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Oct.05.2021

Community-Acquired Pneumonia in Children (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 Chlamydia 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 lower than 90%, IV fluids for dehydration, and antipyretics for a fever r1

Urgent Action

  • Administer supplemental oxygen for oxygen saturation lower than 90% r1
  • Consider noninvasive positive pressure ventilation for patients with greater than 50% FiO₂ requirement or other signs of significant respiratory distress
  • Administer antibiotics as soon as possible to any ill-appearing patient or patients suspected of having bacterial pneumonia

Pitfalls

  • Consider a foreign body in a child with recurrent pneumonia

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, Chlamydia 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: more than 50 breaths per minute r1
    • Aged 1 to 5 years: more than 40 breaths per minute r1
    • Older than 5 years: more 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 c23
    • Absent breath sounds and dull percussion raise concern for an effusion r3c24c25

Causes and Risk Factors

Causes

  • Most common, by age group
    • Neonatal
      • Bacterial r5
        • Group B streptococci c26c27c28
        • Listeria monocytogenes
        • Gram-negative bacilli
        • Chlamydia trachomatis c29
    • Children older than 1 month
      • Viral (up to 70% of cases) r5
        • Human respiratory syncytial virus (more common among children younger than 5 years) r6c30c31
        • Parainfluenzavirus 1, 2, and 3 c32
        • Influenza A and B virus c33c34
        • Human adenovirus (more common among children younger than 5 years) r6c35c36
        • Human rhinovirus c37
        • Human herpesvirus 1 and 2 c38
        • Human metapneumovirus (more common among children younger than 5 years) r6c39c40
        • Human enterovirus c41
      • Bacterial r5
        • Streptococcus pneumoniae (routine childhood vaccination has led to reduced incidence) c42
        • Haemophilus influenzae type b (routine childhood vaccination has led to reduced incidence) c43
        • Moraxella catarrhalisc44
        • Staphylococcus aureusc45
        • Mycoplasma pneumoniae (more common among older children and adolescents) c46
        • Chlamydia pneumoniae (more common among older children and adolescents) c47

Risk factors and/or associations

Age
  • Highest incidence among children younger than 2 years r6c48c49c50
  • Higher incidence in premature infants r7c51
Sex
  • Boys have higher incidence at all ages r7c52c53
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 r8c60
  • Risk factors in developing countries: r9
    • 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 r9
      • 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
    • Perform pulse oximetry in all children with suspected hypoxemia c73
  • Additional testing for patients admitted to the hospital (those meeting requirements for moderate to severe pneumonia)
    • Chest radiograph c74
    • Blood and sputum cultures c75c76
    • Viral pathogen testing c77
    • Testing for Mycoplasma infection (if suspected) c78
    • CBC c79
    • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin concentration) may be helpful in some patients c80c81c82

Laboratory

  • Blood cultures c83
    • 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 c84
    • Obtain culture and Gram stain in children who are hospitalized and can produce sputum r1c85
  • Tracheal aspirates r1
    • Obtain if child requires endotracheal intubation c86
      • Gram stain and culture
      • Viral pathogens, including influenza virus
  • Viral pathogen testing c87
    • 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 c88
      • If suspicion exists for Mycoplasma pneumoniae, a variety of diagnostic tests are available, but polymerase chain reaction is the most rapid and accurate method r1r10
      • Testing for Chlamydia pneumoniae is not recommended r1
  • CBC c89
    • Obtain in hospitalized patients r1
  • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein concentration, serum procalcitonin concentration) c90c91c92
    • No need to measure routinely in fully immunized children with community-acquired pneumonia who will be treated as outpatients, but may be helpful to measure in children with more serious disease or complications r1
      • May help in monitoring response to therapy and course of disease
      • May help distinguish between bacterial and viral disease but should not be the sole criteria used r1
        • Elevated levels of procalcitonin are associated with greater likelihood of bacterial cause for pneumonia; however, predictive thresholds are not well established r11

