Objectives After completing this article, readers should be able to:
1. Discuss the major pathogens of childhood pneumonia, including the usual age groupsaffected and clinical features.
2. Recognize the major findings that distinguish children who have pneumonia fromthose who have other respiratory tract infections.
3. Outline the antibiotic regimens used to treat pneumonia in ambulatory children.4. Describe the clinical circumstances that warrant radiographic and laboratory studies
and consideration of hospitalization.5. Explain the hospital management of pneumonia, lung abscess, and empyema.6. Identify preventive measures for reducing the risk of pneumonia.
IntroductionPneumonia (infection of the lung parenchyma) in children is encountered commonly indaily practice, and otherwise healthy children typically do well with outpatient treatment.It is important, however, to recognize those children who are at risk for or who already areexperiencing severe or complicated pneumonia and to monitor and treat them. Pneumoniausually can be diagnosed clinically, although radiographs may be useful to corroborate theclinical findings or identify complications. Antibiotic selection is important, and thetreating clinician should consider prevalent organisms, the child’s age, and the presence ofrisk factors for atypical or resistant organisms. Occasionally, in more severe or complicatedcases, hospitalization may be necessary to provide intravenous (IV) antibiotics, fluids,oxygen, and other supportive measures and to facilitate necessary invasive procedures todiagnose and treat complications. Fortunately, appropriate immunization and properpersonal hygiene can go far in preventing pneumonia.
EpidemiologyAbout 150 million cases of pneumonia occur worldwide each year in children youngerthan age 5 years, according to the World Health Organization, with up to 20 million casesclassified as sufficiently severe to require hospital admission. In North America, theincidence of disease in children younger than age 5 years is estimated to be 35 to 40 casesper 1,000, with a decrease to 7 per 1,000 among adolescents ages 12 to 15 years. Thus, apractitioner who has 500 children younger than age 5 years and 500 adolescents under hisor her care is likely to encounter 17 to 20 cases of pneumonia per year in young childrenand 3 to 5 cases in adolescents. This figure does not include the much larger number ofchildren who have other viral lower respiratory tract infections (LRTIs), such as bronchi-olitis, or children who have exacerbations of asthma. Mortality among children indeveloped countries is low, at less than 1 per 1,000 annually, but is substantial in thedeveloping world, with 4 million cases per year making it the number one killer of children,ahead of malaria and gastroenteritis accompanied by dehydration.
In temperate climates, pneumonia is more common in cold months, presumablyreflecting enhanced person-to-person droplet spread of respiratory pathogens due tocrowding, along with diminished host resistance due to impaired mucociliary clearancefrom dry indoor air. Children exposed to cigarette or wood stove smoke and children fromlower socioeconomic levels have a higher incidence of pneumonia, as do boys compared
*Professor of Pediatrics and Medicine.†Associate Professor of Pediatrics, University of Massachusetts Medical School, Worcester, Mass.
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with girls. Adolescents who smoke cigarettes or drinkalcohol are at higher risk for acquiring pneumonia as aresult of impaired mucociliary clearance and increasedrisk of aspiration. Children who have underlying medicaldisorders such as sickle cell disease, bronchopulmonarydysplasia, gastroesophageal reflux, asthma, cystic fibrosis,congenital heart disease, and immunodeficiency syn-dromes are at higher risk for pneumonia and its compli-cations. Similarly, children who have neuromusculardisease or seizure disorder are at risk for aspiration pneu-monia.
PathogenesisPneumonia typically follows an upper respiratory tractinfection. Organisms that cause LRTIs usually are trans-mitted by droplet spread directly from close personalcontact or indirectly by contaminated fomites. Followinginitial colonization of the nasopharynx, organisms maybe inhaled, leading to a pulmonary focus of infection; lesscommonly, bacteremia results from the initial upper air-way colonization, with subsequent seeding of the lungparenchyma. The normal pulmonary host defense systemconsists of multiple mechanical barriers, including saliva,nasal hair, the mucociliary apparatus, the epiglottis, andthe cough reflex. Humoral immunity, including secre-tory immunoglobulin A (IgA) and serum IgG, defendsagainst pneumonia, and other airway constituents such assurfactant, fibronectin, and complement play roles inmicrobial killing. Phagocytic cells, including polymor-phonuclear cells and alveolar macrophages, play impor-tant defense roles, and cell-mediated immunity is impor-tant in the defense against certain pathogens, especiallyviral agents and other intracellular organisms.
CausesStudies of the etiologic agents of pneumonia in childrenare hampered by the impracticality of obtaining speci-mens of lung tissue to identify the precise pathogen.Thus, most of the data about etiologic agents are indi-rect, obtained either by using secretions (usually fromthe upper respiratory tract) for culture, antigen, or nu-cleic acid detection or by measuring host serologic re-sponses. Another problem is the generalizability of datafrom one region and one season to other settings becausethere are considerable geographic and seasonal variationsin pathogens. Dual infection, with viral and bacterialagents isolated from the same patient, is reported fre-quently. However, up to 50% of patients who havepneumonia, even when exhaustively investigated, haveno specific microbe identified. Fortunately, discoveries ofnew agents (eg, human metapneumovirus this decade)
continue, making it possible to identify the pathogenmore frequently.
