that can be managed as an outpatient r1
    • Moderate to severe community-acquired pneumonia, as defined by respiratory distress and/or hypoxemia, that should be managed with general ward admission r1
      • Respiratory distress
        • Tachypnea, retractions, grunting, and nasal flaring
        • Apnea
        • Altered mental status
      • Hypoxemia
        • Pulse oximetry measurement less than 90% on room air
    • Severe pneumonia that meets at least 1 major or 2 minor severity criteria that requires ICU admission r1
      • Major criteria
        • Needs for invasive mechanical ventilation
        • Fluid refractory shock
        • Acute need for noninvasive positive pressure ventilation
        • Hypoxemia requiring FiO₂ greater than inspired concentration or flow feasible in general care area
      • Minor criteria
        • Respiratory rate higher than WHO classification for age
        • Apnea
        • Increased work of breathing (eg, retractions, dyspnea, nasal flaring, grunting)
        • PaO₂ to FiO₂ ratio less than 250
        • Multilobar infiltrates
        • Pediatric Early Warning score (bedside nursing assessment tool based on vital signs and neurologic examination) greater than 6 r2
        • Altered mental status
        • Hypotension
        • Presence of effusion
        • Comorbid conditions (eg, sickle cell anemia, immunosuppression, immunodeficiency)
        • Unexplained metabolic acidosis

Diagnosis

Clinical Presentation

History

  • Common symptoms
    • Fever c1
    • Cough c2
    • Respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions) c3c4c5
    • Poor feeding c6
    • Irritability c7
  • Less common
    • Abdominal pain c8
    • Nausea or vomiting c9c10
    • Chest pain c11
  • Receipt of conjugate pneumococcal vaccine decreases probability of bacterial pneumonia r3

Physical examination

  • Tachypnea alone is a sensitive sign of pneumonia r4c12
    • Aged 2 to 12 months: greater than 50 breaths per minute r1
    • Aged 1 to 5 years: greater than 40 breaths per minute r1
    • Older than 5 years: greater than 20 breaths per minute r1
    • Less sensitive in early illness (within first 3 days) r4
  • Nasal flaring, retractions, and reduced oxygen saturation increase likelihood of pneumonia diagnosis c13c14c15
  • Fever
  • Abnormal lung examination
    • Localized rales on auscultation in younger children c16
    • Rales, bronchial breathing, and pleural rub on auscultation in older children c17c18c19c20c21c22
    • Wheezing more commonly associated with atypical or viral pneumonia c23c24c25
    • Absent breath sounds and dull percussion raise concern for an effusion r3c26c27

Causes and Risk Factors

Causes

  • Most common, by age group
    • Neonatal
      • Bacterial
        • Group B streptococci, gram-negative bacilli, and Listeria monocytogenesc28c29c30
    • Children older than 1 month
      • Viral (up to 90% of cases)
        • Human respiratory syncytial virus (more common among children younger than 5 years) r5c31c32
        • Parainfluenzavirus 1, 2, and 3c33
        • Influenza A and B virusc34c35
        • Human adenovirus (more common among children younger than 5 years) r5c36c37
        • Human rhinovirusc38
        • Human herpesvirus 1 and 2c39
        • Human metapneumovirus (more common among children younger than 5 years) r5c40c41
        • Human enterovirusc42
      • Bacterial
        • Streptococcus pneumoniaec43
        • Haemophilus influenzae type b c44
        • Moraxella catarrhalisc45
        • Staphylococcus aureusc46
    • Older children and adolescents
      • Bacterial
        • Mycoplasma pneumoniae c47
        • Chlamydophila pneumoniaec48

