Pneumonia is the single most common cause of death in children worldwide, with more than 2 million children younger than 5 years dying of pneumonia annually. In the United States, 525 children younger than 15 years died as a result of pneumonia and other lower respiratory tract infections in 2006.
Updated guidelines from the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America give guidance on a number of aspects of care for community-acquired pneumonia (CAP) in infants and children.
Diagnostic Testing
Diagnostic testing is not required in nontoxic, fully immunized children who are treated as outpatients. Pulse oximetry should be performed on all children. To look for complications of pneumonia – including effusions, necrotizing pneumonia, and pneumothorax – obtain both anterior-posterior and lateral chest x-rays (CXR) in those with hypoxemia or respiratory distress and in those who failed initial antibiotic therapy.
Those who failed to improve within 48-72 hours of antibiotic administration and those with clinical deterioration should have blood cultures drawn.
By Dr. Neil Skolnik and Dr. Phuong Tien
In inpatient settings, blood cultures should be obtained for presumed bacterial CAP. A positive blood culture with pending identification and susceptibility should not preclude discharge if the patient is clinically improving. Sputum sample and urinary antigen detection are not recommended because of the difficulty of obtaining samples and the high rate of false positives. Testing for influenza virus and other respiratory viruses should be done if they are clinically suspected.
If a patient is admitted, CXR should be done to document the size and character of infiltrates and to look for complications of pneumonia. Repeated CXR is not routinely recommended, but should be obtained in those who fail to improve. Repeated CXR at 4-6 weeks after diagnosis of CAP should be obtained in children with recurrent pneumonia that involves the same lobe, and in those who have lobar collapse with suspicion for anatomical anomaly or chest mass.
Site of Care
A decision regarding the site of care is based on the severity of clinical presentation. The following children should be hospitalized: those with moderate to severe CAP, including those with respiratory distress and hypoxemia (saturation less than 90% in room air); those with CAP-MRSA (methicillin-resistant Staphylococcus aureus), because of high virulence; and those who are unable to comply with therapy or who would be unavailable for follow-up.
Recommended Antibiotic Therapy
Antimicrobial therapy is not routinely needed for preschool-age children with CAP, because a viral etiology is the cause of the pneumonia in the majority of patients.
If a bacterial infection is believed to be possible, then high-dose amoxicillin (90 mg/kg per day) in two to three doses daily is recommended as first-line therapy for fully immunized infants and preschool children who are treated as outpatients.
For school-age children and adolescents with mild to moderate CAP, Streptococcus pneumoniae is the most common pathogen, and high-dose amoxicillin is recommended as first-line therapy (rated as a "strong recommendation"). If there is concern of atypical pathogens in school-age children and adolescents, the addition of a macrolide should be considered, a recommendation that is rated as a "weak recommendation."
During influenza season, influenza antiviral therapy should be given in children with moderate to severe CAP that is clinically suspected of resulting from influenza, without waiting for the confirmatory results of influenza testing.
For inpatients, IV ampicillin or penicillin G are the drugs of choice in fully immunized children. For children who are not fully immunized, those with life-threatening infections such as empyema, or those who live in areas of invasive pneumococcal strains resistant to penicillin, empiric therapy with third-generation cephalosporins (ceftriaxone or cefotaxime) is recommended. A macrolide can be added to a beta-lactam if there’s clinical consideration for Mycoplasma and Chlamydia pneumoniae. Vancomycin should be used in addition to beta-lactam for those with possible CAP-MRSA.
Duration of antibiotic therapy should be 10 days, but may be longer in CAP-MRSA. Patients should improve within 48-72 hours of starting antibiotics.
Discharge Planning
Discharge planning for patients who are admitted to the hospital can be considered once there is clinical improvement reflected in return of appetite, baseline mental status, toleration of oral antibiotics, afebrile status for 12-24 hours, and pulse oximetry greater than 90% in room air for 12-24 hours.
Prevention
Prevention of CAP is important. Children should be immunized against S. pneumoniae, Haemophilus influenzae type b, and pertussis. Annual flu vaccination is recommended for children older than 6 months. Parents and caretakers of infants younger than 6 months, including pregnant adolescents, should be immunized against influenza and pertussis. Finally, palivizumab (Synagis) should be offered in high-risk infants to decrease the risk of severe pneumonia caused by respiratory syncytial virus.