Pneumonia pathogens in children (Table 1) often arediscussed in reference to age groups, with infants, tod-dlers, and school-age children representing broad cate-gories. In the first postnatal month, neonatal bacterialpathogens (eg, group B Streptococcus, gram-negative ba-cilli) account for many respiratory tract infections. From1 month to 3 to 4 months of age, viruses are the mostcommon pathogens. Respiratory syncytial virus (RSV)leads the list, with its highest attack rate in the first 6postnatal months. Children who have RSV disease typi-cally present with symptoms of bronchiolitis, but pneu-monia with focal infiltrates and absence of wheezing isseen occasionally. Parainfluenza virus can cause similarlower respiratory tract disease in young infants and usu-ally is detected earlier in the fall than is RSV. Chlamydiatrachomatis causes a distinctive respiratory tract illnesstypically at about 6 weeks of age (range, 2 to 8 wk).Children present with tachypnea, and radiographs showinterstitial infiltrates, but the children are strikingly afe-brile and usually do not appear ill. Pneumococcal pneu-monia is the most common pyogenic lung infectionthroughout childhood, starting at this age, with impor-tant therapeutic implications and concern for suppura-tive complications.
In the next age group, from a few months of agethrough preschool, viruses continue to predominate,notably RSV and parainfluenza. Other agents such as thehuman metapneumovirus, rhinovirus, influenza, and ad-enovirus may cause pneumonia. Newly recognizedagents such as coronaviruses and bocaviruses also may beresponsible for LRTIs in this age group. The majorbacterial pathogen in this age group is the pneumococ-cus, and related suppurative complications (especiallyempyema) have occurred more commonly in the pastdecade than in prior decades. Group A Streptococcus andStaphylococcus aureus (including methicillin-resistantstrains) are rare causes of invasive pneumonia in chil-dren, and Haemophilus influenzae type B (Hib) has beenvirtually eliminated as a cause of pneumonia in theUnited States with the introduction of vaccine in theearly 1990s. Mycoplasma pneumoniae and Chlamy-dophila pneumoniae infections occasionally are seen inpreschool-age children and may be increasing in inci-dence in this age group.
Once children reach school age, M pneumoniae be-comes an important pathogen, and C pneumoniae alsoappears to be a significant cause of illness, especially inteenagers. S pneumoniae remains an important cause,and tuberculosis must be considered in populations at
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risk due to geography or other exposures. S aureus andgroup A Streptococcus are uncommon pathogens in thisage group. Viral pathogens continue to be recovered butconstitute a smaller percentage of cases.
Less common but important pathogens associatedwith pneumonia in children are listed in Table 2. This listis not exhaustive but does include most of the otheragents seen in children in North America who havepneumonia syndromes. Additional discussion of theseorganisms is beyond the scope of this review; the Amer-ican Academy of Pediatrics Red Book and other sourcescan be consulted for additional information on diag-nosis and management of disease caused by thesepathogens.
Clinical FeaturesThe hallmark symptoms of pneumonia are fever andcough. Most children who have these two symptoms do
not have pneumonia, but clinicians always should con-sider the possibility of pneumonia if these are present.The clinician should check the patient’s temperature,pulse, respiratory rate, and pulse oximetry reading (ifavailable) and can evaluate illness severity by observingthe child while taking the history, evaluating the qualityof the cough and degree of respiratory distress. Thechild’s general demeanor, attention to the environment,willingness to drink, degree of hydration, color, andpresence of cyanosis can be assessed readily while askingquestions.
For the typical child who does not appear urgently ill,the history should focus on duration of illness, respira-tory symptoms (eg, quality of cough, wheezing, diffi-culty with breathing), and extrarespiratory symptoms(eg, fever, headache, sore throat, myalgias, lethargy).Other important questions should address previous epi-
Table 1. Childhood Community-acquired Pneumonia: Common Pathogensby Age
Age Pathogen Comments
3 wk to 3 mo Chlamydia trachomatis • Vertical transmission• Afebrile• Interstitial infiltrates on chest radiograph
Respiratory syncytial virus(RSV)
• Bronchiolitis with wheezing mostcommon; focal pneumonia possible
• Onset usually late fallParainfluenza • Bronchiolitis or pneumonia
• Seen fall through springStreptococcus pneumoniae • Major bacterial cause throughout
childhoodBordetella pertussis • Tracheobronchitis with severe paroxysmal
cough, no fever• Pneumonia occasionally seen, usually
related to aspiration3 mo to age 4 y RSV, parainfluenza, human
metapneumovirus,influenza, rhinovirus
• Most toddler pneumonia is viral
S pneumoniae • Major treatable pathogen in this agegroup
Mycoplasma pneumoniae • Possible in all ages• Increased incidence in children
approaching school age5 y through adolescence M pneumoniae • Major treatable cause in school-age
children and adolescentsChlamydophila
pneumoniae• Also an important cause; similar clinical
presentation to MycoplasmaS pneumoniae • Still an important cause
• Complications, especially empyema, oftenensue
Mycobacteriumtuberculosis
• Primarily in areas or populations of hightuberculosis prevalence
• Higher risk at puberty and in pregnancy
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sodes of respiratory illness, ill contacts, recent antibiotictherapy and other medications, and chronic illnesses.
The physical examination, following the general ob-servations discussed previously, should focus on the re-spiratory system. Tachypnea, retractions (intercostal,subcostal, suprasternal), wheezing, nasal flaring, andgrunting should be noted. Tachypnea (�50 breaths/min at 2 to 12 months of age, �40 breaths/min at 1 to5 years, �20 breaths/min for those older than 5 years,subtracting 10 if the child is febrile) is the most sensitiveand specific sign of pneumonia, found twice as frequentlyin children who have evidence of pneumonia on chestradiography than for those who have no such findings.Although most children who have pneumonia exhibittachypnea, a few may not, requiring the clinician toconsider the entire clinical presentation. Findings of in-creased work of breathing (retractions, flaring, grunting)and decreased oxygen saturation (�95%) also are predic-tive of LRTI. Grunting, in particular, may be a sign ofpneumonia as well as of impending respiratory failure.New onset of wheezing usually is not associated withpyogenic bacterial pneumonias.