Risk factors and/or associations

Age
  • Highest incidence among children younger than 2 years r5c49c50
  • Higher incidence in premature infants r6c51
Sex
  • Boys have higher incidence at all ages r6c52c53
Other risk factors/associations
  • Chronic respiratory conditions leading to infection (eg, cystic fibrosis, bronchiectasis) c54c55c56
  • Immune deficiency c57
  • Chronic lung disease of prematurity c58
  • Congenital heart disease c59
  • Use of gastric acid inhibitors r7c60
  • Risk factors in developing countries: r8
    • Definite risk factors
      • Malnutrition c61
      • Low birth weight (2500 g or less) c62
      • Nonexclusive breastfeeding (especially during the first 4 months of life) c63
      • Lack of measles immunization within the first 12 months of life c64
      • Indoor air pollution c65
      • Crowding c66
    • Likely risk factors
      • Parental smoking c67
      • Zinc deficiency c68
      • Other coexisting diseases (eg, diarrhea, heart disease, asthma) c69c70c71

Diagnostic Procedures

Primary diagnostic tools

  • History and physical examination are the primary diagnostic tools c72
    • WHO criteria for pneumonia require only the findings of cough and tachypnea on physical examination r8
      • WHO definition of tachypnea
        • Aged 2 to 12 months: more than 50 breaths per minute
        • Aged 1 to 5 years: more than 40 breaths per minute
    • Pulse oximetry should be performed in all children with suspected hypoxemia
  • Additional testing for patients admitted to the hospital (those meeting requirements for moderate to severe pneumonia)
    • Chest radiograph
    • Blood and sputum cultures
    • Viral pathogen testing
    • Testing for Mycoplasma infection (if suspected)
    • CBC
    • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin concentration) may be helpful in some patients

Laboratory

  • Blood cultures c73c74
    • Obtain if child has probable bacterial pneumonia that is moderate to severe, associated with complications, or requires admission r1
    • Not routinely needed in children with community-acquired pneumonia who have nontoxic appearance, are fully immunized, and are being treated in the outpatient setting r1
      • Obtain if child deteriorates or symptoms get worse after antibiotics are started r1
  • Sputum culture c75
    • Obtain culture and Gram stain in children who are hospitalized and can produce sputum r1c76
  • Tracheal aspirates r1
    • Obtain if child requires endotracheal intubation c77
      • Gram stain and culture
      • Viral pathogens, including influenza virus
  • Viral pathogen testing c78
    • Obtain in hospitalized patients
    • Use sensitive and specific tests for the rapid diagnosis of influenza virus and other respiratory viruses
      • Positive influenza test result reduces additional diagnostic studies and antibiotic use, and guides use of antiviral agents r1
      • Initial negative results, especially from rapid antigen tests, do not exclude influenza r1
  • Atypical bacterial testing
    • Polymerase chain reaction c79
      • If suspicion exists for Mycoplasma pneumoniae, a variety of diagnostic tests are available, but polymerase chain reaction is the most rapid and accurate method r1r9
      • Testing for Chlamydophila pneumoniae is not recommended r1
  • CBC c80
    • Obtain in hospitalized patients r1
  • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein concentration, serum procalcitonin concentration) c81c82c83
    • Cannot be used to distinguish between bacterial and viral disease r1
    • Should not be routinely measured in fully immunized children with community-acquired pneumonia, but may be helpful to assess response to therapy or in patients with more serious disease or complications r1

Imaging

  • Chest radiography c84c85c86c87
    • Not necessary in patients with suspected community-acquired pneumonia who do not require admission r1
    • Posteroanterior and lateral views should be done when patient has hypoxemia, respiratory distress, antibiotic therapy failure, or upon admission r1
      • British Thoracic Society guidelines do not advocate for routine lateral films r3
      • Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in viral pneumonia
      • Lobar consolidation is typically seen in pneumococcal pneumonia
    • Repeat chest radiography in children who do not improve, have worsening of symptoms, or have clinical deterioration within 48 to 72 hours of starting antibiotic therapy
  • Lung ultrasonography c88c89c90c91
    • Indicated as first line imaging in patients with complicated pneumonia r10
    • Current evidence supports lung ultrasonography as an imaging alternative for the diagnosis of childhood pneumonia r11
    • Valuable for diagnosis/assessment of pleural effusions
  • Chest CT c92c93c94c95
    • Reserve chest CT for complicated pneumonia cases in which chest ultrasonography is technically limited or discrepant with the clinical findings r10
    • Lung ultrasonography and chest CT are similar in their ability to detect loculated effusion and lung necrosis or abscess