Imaging

  • Chest radiography c93
    • Not necessary for patients with suspected community-acquired pneumonia with mild symptoms who do not require admission r1r12
    • Use posteroanterior and lateral radiographic views for patients with hypoxemia, respiratory distress, or other indications for hospitalization and for patients who do not respond to initial outpatient antibiotic therapy r1r12
      • British Thoracic Society guidelines do not advocate for routine lateral films r3
    • Lobar consolidation is typically seen in pneumococcal pneumonia
    • Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in viral 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 c94
    • Indicated as first line imaging in patients with complicated pneumonia r12r13
      • Valuable for diagnosis and assessment of pleural effusions
    • Evidence supports lung ultrasonography (which does not require radiation exposure) as an alternative to chest radiography for initial diagnosis of pneumonia in children r14r15r16
  • Chest CT c95
    • Reserve chest CT for complicated pneumonia cases in which chest ultrasonography is technically limited or discrepant with the clinical findings r13
    • Indicated for investigation of suspected bronchopleural fistula, lung abscess, or recurrent pneumonia r12

Functional testing

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

Differential Diagnosis

Most common

  • Bronchitis c97d1
    • 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 c98d2
    • Acute infection of the lower respiratory tract resulting in small airway obstruction
    • Respiratory syncytial virus is the most common cause of bronchiolitis in children younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction, 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
  • COVID-19 (coronavirus disease 2019) c99d3
    • Spectrum of illness ranging from fever, cough, and shortness of breath to mild upper respiratory tract symptoms, gastrointestinal symptoms, fatigue, or loss of appetite
      • Hospitalization for severe respiratory symptoms is rare in children
    • May have known exposure to confirmed case (typically within own household)
    • Diagnosed based on rapid polymerase chain reaction for SARS-CoV-2 (2019 novel coronavirus) on specimens from upper respiratory tract
    • Chest imaging may reveal bilateral pulmonary infiltrates
  • Pertussis c100d4
    • Symptoms occur in 3 phases:
      • Catarrhal
        • Low-grade fever, upper respiratory tract 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
  • Asthma c101d5
    • 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 c102d6
    • Suspect when child is from an endemic area or has had contact with persons who are at high risk of having the disease, including those who are urban homeless, are incarcerated, and have HIV infection
    • Presents subacutely with anorexia, weight loss, and night sweats
    • Differentiate based on history of either being from an endemic area or having exposure to high-risk individuals
  • Acute respiratory distress syndrome c103d7
    • 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 are classified as having acute respiratory distress syndrome

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: more than 60 breaths per minute
    • Aged 2 to 12 months: more than 50 breaths per minute
    • Aged 1 to 5 years: more than 40 breaths per minute
    • Older than 5 years: more 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
  • Do not use severity of illness scores as the only criteria for ICU admission; use them 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

Empiric antibiotic therapy r1

  • Prescribe empiric antibiotic therapy according to age and care setting; typical duration is 7 to 10 days r5
    • Shorter courses may be equally effective for mild illness managed as outpatient r1
    • Investigate further if deterioration or failure to improve occurs after 48 to 72 hours of antibiotic therapy r5
  • Outpatient r1
    • Older than 3 months to younger than 5 years
      • Antimicrobial therapy not routinely required for preschool-aged children with community-acquired pneumonia because the majority of cases are viral
      • Amoxicillin is first line therapy for appropriately immunized infants or preschool-aged children with suspected typical bacterial community-acquired pneumonia
      • Azithromycin is the first line therapy for children with community-acquired pneumonia suspected to be caused by atypical organisms
    • Aged 5 to 17 years
      • Amoxicillin is first line therapy for appropriately immunized school-aged children and adolescents with suspected typical bacterial community-acquired pneumonia
        • Combination therapy with a macrolide in addition to a β-lactam antibiotic can be prescribed if there are no features to distinguish bacterial from atypical pneumonia
      • Azithromycin is first line therapy for children with community-acquired pneumonia suspected to be caused by atypical organisms
  • Inpatient (older than 3 months) r1
    • 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
    • Add antistaphylococcal coverage (eg, clindamycin or vancomycin) if methicillin-resistant Staphylococcus aureus is suspected
    • Add a macrolide (oral or parenteral) in addition to a β-lactam antibiotic if atypical organisms 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 a subset of children with confirmed atypical bacteria r17