The lung examination should be performed when thechild is cooperative, often while still in a parent’s armsand before undertaking more threatening parts of the
examination (eg, oral, aural, and abdominal). The mostcommon signs of pneumonia detected by office-basedclinicians are dullness to percussion, crackles, decreasedbreath sounds, and bronchial breath sounds (louder-than-normal tubular breath sounds often accompaniedby egophony [E to A change]). Coarse-sounding upperairway breath sounds, often termed “rhonchi” and re-lated to secretions in the large airways, are not necessarilyindicative of pneumonia. The remainder of the physicalassessment can follow the lung examination. In the ab-sence of fever, tachypnea, increased work of breathing,and auscultatory abnormalities, bacterial pneumonia isunlikely.
It is important to review the overall severity of illnessfor children whose lung findings are consistent withpneumonia. Those who are ill-appearing, dehydrated, orin respiratory distress require rapid and aggressive man-agement, including blood cultures, chemistry profiles,complete blood count (CBC), and chest radiography, aswell as administration of IV fluids, oxygen, and antibiot-ics. Hospital admission often is indicated.
Outpatient management is sufficient for most chil-dren diagnosed with pneumonia in primary care practice.If the diagnosis is based on the lung findings and thechild’s condition does not warrant hospital admission,
Table 2. Other Miscellaneous Pneumonia PathogensSource Disease/Organism Comments
Geographic tropism Histoplasmosis Ohio and Mississippi River valleys; CaribbeanCoccidioidomycosis California, Arizona, New MexicoBlastomycosis Ohio and Mississippi River valleys; Great Lakes
statesLegionella Infected water worldwideSevere acute respiratory syndrome AsiaAvian influenza Southeast Asia
the clinician should obtain additional history to assess forclues to a possible causative agent (Table 3), payingparticular attention to questions about travel, animalexposures, ill contacts, and tuberculosis exposure.
The next step in outpatient management is decidingwhether to obtain laboratory studies or a chest radio-graph. In most instances, blood tests such as a CBC,chemistries, or serology will not help to identify the causeor aid in management. For a highly febrile child, it isreasonable to obtain a blood culture, recognizing thateven in documented pneumococcal pneumonia in chil-dren, the organism generally is recovered from the bloodno more than 10% of the time. Erythrocyte sedimenta-tion rate and C-reactive protein determinations are notuseful. Diagnostic tests for bacterial pathogens with nu-cleic acid or rapid antigen detection performed on respi-ratory tract secretions are too expensive and impracticalfor most children in the community outpatient settingand generally do not affect therapy. In some settings, arapid influenza test may help identify the cause of feverand reduce the subsequent use of antibacterial agents.
A chest radiograph also will not change clinical man-agement for most children who are being treated asoutpatients. For those who do not appear particularly illbut who do have impressive auscultatory findings, such asmarkedly diminished or altered breath sounds suggestingdense consolidation or significant effusion, a radiograph
may help to determine whether a complicated pneumo-nia is present that requires more intense monitoring,parenteral therapy, or hospital management. Afebrilechildren normally do not require chest radiography.
A tuberculin skin test and close follow-up should beconsidered for any child who has known exposure or otherrisk factors for tuberculosis, chronic symptoms, or otherunusual historical features. Primary tuberculosis in childrenmay present with the picture of focal pneumonia.
A chest radiograph occasionally may be indicated forthe febrile child who has no discernible source of infec-tion if fever is prolonged, there is a history of multipleLRTIs or risk factors for pneumonia, or the physicalexamination raises suspicion for pneumonia.
The decision about antibiotic choice involves consid-eration of age, time of year, and other specific epidemi-ologic features. In addition to the afebrile pneumoniasyndrome of infancy associated with C trachomatis, thereare three child and adolescent pneumonia syndromes:bacterial (suppurative), atypical, and viral (Table 4).Classic bacterial pneumonia, usually caused by pneumo-coccus, has an abrupt onset (often following an upperrespiratory tract infection [URI]), with fever and toxic-ity, mild respiratory distress, a cough that may be pro-ductive, and focal findings on examination. Occasionally,affected children present with emesis and abdominal painand initially are evaluated for appendicitis. Other cluesthat suggest a bacterial cause include chest pain and theabsence of wheezing or prominent extrarespiratorysymptoms. If a chest radiograph is performed, it typicallyshows a unilateral focal infiltrate. Figures 1 through 6show representative radiographs of pneumonia caused byvarious pathogens.
Children who have atypical pneumonia (resultingfrom Mycoplasma or C pneumoniae) usually are of schoolage or older and usually present with constitutionalsymptoms of myalgias, fever, malaise, headache, andgradual development of dry cough later in the illness asother symptoms improve. The chest radiograph oftenshows bilateral patchy infiltrates.
Children who have viral LRTIs generally present withURI symptoms, are not highly febrile or toxic, and oftenhave bilateral auscultatory findings. Wheezing is com-mon. Radiographs may show bilateral interstitial infiltrates.
Clinicians should remember that stereotypic presen-tations are not always encountered, the categories ofpathogens often cause overlapping clinical features, andthe chest radiograph may not distinguish the pathogensreliably. In addition, simultaneous infection with morethan one agent (eg, bacterial and viral) occurs commonly.