Functional testing

  • Pulse oximetry c96
    • Perform in all children with pneumonia and suspected hypoxemia
      • Hypoxemia guides admission/discharge decisions and need for further diagnostic evaluation r1

Differential Diagnosis

Most common

  • Bronchitis c97
    • Occurs in older adolescents; acute bronchitis is not usually diagnosed in young children
    • Afebrile or low-grade fever (lower than 38°C), malaise, chest pain, and protracted dry, hacking cough (which may be productive) lasting for 1 to 3 weeks
    • Chest radiographs are usually normal or may have increased bronchial markings
    • Absence of tachycardia, tachypnea, and high fever helps to differentiate from pneumonia
  • Bronchiolitis c98d1
    • Acute infection of the lower respiratory tract resulting in small airway obstruction
    • Respiratory syncytial virus is the most common cause of bronchiolitis in infants younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction testing, but the diagnosis is clinical
    • Commonly occurs in infants aged 1 to 3 months, with peak incidence during winter and early spring
    • Usually starts with sneezing and clear rhinorrhea; fine crackles or overt wheezes with prolongation of the expiratory phase of breathing can be heard on auscultation
    • Chest radiographs may show hyperinflated lungs with patchy atelectasis
  • Pertussis c99d2
    • Symptoms occur in 3 phases
      • Catarrhal
        • Low-grade fever, upper respiratory infection symptoms, and cough
        • Apnea may occur
      • Paroxysmal
        • Coughing episodes; whoop occurs in older children
        • Vomiting
        • Infants typically do not produce a whoop, but have paroxysmal cough and/or apnea with color change
      • Convalescent
        • Persistent cough
    • Differentiate by cough history and polymerase chain reaction testing
  • Asthma c100d3
    • Symptoms include episodic dry cough, expiratory wheezing, chest tightness, feeling of discomfort in the chest, and shortness of breath in response to physical exertion or airway irritants
    • Severe exacerbations are associated with inspiratory and expiratory wheezing, retractions, nasal flaring, and use of accessory respiratory muscles
    • Dyspnea is present, but signs of infection are usually absent
    • Airway obstruction reversible with bronchodilators in the setting of a clear chest radiograph is diagnostic
  • Tuberculosis c101d4
    • Suspect when child is from endemic area or has had contact with persons who are at high risk of having the disease, urban homeless, incarcerated individuals, and persons with HIV infection
    • Presents subacutely with anorexia, weight loss, and night sweats
    • Differentiate based on history of either being from an endemic area or exposure to high-risk individuals
  • Acute respiratory distress syndrome c102
    • Mild respiratory distress with tachypnea, dyspnea, and increased oxygen requirement progresses rapidly to severe hypoxia accompanied by carbon dioxide retention and respiratory failure
    • Chest radiograph may reveal interstitial and alveolar pulmonary edema
    • Patients with a measured PaO₂ to percentage of the FiO₂ ratio of less than 200 are considered to have severe hypoxia and classified as having acute respiratory distress syndrome
  • Severe acute respiratory syndrome–associated coronavirus c103
    • Characterized by:
      • Temperature higher than 38°C and 1 or more clinical findings of respiratory illness:
        • Cough
        • Shortness of breath
        • Difficulty breathing or hypoxia
      • Travel to an endemic area within 10 days of symptom onset
      • Close contact with a person known or suspected to have severe acute respiratory syndrome
    • Differentiate based on history of travel to endemic area

Treatment

Goals

  • Improve respiratory symptoms
  • Eradicate infection with antimicrobials, if indicated
  • Prevent complications

Disposition

Admission criteria

Respiratory distress r1

  • Tachypnea
    • Aged 0 to 2 months: greater than 60 breaths per minute
    • Aged 2 to 12 months: greater than 50 breaths per minute
    • Aged 1 to 5 years: greater than 40 breaths per minute
    • Older than 5 years: greater than 20 breaths per minute
  • Retractions (ie, suprasternal, intercostals, subcostal)
  • Grunting
  • Nasal flaring
  • Apnea
  • Altered mental status