Pathogen-directed therapy r1

  • Adjust antibiotic therapy, if necessary, based on culture results r1
  • 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 r1

  • Indicated for children of any age hospitalized with suspected or confirmed influenza-induced community-acquired pneumonia regardless of duration of symptoms r18
    • Also offer to outpatients with severe, complicated, or progressively worsening illness attributable to influenza and those at high risk of complications due to influenza r18
  • Start treatment as soon as possible; however, even after 48 hours of symptomatic infection treatment, may still provide clinical benefit to those with more severe disease r1
    • Do not delay treatment in case of positive influenza test results r1
  • Oral oseltamivir is the drug of choice in children older than 2 weeks of age; zanamivir, peramivir, and baloxavir are alternatives r18
  • Consult CDC Influenza Surveillance Report for recent drug resistance information to aid drug selection r19

Drug therapy

  • Penicillins c104
    • Amoxicillin c105
      • Amoxicillin Trihydrate Oral suspension; Infants and Children 4 months to 12 years: 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day). May adjust dose to 45 to 100 mg/kg/day PO in divided doses based on identified pathogen.
      • Amoxicillin Trihydrate Oral capsule; Adolescents: 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day) for 5 to 7 days. May adjust dose to 45 to 100 mg/kg/day PO in divided doses based on identified pathogen.
    • Ampicillin c106
      • Ampicillin Sodium Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 150 to 400 mg/kg/day IV/IM in divided doses every 6 hours for 10 days.
      • Dosages of 300 to 400 mg/kg/day IV/IM in divided doses every 6 hours are used as an alternative to ceftriaxone for resistant strains of Streptococcus pneumoniae.
    • Penicillin G c107
      • Penicillin G Sodium Solution for injection; Infants, Children, and Adolescents 4 months to 17 years: 100,000 to 250,000 units/kg/day IV/IM divided every 4 to 6 hours for 10 days.
  • Macrolides c108
    • Azithromycin c109
      • Oral
        • Azithromycin Oral suspension; Infants 3 to 5 months†: 10 mg/kg/dose PO for 1 day, followed by 5 mg/kg/dose PO once daily for 4 days.
        • 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.
        • Azithromycin Oral suspension; Adolescents: 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, Children, and Adolescents 3 months to 15 years†: 10 mg/kg/dose (Max: 500 mg/dose) IV once daily for 2 days, followed by oral therapy to complete a 5-day treatment course.
        • Azithromycin Solution for injection; Adolescents 16 to 17 years: 500 mg IV once daily for at least 2 days, followed by oral therapy to complete a 7- to 10-day treatment course
    • Clarithromycin c110
      • Clarithromycin Oral suspension; Infants 3 to 5 months†: 7.5 mg/kg/dose PO every 12 hours for 10 days.
      • Clarithromycin Oral suspension; Infants and Children 6 months to 12 years: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 days.
      • Clarithromycin Oral tablet; Adolescents: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 5 to 10 days.
    • Erythromycin c111
      • Oral
        • Erythromycin Ethylsuccinate Oral suspension; Infants 4 to 11 months, Children, and Adolescents: 40 mg/kg/day PO in 4 divided doses (Usual Max: 2 g/day) for 10 days.
      • Intravenous
        • Erythromycin Lactobionate Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 20 mg/kg/day IV divided every 6 hours (Max: 4 g/day) for 10 days.
  • Cephalosporins c112
    • Ceftriaxone c113
      • Ceftriaxone Sodium Solution for injection; Infants and Children: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for up to 10 days.
      • Ceftriaxone Sodium Solution for injection; Adolescents: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for 5 to 10 days.
    • Cefotaxime c114
      • Cefotaxime Sodium Solution for injection; Infants and Children: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 10 days.
      • Cefotaxime Sodium Solution for injection; Adolescents: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 5 to 10 days.
  • Vancomycin c115c116
    • Vancomycin Hydrochloride Solution for injection; Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 7 to 21 days for MRSA pneumonia.
    • Vancomycin Hydrochloride Solution for injection; Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 21 days for MRSA pneumonia.
    • Vancomycin Hydrochloride Solution for injection; Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 7 to 21 days for MRSA pneumonia.
    • Vancomycin Hydrochloride Solution for injection; Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 21 days for MRSA pneumonia.
  • Clindamycin c117c118
    • Clindamycin Solution for injection; Infants 4 to 11 months and Children: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
    • Clindamycin Solution for injection; Adolescents: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
  • Antivirals c119
    • Oseltamivir c120
      • Oseltamivir Phosphate Oral suspension; Infants 1 to 8 months: 3 mg/kg/dose PO twice daily for 5 days.
      • Oseltamivir Phosphate Oral suspension; Infants 9 to 11 months: 3.5 mg/kg/dose PO twice daily for 5 days.
      • 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 and Adolescents weighing more than 40 kg: 75 mg PO twice daily for 5 days.
    • Zanamivir c121
      • Zanamivir Inhalation powder; Children and Adolescents 7 to 17 years: 10 mg by oral inhalation every 12 hours for 5 days.
      • Administer 2 doses on the first day provided there are at least 2 hours between doses
    • Peramivir c122
      • For the treatment of uncomplicated acute influenza (eg, influenza A virus infection or influenza B virus infection)
        • Peramivir Solution for injection; Infants and Children 6 months to 12 years: 12 mg/kg/dose (Max: 600 mg/dose) IV as a single dose.
        • Peramivir Solution for injection; Adolescents: 600 mg IV as a single dose.
      • For the treatment of novel influenza A viruses associated with severe human disease†, including avian influenza A virus infection†
        • Peramivir Solution for injection; Infants 91 to 180 days: 10 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
        • Peramivir Solution for injection; Infants older than 180 days and Children 1 to 5 years: 10 to 12 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
        • Peramivir Solution for injection; Children and Adolescents 6 to 17 years: 10 mg/kg/dose IV once daily (Max: 600 mg/dose) for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
    • Baloxavir
      • Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing less than 80 kg: 40 mg PO as a single dose.
      • Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing 80 kg or more: 80 mg PO as a single dose.