Table 3. Community-acquiredPneumonia: Clues to Causes• Age, season of year• Fever• Extrarespiratory symptoms (eg, headache,
TreatmentTreatment must be directed initially at assessing whetherthe child needs to be admitted to the hospital or canremain at home. Typical indications for hospital admis-sion include very young age (�3 mo) (because suchpatients can deteriorate rapidly and are more prone tohypoxemia and bacteremia), persistent hypoxemia re-quiring supplemental oxygen, complicating factors suchas dehydration or severe vomiting requiring IV fluids,
toxic appearance, or the presence of a serious concomi-tant chronic condition. Children who have none of thesefeatures almost always can be treated as outpatients.
OutpatientChildren in the 3-month to 5-year age group who havepneumonia most commonly have viral infections. Thus,infants and young children who are only mildly ill and
Figure 1. Radiographic findings of viral pneumonia caused byrespiratory syncytial virus: Hyperinflation, mild peribronchialcuffing, increased parahilar markings, and patchy lingularopacity (note the loss of the left heart border on the frontalview), likely representing atelectasis.
Figure 2. Radiographic findings of Mycoplasma pneumonia:Bilateral reticular/nodular interstitial infiltrates, with morefocal patchy alveolar opacity in the right middle lobe, andopacity in the right upper lobe abutting the slightly elevatedminor fissure, indicative of subsegmental right upper lobeatelectasis.
Table 4. Common Clinical Pneumonia Syndromes of ChildhoodSyndrome Typical Cause Age Group Typical Clinical Features
Bacterial (suppurative) Pneumococcus;others
All ages; younger children(<6 y) more common
Abrupt onset, high fever, ill/toxic appearance,more focal findings on examination, chest/abdominal pain, focal infiltrate if CXR isobtained
Atypical—infancy Chlamydiatrachomatis
<3 mo Tachypnea, mild hypoxemia, lack of fever,wheezing, interstitial infiltrates on CXR
Atypical–olderchildren
Mycoplasma >5 y Gradual onset, low-grade fever, diffuseexamination findings, diffuse infiltrates ifCXR is obtained
Viral Multiple viruses All ages; 3 mo to 5 ymore common
Prominent URI symptoms, low-grade or absentfever, diffuse findings/wheezes onexamination, possible diffuse interstitialinfiltrates if CXR is obtained
afebrile and who have diffuse findings on chest examina-tion generally need not receive antimicrobials. Agents areavailable for treating influenza, but there are no specificdata on the efficacy of such drugs in pneumonia, and
there is no consensus for such treatment in the outpatientsetting. For those who are suspected of having bacterialpneumonia, treatment for S pneumoniae is warranted.The first-line agent is amoxicillin, given orally at the doseof 80 to 100 mg/kg per day divided every 8 hours toprovide effective coverage for penicillin-nonsusceptible
Figure 3. Radiographic findings of pneumococcal pneumonia:Rounded area of airspace consolidation in the superior seg-ment of the right lower lobe. A few air bronchograms are seenmedially.
Figure 4. Radiographic findings of pneumococcal empyema:Left lower lobe and lingular consolidation (note loss of the lefthemidiaphragm and lower left heart border) with associatedlarge left pleural effusion tracking up laterally. Volume loss onthe left also indicates a component of atelectasis.
Figure 5. Radiographic findings of necrotizing pneumonia:Airspace consolidation in the right middle lobe with numerouscentral cavities.
Figure 6. Radiographic findings of tuberculosis: Patchy air-space opacity in the right lower lobe and prominence of theinferior aspect of the right pulmonary hilum, consistent withhilar adenopathy, in a child whose purified protein derivativetest result is positive.
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organisms (Table 5). Some clinicians elect to administerone dose of ceftriaxone intramuscularly on the first day toachieve rapidly effective serum concentrations.
Although penicillin-nonsusceptible pneumococcalstrains are present in most communities, high-level resis-tance to beta-lactam antibiotics still is relatively rare, andpenicillins and cephalosporins administered at appropri-ate doses usually are sufficient to treat such organisms.Antibiotics such as vancomycin seldom are required fortreatment of pneumonia. For children who have nontype1 allergy to amoxicillin, a cephalosporin such as cefdinir,cefpodoxime, or cefuroxime may be used. For those whohave a history of type 1 reactions, including hives, ana-phylaxis, and other severe reactions, clindamycin or amacrolide such as azithromycin may be chosen. How-ever, pneumococcal resistance to these last two agents,especially azithromycin, is increasing. Children who donot improve after 48 hours should be reassessed, withconsideration given to performing a chest radiograph torule out a complication of pneumonia such as a para-pneumonic effusion. For children whose pneumonia issuspected of being due to atypical agents, treatment withazithromycin also can be considered.
The atypical organisms M pneumoniae and C pneu-moniae are the most likely potentially treatable patho-gens in children and adolescents 5 to 20 years of age, anda macrolide is the drug of choice. Azithromycin is rec-ommended most often because of its ease of administra-tion, with once-daily dosing for 5 days. For childrenolder than age 8 years, doxycycline is an excellent alter-native. These agents are not ideal for treating S pneu-moniae; hence, children who have an abrupt onset ofsymptoms, ill appearance, high temperature, or focal
pulmonary findings on examination and radiographyprobably should be treated with a beta-lactam antibiotic.The benefits of treating pneumococcal infections andcomplications of nontreatment are well established. Incontrast, the need for antimicrobial treatment of atypicalorganisms is less clear, and complications from nontreat-ment are rare. In some situations, when it is more pru-dent to treat for both bacterial and atypical pneumonia,treatment with two agents (a beta-lactam and a macro-lide or doxycycline) may be the best course of action,given the more severe consequences of inadequatelytreated bacterial pneumonia.