Hypoxemia (defined by pediatric pneumonia guidelines as sustained saturation less than 90% on room air) r1

Age younger than 3 to 6 months and suspected bacterial community-acquired pneumonia r1

Suspected or documented community-acquired pneumonia caused by a potentially virulent pathogen, such as community-associated MRSA r1

Concern about observation at home, inability to comply with therapy, or unavailability for follow-up r1

Criteria for ICU admission
  • Need for noninvasive positive pressure ventilation or endotracheal intubation r1
  • Impending respiratory failure r1
  • Sustained tachycardia, hypotension, or need for pharmacologic support of blood pressure or perfusion r1
  • Inspired oxygen greater than 50% results in a pulse oximetry measurement of 92% or less r1
  • Altered mental status, due to hypercarbia or hypoxemia resulting from pneumonia r1
  • Severity of illness scores should not be used as the only criteria for ICU admission but should be used in the context of other clinical, laboratory, and radiologic findings r1

Recommendations for specialist referral

  • Refer to pediatric infectious disease specialist for:
    • Age younger than 6 months
    • No improvement on antibiotics
    • Recurrent or complicated pneumonia
  • Refer to pediatric surgeon for:
    • Pleural effusion

Treatment Options

Outpatient therapy

  • Antimicrobial therapy not routinely required for preschool-aged children with community-acquired pneumonia since the majority of cases are viral
  • Amoxicillin is first line therapy for appropriately immunized infants, preschool- and school-aged children, and adolescents with suspected typical bacterial community-acquired pneumonia
    • Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most common invasive bacterial pathogen
  • Macrolide antibiotics are first line therapy for children with community-acquired pneumonia suspected to be caused by atypical organisms
  • Influenza antiviral therapy (eg, oseltamivir, zanamivir, peramivir) is indicated for children with suspected influenza-induced moderate to severe community-acquired pneumonia r1
    • Consider during widespread influenza epidemics, particularly for those with clinically worsening disease
    • Treatment should not be delayed for positive influenza test results r1
    • Treatment after 48 hours of symptomatic infection may still provide clinical benefit to those with more severe disease r1
  • OTC cough medicines are not effective against pneumonia r12

Inpatient therapy r1

  • Empiric therapy (according to Pediatric Infectious Disease Society)
    • Ampicillin or penicillin G is first line therapy for fully immunized infant or school-aged child admitted to a hospital ward with community-acquired pneumonia when there is no local substantial high-level penicillin resistance for invasive Streptococcus pneumoniae
    • A third-generation parenteral cephalosporin (eg, ceftriaxone, cefotaxime) is first line therapy for hospitalized infants and children who are not fully immunized, in regions where invasive pneumococcal strains demonstrate high-level penicillin resistance (minimum inhibitory concentrations 4.0 mcg/mL or higher), and for infants and children with life-threatening infection, including those with empyema
      • Non–β-lactam agents, such as vancomycin, are not more effective than third-generation cephalosporins in the treatment of pneumococcal pneumonia for the degree of resistance noted currently in North America
    • Combination therapy with a macrolide (oral or parenteral), in addition to a β-lactam antibiotic, should be prescribed for the hospitalized child for whom Mycoplasmapneumoniae and Chlamydophilapneumoniae are significant considerations
      • However, empirical macrolide combination therapy conferred no benefit over β-lactam monotherapy for children hospitalized with community-acquired pneumonia in prospective study, including subset of children with confirmed atypical bacteria r13
    • Vancomycin or clindamycin should be given if clinical, laboratory, or imaging findings suggest infection caused by Staphylococcus aureus
  • Antibiotic therapy should be adjusted, if necessary, based on culture results. Recommended antibiotic regimens for specific pathogens are available in Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America r1
  • Influenza antiviral therapy (eg, oseltamivir, zanamivir, peramivir) is indicated for children hospitalized with suspected influenza-induced moderate to severe community-acquired pneumonia
    • While the American Academy of Pediatrics recommends oseltamivir as the drug of choice, CDC guidelines recommend use of any of the 3 available antiviral drugs for influenza r14
    • Consult CDC's Influenza Surveillance report for recent drug resistance information to aid drug selection r15