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 lower than 90% r1
Procedures
Noninvasive positive pressure ventilation c125
General explanation
  • Delivery of mechanical respiratory support without the use of endotracheal intubation r20
  • 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 r20

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

Monitoring

  • Arrange clinical follow-up for outpatient-treated patients within 24 to 48 hours; consider hospitalization if condition has deteriorated
  • Follow-up chest radiographs are not typically required for uncomplicated cases c131

Complications and Prognosis

Complications

  • Necrotizing pneumonia c132
    • Rare complication; occurs most commonly in preschool-aged children r21
    • Streptococcus pneumoniae most common cause r21
    • May also occur with other common bacterial pathogens
    • Patient develops parapneumonic effusion, pleural empyema, or bronchopleural fistula r21
    • Predisposing conditions include congenital cysts, sequestrations, bronchiectasis, neurological disorders, and immunodeficiency r22
    • Obtain infectious disease and surgical consultation; may require chest tube/surgical intervention
  • Empyema and pleural effusions c133c134c135c136
    • 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 c137c138
    • 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 c139
    • Occurs in approximately 2% to 8% of hospitalized children with pneumonia r23
    • Most commonly associated with Staphylococcus aureus and Streptococcus pneumoniae infections r24
    • Thin-walled, air-filled intraparenchymal cysts develop secondary to localized bronchiolar and alveolar necrosis, allowing one-way passage of air into the interstitial space
    • With mechanical ventilation, patients have an increased risk for developing complications related to pneumatoceles r25
    • Most pneumatoceles cases (more than 85%) resolve spontaneously, partially, or completely over weeks
  • Recurrent pneumonia c140
    • Most patients have an underlying condition, such as: r26
      • Oropharyngeal in coordination 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 r9

Screening and Prevention

Screening c141

Prevention

  • Interventions to prevent community-acquired pneumonia include breastfeeding, frequent handwashing, and avoidance of exposure to tobacco smoke c142c143c144
  • Immunizations
    • Administer pneumococcal conjugate vaccine (Prevnar 13) to prevent invasive pneumococcal disease in children aged 6 weeks to younger than 6 years r27c145
    • Administer influenza, Haemophilus influenzae type b, pertussis, varicella, and measles vaccines according to recommended schedules r28c146c147c148c149c150
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