Older adolescents may be treated with fluoroquino-lones, such as levofloxacin or moxifloxacin, which areactive against both S pneumoniae and the organismscausing atypical pneumonia. These antibiotics providesimple, once-daily therapy. Increasing data suggest thatthese agents are safe in children and that they eventuallymay be approved for children younger than age 18 years.Again, there may be clinical situations where treat-ment for bacterial disease with amoxicillin or a cephalo-sporin is more prudent than treating only for atypicalorganisms with azithromycin or doxycycline, given themore severe consequences of inadequately treated bacte-rial pneumonia.
Patients who are suspected of having aspiration pneu-monia, such as children who have seizure disorders orunderlying neuromuscular disease, usually are givenamoxicillin or amoxicillin-clavulanate to treat mouth or-ganisms, including anaerobes. For those who have apenicillin allergy, clindamycin can be used.
The duration of therapy generally should be 7 to10 days, in part depending on the clinical response. If the
Table 5. Antimicrobials Used in OutpatientsAgent Dose (mg/kg per day) Usual Maximum Dose
Amoxicillin 80 to 100 divided BID/TID 1 g TIDCefdinir 14 divided QD/BID 600 mg QDCefuroxime 30 divided BID 500 mg BIDCefpodoxime 10 divided BID 200 mg BIDCeftriaxone 50 mg IM given QD 2 g QDAzithromycin 10 mg QD day 1 500 mg
5 mg QD days 2 to 5OR
250 mg daily
10 mg QD for 3 d 500 mg daily for 3 dDoxycycline 4 mg divided BID 100 mg BIDLevofloxacin (not recommended for children <18 y) 750 mg dailyClindamycin 20 to 40 mg divided TID 600 mg TIDAmoxicillin-Clavulanate 80 to 100 divided BID/TID 2 g BID
QD�once daily, BID�twice a day, TID�three times a day, IM�intramuscular.
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child’s condition deteriorates or does not improve in 2 or3 days, other pathogens should be considered, as shouldthe possibility of a complication such as empyema orabscess. For children who improve with treatment, re-peat chest imaging is not recommended unless therehave been previous episodes of pneumonia (in whichcase, additional images are obtained to ascertain thatthere are no anatomic or functional abnormalities toaccount for recurrent infections).
InpatientAs noted previously, although most children diagnosedwith pneumonia can be treated as outpatients, there areinstances in which hospitalization may be recommended.Infants between 3 weeks and 3 months of age whohave pneumonia typically are admitted to the hospital,especially if they have fever, hypoxia, respiratory distress,or dehydration. Older infants, children, and adolescentswho present with signs of ongoing respiratory distress,including tachypnea, grunting, increased work of breath-ing, or hypoxemia, should be admitted, as should chil-dren who are significantly dehydrated or highly febrileand toxic in appearance. Other children for whom ad-mission should be considered include those who haveunderlying cardiac, pulmonary, metabolic, immuno-logic, hematologic (especially sickle cell disease), orneoplastic disease. In addition, children who worsenclinically despite appropriate outpatient therapy, in-cluding those who develop complications of pneumoniasuch as parapneumonic effusion or lung abscess, shouldbe hospitalized.
When children are admitted to the hospital, chestimaging and laboratory tests should be performed, in-
cluding CBC, blood culture, and a chemistry panel. It isimportant to attempt to determine the causative patho-gen(s) to optimize antimicrobial therapy. For childrenwho are able to expectorate, sputum should be obtainedand tested for bacterial pathogens. A rapid diagnostic testperformed on nasopharyngeal secretions can lead to atimely diagnosis of the major viral respiratory tract patho-gens, with confirmation using traditional viral culture. Inmost clinical settings, the presence of Mycoplasma,Chlamydophila, and Legionella can be determined sero-logically; Legionella and pneumococcal infections aredetectable with urine antigen tests.
Hospital management includes basic supportive care.Supplemental oxygen, suctioning, IV fluids, analgesics,and antipyretics should be administered as needed. Vitalsigns should be monitored and serial examinations per-formed.
The choice of antibiotic depends on the clinical sce-nario (Table 6). Infants younger than 3 months of agewho have an illness suggestive of the atypical pneumoniasyndrome of infancy (tachypnea, mild hypoxemia, ab-sence of fever, and interstitial infiltrates on chest film)should be treated with a macrolide antibiotic. Azithro-mycin generally is recommended because of the once-daily dosing schedule. Initial empiric coverage for pneu-mococcus with a broad-spectrum antibiotic, such asceftriaxone, is recommended if suppurative pneumonia(based on toxic appearance, leukocytosis, radiographicfindings) is a concern.
For older infants and children, pneumococcus is themajor pathogen of concern, and treatment with ceftriax-one or ampicillin is appropriate. These drugs also areeffective against group A Streptococcus. Children who
Table 6. Antimicrobials Used for Inpatients
Agent IV Dose (mg/kg per day)Usual MaximumDaily Dose
Ceftriaxone 50 2 gAmpicillin 200 divided QID 12 gVancomycin 40 to 60 divided BID 3 to 4 gClindamycin 30 to 40 divided TID 2.7 gLevofloxacin Not recommended for children 750 mgAzithromycin 10 day 1 500 mg
5 days 2 to 5 250 mgDoxycycline Not recommended for children 200 mgNafcillin/Oxacillin 200 divided q 6 h 12 gLinezolid 30 divided TID <12 y; 20 divided BID >12 y 600 mg BIDAmpicillin-Sulbactam 200 ampicillin component divided q 6 h 12 gPiperacillin-Tazobactam 300 piperacillin component divided q 6 h 16 gMeropenem 60 divided q 8 h 3 g
IV�intravenous, QID�once daily, BID�twice a day, TID�three times a day.