Drug therapy

  • Penicillins c104
    • Amoxicillin c105
      • Amoxicillin Trihydrate Oral suspension; Infants older than 3 months, Children, and Adolescents: 45 mg/kg/day PO divided every 12 hours (Max: 875 mg/dose) or 40 mg/kg/day PO divided every 8 hours (Max: 500 mg/dose) is FDA-approved dosing; 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day) recommended by IDSA for CAP.
    • Ampicillin c106
      • Ampicillin Sodium Solution for injection; Infants, Children, and Adolescents: 100 to 150 mg/kg/day IV/IM divided every 6 hours (Max: 4 g/day) for mild/moderate infections and 200 to 400 mg/kg/day divided every 6 hours (Max: 12 g/day) for severe infections is recommended by AAP. Per IDSA: 150 to 200 mg/kg/day IV/IM divided every 6 hours (Max: 12 g/day) for empiric treatment of CAP; 300 to 400 mg/kg/day IV/IM divided every 6 hours as alternative for resistant strains of S. pneumoniae. FDA-approved dosage is 25 to 50 mg/kg/day IV/IM divided every 6 hours (Max: 2 g/day).
    • Penicillin G c107
      • Penicillin G Sodium Solution for injection; Infants, Children, and Adolescents: 150,000 to 300,000 units/kg/day IV/IM divided every 4 to 6 hours (Max: 24 million units/day).
  • Macrolides c108
    • Azithromycin c109
      • Oral
        • Azithromycin Oral suspension; Infants (3 - 6 months): 10 mg/kg/dose PO on day 1, followed by 5 mg/kg/day PO once daily on days 2 through 5.
        • Azithromycin Oral suspension; Infants and Children 6 months to 12 years: 10 mg/kg/dose (Max: 500 mg/dose) PO for 1 day, followed by 5 mg/kg/dose (Max: 250 mg/dose) PO once daily for 4 days.
      • Intravenous
        • Azithromycin Solution for injection; Infants older than 3 months†, Children†, and Adolescents less than 16 years†: 10 mg/kg/dose (Max: 500 mg/dose) IV once daily for at least 2 days, then conversion to 5 mg/kg/day (Max: 250 mg/day) PO once daily if possible to complete a 5 day course. 
        • Azithromycin Solution for injection; Adults and Adolescents 16 years and older: 500 mg IV infusion daily for at least 2 days, then 500 mg PO daily to complete 7 to 10 day course; switch to PO at physician discretion and clinical response.
    • Clarithromycin c110
      • Clarithromycin Oral suspension; Infants 3?5 months†: 7.5 mg/kg PO q12h x10 days is recommended by IDSA.
      • Clarithromycin Oral tablet; Infants and Children 6 months to 12 years: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 days.
    • Erythromycin c111
      • Oral
        • Erythromycin Ethylsuccinate Oral suspension; Infants, Children, and Adolescents: 30 to 50 mg/kg/day (Max: 1 to 2 g/day) PO in 3 to 4 divided doses; 40 mg/kg/day PO in 4 divided doses is recommended by the IDSA for CAP due to presumed/confirmed atypical pathogens as an alternative therapy to azithromycin.
      • Intravenous
        • Erythromycin Lactobionate Solution for injection; Infants, Children, and Adolescents: 15 to 20 mg/kg/day (Max: 2 to 4 g/day) IV divided every 6 hours; IDSA recommends 20 mg/kg/day IV divided every 6 hours in children with CAP due to presumed/confirmed atypical pathogens as an alternative therapy to azithromycin.
  • Cephalosporins c112
    • Ceftriaxone c113
      • Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents: 50 to 100 mg/kg/day IV/IM divided every 12 to 24 hours (Max: 4 g/day) for up to 10 days.
    • Cefotaxime c114