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have more fulminant or extensive disease, characterizedby rapid onset of large pleural fluid collections or pneu-matoceles, and children who have failed treatment witheffective antipneumococcal therapy generally should betreated with broader-spectrum agents, such as clinda-mycin or vancomycin, that provide good coverage forS aureus (including methicillin-resistant S aureus [MRSA])in addition to S pneumoniae and group A Streptococcus.Children who have aspiration pneumonia may be treatedwith ampicillin, ampicillin-sulbactam, or clindamycin.
Pneumonia caused by atypical agents usually is treatedwith a macrolide, most commonly azithromycin becauseof its once-daily dosing schedule and availability for IVtreatment. This agent also covers Legionella, a rare butpotentially serious cause of childhood pneumonia. Forchildren older than age 8 years, doxycycline can be usedfor Mycoplasma and Chlamydia. Older teens may begiven levofloxacin, which is active against pneumococ-cus, Mycoplasma, Chlamydophila, and Legionella. In someinstances, therapy with two agents may be warranted (eg, amacrolide combined with a beta-lactam agent).
The length of therapy for children hospitalized withpneumonia that otherwise is uncomplicated depends onthe clinical course. Once the child is afebrile and clinicallystable, oral therapy should be sufficient, using the agentsoutlined in Table 5, for a total duration of 7 to 10 days(5 days for azithromycin because of its long half-life).Follow-up radiographs generally are not recommendedfor children who have had good clinical responses.
ComplicationsMajor suppurative complications of pneumonia includeparapneumonic effusion, lung abscess, and necrotizingpneumonia. Necrotizing pneumonia is a rare complica-tion of bacterial pneumonia in which liquefaction andnecrosis of lung tissue is caused by toxins of highlyvirulent organisms. Children who have this complicationgenerally appear very ill. Routine imaging and chestcomputed tomography scan reveal a characteristic radio-graphic appearance. Treatment consists of a long course(typically 4 weeks) of antibiotics, usually administeredparenterally. If no pathogen is identified, therapy gener-ally should include coverage for S pneumoniae, groupA Streptococcus, and S aureus, with vancomycin or clin-damycin being first-line choices.
Lung abscess is diagnosed based on characteristicchest imaging showing a thick-walled cavity with anair-fluid level in a child who has symptoms of pneumonia.Abscesses in the lung typically develop following anaspiration event, sometimes related to a seizure or under-lying neuromuscular disease. Frequently involved mi-
crobes are mouth organisms, including Streptococcus andanaerobes; S aureus and gram-negative rods also may beinvolved. Tuberculosis always should be considered andan appropriate evaluation undertaken, including apply-ing a skin test and obtaining acid-fast bacilli sputumsmears and cultures. Treatment of lung abscess may beempiric, using clindamycin or another antibiotic effectiveagainst anaerobic organisms. However, needle aspirationof the abscess to obtain culture specimens often is rec-ommended, especially in children who have underlyingdisorders or who do not respond to initial empiric ther-apy. Duration of treatment generally is several weeks,depending on the rapidity of the response and the radio-graphic resolution of the process; treatment may includea combination of parenteral and oral antibiotics.
In contrast to the previously noted complications, thedevelopment of simple sterile parapneumonic effusionsin association with bacterial pneumonia is common.With therapy directed against the causative organism,such sympathetic effusions typically resolve without ad-ditional intervention. However, purulent effusions with aresultant empyema have become increasingly common.Children who have empyema typically present with per-sistent fever, diminished appetite, fatigue, chest pain, andsome degree of respiratory distress. This may representthe initial presentation to the clinician for some children;in others, this picture develops over time while the childis receiving medical care and antibiotics. Affected chil-dren usually appear ill, with fever and tachypnea, andoften with chest pain and splinting. Physical examinationfindings are striking, including dullness to percussionand markedly diminished air movement.
Imaging studies guide the clinical management ofchildren who have parapneumonic effusions. Plain radio-graphs establish the diagnosis of an effusion, and decub-itus views can help in determining whether the fluid isfree-flowing, typical of an early effusion, or loculated.Ultrasonography often can determine the location,quantity, and quality of fluid (eg, thickness, fibrinousstreaking, and presence of loculations) and identify anoptimal location for chest tube insertion. Chest com-puted tomography scan can complement ultrasono-graphic evaluation and may enhance anatomic detail, butis not necessary in planning management.
Pleural fluid ideally should be analyzed before antibi-otics are administered, but it is unusual for children whohave significant effusions not to have received antibiotictherapy before pleural fluid is obtained. Children whohave small, free-flowing effusions should be given a trialof antibiotics before considering a pleural fluid aspirationto see if the effusion resolves. When obtained, pleural
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fluid should be sent for Gram stain and routine andanaerobic culture; cell count and differential count; pH,glucose concentration, and lactate dehydrogenase mea-surement (to help differentiate a transudate from anexudate); rapid antigen detection for pneumococcus;specific and broad-range polymerase chain reaction test-ing for bacterial pathogens (if available); acid-fast bacillusand fungal culture (if indicated); and cytology if malig-nancy is under consideration (eg, based on absence offebrile illness or mass on chest radiograph).
The approach to surgical intervention for infectedparapneumonic effusions has been controversial, with avariety of methods advocated. Most institutions havedeveloped their own preference, depending, in part, onthe local experience and expertise. Options include med-ical management alone or in combination with thora-centesis, chest tube drainage, video-assisted thorascopicsurgery (VATS) with chest tube drainage, intrapleuralfibrinolytic therapy, and thoracotomy. A recent meta-analysis of studies in children showed that those receivingprimary operative therapy (usually VATS) had a lowermortality rate, length of hospitalstay, and duration of antibiotictherapy compared with thosetreated with antibiotics and thora-centesis or tube drainage alone.
Intrapleural fibrinolytic ther-apy has been promoted as a possi-ble approach in centers whereVATS procedures are not avail-able. Data showing benefit fromthis procedure have been less im-pressive than the results of VATS, and a recent large study inadults demonstrated no benefit to patients who receivedintrapleural fibrinolytic therapy via chest tube comparedwith those who received intrapleural saline.
Based on these observations, one practical approachto surgical management of significant pleural effusions isto perform a simple thoracentesis under anesthesia inchildren whose imaging studies suggest free-flowingfluid. This procedure is undertaken for diagnostic andtherapeutic reasons, with removal of as much fluid aspossible and (usually) insertion of a chest tube. If thefluid is purulent or loculated, VATS then can be per-formed; otherwise, VATS can be delayed while awaitingclinical response to chest tube drainage. For children inwhom noninvasive studies suggest more complex locu-lated effusions, VATS may be carried out initially. TheVATS procedure also allows for lung biopsy in caseswhere the diagnosis is uncertain or the child is notresponding to treatment.
Supportive care of children who have parapneumonicdisease includes antipyretics, fluids, analgesia, and oxy-gen, if required. Chest physical therapy is not recom-mended, and bronchodilator therapy generally is contra-indicated because it may worsen ventilation/perfusionmismatch by opening up nonperfused areas of the lung.
Antibiotic therapy is tailored to the characteristics ofthe patient, the local microbial epidemiology, and theresults of microbiologic studies. In general, coverage forpneumococcus and S aureus is warranted; anaerobes andgram-negative rods typically are not involved in empy-ema in otherwise healthy children.
Potential empiric agents include ceftriaxone, often incombination with clindamycin or vancomycin. Vanco-mycin has the best activity against pneumococcus andMRSA, but does not achieve as high tissue concentra-tions as others and does not convert to an oral equivalentonce parenteral therapy is stopped. Ceftriaxone is notideal for methicillin-sensitive S aureus and is ineffectiveagainst MRSA, but is the easiest to administer and has along and successful track record in treating serious pneu-
mococcal infections, including strains that are penicillin-nonsusceptible. Clindamycin is active against moststrains of pneumococcus and S aureus, including some,but not all, strains of MRSA.
The duration of antibiotic therapy is not definedclearly. Following chest tube drainage or VATS, contin-uation of IV treatment (with adjustments based on sus-ceptibility data) generally is recommended until the pa-tient has been afebrile for a few days, followed by 2 weeksof high-dose oral therapy. Long-term parenteral therapyfor children who undergo VATS typically is not required.
Recurrent PneumoniaRecurrent pneumonia is defined as more than one radio-graphically confirmed episode in a year or more thanthree episodes in a lifetime (with clinical or radiographicresolution between episodes). In general, the differentialdiagnosis includes anatomic lesions such as vascularrings, cysts, and pulmonary sequestration; respiratory
For children in whom noninvasive studiessuggest more complex loculated effusions,video-assisted thorascopic surgery may becarried out initially.
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tract disorders such as cystic fibrosis, gastroesophagealreflux, and aspiration; and immunologic disorders suchas human immunodeficiency virus (HIV) infection,chronic granulomatous disease, and hypogammaglobu-linemia. In clinical practice, asthma is the most commonlung disease for which children receive multiple coursesof antibiotics (and are labeled as having recurrent pneu-monia), but the radiographic changes that frequently aremistaken for pneumonia in such children usually repre-sent areas of atelectasis. Most children whose recurrentpneumonia has been documented should be referred to aspecialist for additional evaluation. Depending on the clin-ical scenario, referral to a pulmonary, infectious disease, orimmunology/allergy specialist may be appropriate.
PreventionPrevention of pneumonia can save lives and money. Aswith any type of infection that is spread by droplet orcontact transmission, good hand washing along withgood personal respiratory hygiene (including wearing amask around others and covering one’s mouth and noseduring sneezing and coughing) are important. Breastfeed-ing and limiting exposure to ill individuals are helpful.
Immunization of young children with Hib, pertussis,and heptavalent pneumococcal vaccines is very impor-tant. Although recent serotype shifts have increased theprevalence of pneumococcal strains not contained in thisvaccine in the community, the vaccine remains very effectivein decreasing invasive bacterial disease. Recent studies fromAfrica have demonstrated a reduction in viral pneumonia inrecipients of pneumococcal vaccine. Children older thanage 2 years at high risk for pneumococcal disease, such asthose who have sickle cell disease, chronic heart or lungdisease, HIV disease, or diabetes mellitus, also should re-ceive the 23-valent pneumococcal polysaccharide vaccine.Because viral infections usually are either the direct cause ofpneumonia or predispose children to infection with bacte-rial or atypical pathogens, immunization against influenza isparticularly helpful. Finally, prevention of exposure to cig-arette smoke can decrease the occurrence of pneumonia inboth infants and their parents.