      • Cefotaxime Sodium Solution for injection; Infants, Children, and Adolescents weighing less than 50 kg: 150 to 180 mg/kg/day IV/IM divided every 6 to 8 hours (Max: 2 g/dose); treat for 10 days for CAP in infants and children aged 3 months and older.
      • Cefotaxime Sodium Solution for injection; Children and Adolescents weighing 50 kg or more: For uncomplicated infections: 1 g IV/IM every 12 hours; for moderate/severe infections: 1 to 2 g IV/IM every 8 hours; for severe infections: 2 g IV every 6 to 8 hours. IDSA recommends 2 g IV every 8 hours for 10 days is for CAP.
  • Vancomycin c115c116
    • Vancomycin Hydrochloride Solution for injection; Infants, Children, and Adolescents: 60 mg/kg/day IV divided every 6 hours for MRSA per IDSA. FDA-approved dosage = 40 mg/kg/day IV divided every 6 hours. For MRSA, IDSA recommends to treat for 7 to 21 days for pneumonia and 10 days for CAP.
  • Clindamycin c117c118
    • Clindamycin Phosphate Solution for injection; Infants, Children, and Adolescents 13 to 16 years: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for MRSA pneumonia; transition to PO when appropriate; total course = 7 to 21 days depending on type and extent of infection. FDA approved dosage is 20 to 40 mg/kg/day IV/IM divided every 6 to 8 hours (Max: 2,700 mg/day) depending on severity.
    • Clindamycin Phosphate Solution for injection; Adolescents 17 years: 600 mg IV every 8 hours for MRSA pneumonia; transition to PO when appropriate; total course = 7 to 21 days depending on type and extent of infection. FDA-approved dosage is 300 mg IV/IM every 6 to 12 hours (less severe infections) and 600 mg IV or IM every 6 to 12 hours to 900 mg IV every 8 to 12 hours (more severe infections); every 6 to 8 hour intervals most commonly used in pediatric practice.
  • Antivirals c119
    • Oseltamivir c120
      • Oseltamivir Phosphate Oral suspension; Infants: 3 mg/kg/dose PO twice daily for 5 days; consider extended course for severely ill patients. AAP recommends 3.5 mg/kg/dose PO twice daily for infants 9 to 11 months old.
      • Oseltamivir Phosphate Oral suspension; Children weighing 15 kg or less: 30 mg PO twice daily for 5 days.
      • Oseltamivir Phosphate Oral suspension; Children weighing 16 to 23 kg: 45 mg PO twice daily for 5 days.
      • Oseltamivir Phosphate Oral suspension; Children weighing 24 to 40 kg: 60 mg PO twice daily for 5 days.
      • Oseltamivir Phosphate Oral suspension; Children weighing more than 40 kg and Adolescents: 75 mg PO twice daily for 5 days; consider extended course for severely ill patients.
    • Zanamivir c121
      • Zanamivir Inhalation powder; Children and Adolescents 7 to 17 years: 10 mg by oral inhalation every 12 hours for 5 days.
    • Peramivir c122
      • Peramivir Solution for injection; Infants 91—180 days†: 10 mg/kg/dose IV daily for 5 or 10 days was dosage approved in EUA and was well-tolerated in a pediatric study that included 3 infants < 1 year.
      • Peramivir Solution for injection; Infants > 180 days† and Children <= 5 years†: 12 mg/kg/dose IV daily for 5 or 10 days was dosage approved in EUA; 10 mg/kg/dose IV daily for up to 5 days was well-tolerated in a pediatric study.
      • Peramivir Solution for injection; Children >= 6 years† and Adolescents†: 10 mg/kg/dose IV daily (Max: 600 mg/dose) for 5 or 10 days was dosage approved in EUA and was well-tolerated in a pediatric study.