SummaryPneumonia in children and adolescents, although com-mon, is encountered less frequently than are other lowerrespiratory tract illnesses such as bronchiolitis andasthma. Findings on the history and physical examina-tion are sufficient to diagnose pneumonia in most cases,with the clinical hallmarks of fever, cough, tachypnea,increased work of breathing, and auscultatory abnormal-ities being most important. Radiographic and laboratory
studies, although helpful in some cases, often are notneeded. Uncomplicated pneumonia in children usuallycan be treated on an outpatient basis, with season and agegroup typically informing the decision about antibioticchoice, if any. Young infants, more severely ill patients,and those who have complications such as pleural effu-sions require laboratory and radiographic studies andaggressive hospital treatment. Prevention of pneumoniais paramount in children and adolescents and includesimmunization, avoidance of cigarette smoke, and goodhand washing and personal hygiene practices.
ACKNOWLEDGMENTS. The authors thank Dr JosephMakris for providing the radiographs and their descriptions.
Suggested ReadingAlario AJ, McCarthy PL, Markowitz R, et al. Usefulness of chest
radiographs in children with acute lower respiratory tract dis-ease. J Pediatr. 1987;111:187–193
Avansino B, Goldman B, Sawin R, et al. Primary operative versusnon-operative therapy for pediatric empyema: a meta-analysis.Pediatrics. 2005;115:1652–1659
Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelinesfor the management of pleural infection in children. Thorax.2005;60:1–21
Community Acquired Pneumonia Guideline Team, CincinnatiChildren’s Hospital Medical Center. Evidence-based guide-line for medical management of community-acquired pneu-monia in children 60 days to 17 years of age. Guideline 14,pages 1–16, December 22, 2005. Available at: http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/pneumonia.htm.
Hazir T, Fox LM, Nisar YB, et al. Ambulatory short-course high-dose amoxicillin for treatment of severe pneumonia in children:a randomized equivalency trial. Lancet. 2008;371:49-56
Kaplan KA, Beierle EA, Faro A, et al. Recurrent pneumonia inchildren: a case report and approach to diagnosis. Clin Pediatr.2006;45:15–22
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious DiseasesSociety of America/American Thoracic Society consensusguidelines on the management of community-acquired pneu-monia in adults. Clin Infect Dis. 2007;44(suppl 2):S27–S72
Margolis P, Gadomski A. Does this infant have pneumonia? JAMA.1998;279:308–313
McIntosh K. Community-acquired pneumonia in children. N EnglJ Med. 2002;346:429–437
Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinicalcharacteristics of community-acquired pneumonia in hospital-ized children. Pediatrics. 2004;113:701–707
Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book:2006 Report of the Committee on Infectious Diseases. 27th ed. ElkGrove Village, Ill: American Academy of Pediatrics; 2006
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PIR QuizQuiz also available online at www.pedsinreview.org.
1. Which of the following statements regarding pneumonia in children is true?
A. A specific microbial pathogen usually can be identified.B. All children who have pneumonia should be hospitalized for observation and treatment.C. Pneumonia is a rare cause of child mortality worldwide.D. Radiographs of the chest always should be obtained to determine the cause.E. Viral agents are the most common causes of pneumonia in older infants and young children.
2. You are evaluating an 8-year-old boy who has a 7-day history of malaise and worsening cough. His motherreports that he has had a low-grade subjective fever. Physical examination reveals a well-appearing boywhose respiratory rate and pulse oximetry findings are normal. His lung examination documents bilateralcrackles without wheezing. A chest radiograph shows bilateral interstitial infiltrates without effusion. Ofthe following, the most likely pathogen is:
3. An 8-week-old girl is brought to the emergency department because of increased work of breathing for thepast day. She has a temperature of 101.1°F (38.4°C) and has had difficulty breastfeeding because ofsignificant nasal congestion. Her respiratory rate is 70 breaths/min and pulse oximetry is 90% on room air.Lung examination reveals bilateral wheezes and crackles, and a chest radiograph shows increased perihilarmarkings bilaterally and a right middle lobe opacity. Of the following, the most likely cause of hersymptoms is:
A. Adenovirus.B. Bordetella pertussis.C. Chlamydia trachomatis.D. Group B Streptococcus.E. Respiratory syncytial virus.
4. A previously healthy 5-year-old girl is admitted to the hospital because of a temperature of 104°F(40.0°C), hypoxia, respiratory distress, and findings on a chest radiograph consistent with left lower lobepneumonia. She is believed to have infection with S pneumoniae and is placed on intravenous ceftriaxoneand maintenance fluid hydration. After 2 days of therapy, she remains febrile and complains of increasedleft chest pain and shortness of breath. Of the following, the most likely explanation for her symptoms atthis time is:
A. Aspiration of anaerobic organisms from the mouth.B. Concurrent presence of a viral infection.C. Development of an empyema.D. Inappropriate microbial therapy for S pneumoniae.E. Infection with M tuberculosis rather than S pneumoniae.
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5. You are seeing a 4-year-old girl who has had a fever to 103.5°F (39.8°C), cough, and decreased appetitefor 3 days. She is well hydrated and appears tired, with a pulse oximetry of 95% on room air. She has anormal respiratory rate but a frequent cough during the examination. Her lung examination reveals focalcrackles in the right lower lobe, with mild dullness to percussion. She is able to tolerate oral fluids in youroffice, and she has no drug allergies. Of the following, the most appropriate management of this girl’sillness is:
A. Hospitalization and intravenous clindamycin.B. Hospitalization and intravenous vancomycin.C. Outpatient treatment with high-dose oral amoxicillin.D. Outpatient treatment with oral azithromycin.E. Placement of a tuberculin skin test and isolation until results are known.
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