Nondrug and supportive care

IV fluids c123

  • Indicated for patients who are unable to tolerate oral fluids, have an oxygen requirement, or have moderate to severe disease

Supplemental oxygen c124

  • Indicated for patients with pulse oximetry readings less than 90% r1
Procedures
Noninvasive positive pressure ventilation c125
General explanation
  • Delivery of mechanical respiratory support without the use of endotracheal intubation r16
  • Goal of ventilatory support is to unload work of respiratory muscles, increase ventilation, and thus reduce dyspnea and respiratory rate and improve gas exchange
Indication
  • When FiO₂ of greater than 0.5 is necessary to maintain adequate oxygenation
Contraindications
  • Best predictive factors for noninvasive positive pressure ventilation failure within the setting of acute respiratory failure appear to be the level of FiO₂ (greater than 0.6) and higher PaCO₂ on admission or within the first hours after starting noninvasive positive pressure ventilation r16

Comorbidities

  • Children with the following comorbidities require more careful evaluation for pneumonia (in addition to consultation with an appropriate subspecialist):
    • Congenital heart disease c126
    • Chronic lung disease of prematurity c127
    • Chronic respiratory conditions leading to infection, such as:
    • Immune deficiency c130
  • There is a lower threshold for admission of patients with these comorbidities, and they should be monitored for possible worsening of disease

Complications and Prognosis

Complications

  • Necrotizing pneumonia c131
    • Rare complication; occurs most commonly in preschool-aged children r17
    • Streptococcus pneumoniae most common cause r17
    • May also occur with other common bacterial pathogens
    • Patient develops parapneumonic effusion, pleural empyema, or bronchopleural fistula r17
    • Predisposing conditions include congenital cysts, sequestrations, bronchiectasis, neurological disorders, and immunodeficiency r18
    • Obtain infectious disease and surgical consultation; may require chest tube/surgical intervention
  • Empyema and pleural effusions c132c133c134c135
    • Uncommon in outpatients, but incidence increased in patients admitted to hospital r3
    • Treatment options include therapeutic thoracentesis, drainage catheter placement, fibrinolytic therapy, pleurodesis, and surgery
  • Bacteremia/sepsis c136c137c138c139c140c141c142c143
    • More likely to occur in patients with pneumonia complicated by moderate to large pleural effusion, empyema, or bronchopleural fistula
    • Blood cultures can guide need for antibiotic change
  • Pneumatoceles c144
    • Occurs in approximately 2% to 8% of hospitalized children with pneumonia r19
    • Most commonly associated with Staphylococcus aureus and Streptococcus pneumoniae infections r20
    • Thin-walled, air-filled intraparenchymal cysts develop secondary to localized bronchiolar and alveolar necrosis, allowing 1-way passage of air into the interstitial space
    • With mechanical ventilation, patients have an increased risk for developing complications related to pneumatoceles r21
    • Majority of pneumatoceles cases (more than 85%) resolve spontaneously, partially, or completely over weeks
  • Recurrent pneumonia c145c146c147c148
    • Majority of patients have an underlying condition, such as: r22
      • Oropharyngeal incoordination with aspiration syndrome (respiratory symptoms with feeding in those with gastroesophageal reflux)
      • Immune disorder (recurrent infections at other locations and failure to thrive)
      • Foreign body (consider If pneumonia in same anatomic location)

Prognosis

  • Prognosis is good for children treated for community-acquired pneumonia on an outpatient basis
  • Morbidity and mortality are higher in hospitalized children
  • Pediatric pneumonia is the leading cause of mortality worldwide in children younger than 5 years r8

Screening and Prevention

Screening c149

Prevention

  • Interventions to prevent community-acquired pneumonia include breastfeeding, frequent handwashing, and avoidance of exposure to tobacco smoke c150c151c152
  • Immunizations
    • Administer pneumococcal conjugate vaccine (Prevnar 13) for prevention of invasive pneumococcal disease in children aged 6 weeks to younger than 6 years r23c153
    • Administer influenza, Haemophilus influenzae type b, pertussis, varicella, and measles vaccines according to recommended schedules r24c154c155c156c157c158
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