PNEUMONIA

Neonates to adolescents
 WHAT IS PNEUMONIA?
Infection of the lower respiratory tract
that involves Inflammation of the
alveolar space and surrounding tissues,
often compromising air exchange
Single greatest cause of death in children
worldwide
Annual incidence 3-4 cases per 100 children
<5 years old

WHO defines pneumonia as cough or difficulty

breathing and age-adjusted tachypnea

The way that pneumonia presents clinically can

significantly differ based on the age and
etiology of the pneumonia
 RISK FACTORS
Lack of immunization Abnormal mucociliary
Group daycare clearance
Older siblings Other serious illnesses
Recent URI Gastroesophageal reflux
Smokers in the house
Premature Aspiration (neuro impairment)
Failure to thrive / malnourished Immunocompromised states
Reactive airway disease / Chronic lung disease
asthma (severity) Anatomic abnormalities of the
respiratory tract
Hospitalization (esp. w/
invasive procedures)
 COMPLICATIONS
Pulmonary
Pleural effusion / empyema
Pneumothorax
Lung abscess
Bronchopleural fistulas
Necrotizing pneumonia
Acute respiratory failure

Metastatic
Meningitis, pericarditis, endocarditis, osteomyelitis, septic arthritis

Systemic
Sepsis
 WHO GETS HOSPITALIZED?
Infants less than 3 to 6 months with suspected bacterial CAP will
benefit from hospitalization

Children and infants with moderate/severe CAP (resp. distress /

hypoxemia) OR suspected pathogen with increased virulence
(community-associated MRSA)

If you are concerned careful observation is not available at home or pt. is

unable to follow up or comply with therapy
SIGNS OF RESPIRATORY DISTRESS
1.Tachypnea *
Age 0-2 months: >60
Age 2-12 months: >50
Age 1-5 years: >40
Age >5 yeras: >20
2.Dyspnea
3.Retractions (suprasternal,
intercostal, subcostal)
4.Grunting
5.Nasal flaring
6.Apnea
7.Altered mental status
8.Pulse ox <90% on room air
9.Tripod position
 ANATOMICAL SUBTYPES

Lobar Bronchopneumonia Interstitial Miliary

typical Innflammation patchy / diffuse multiple discrete

many bacteria centered in inflammation necrotizing lesions
Consolidation in1+ bronchioles involving interstitium spread via
lobes Mucopurulent lymphocytes + bloodstream
vascular congestion exudates blocks the macrophages immunocompromise
edema small airways alveoli do not have d
fibropurulent patchy consolidation exudates CMV, herpes, VZV
exudate of adjacent lobes protein-rich hyaline
strep pneumo membranes
viral / atypical

Infectious etiology (bacterial, viral, atypicals, fungal, etc.) ***

Non-infectious etiology (near drowning, systemic disease, inflammatory pneumonitis)
 WHAT TO ASK
Demographics
Fever
Recent URI
Associated symptoms (cough, dyspnea, chest pain etc.)
Duration of symptoms
Immunization status, TB exposure
Maternal chlamydia / group B strep status during pregnancy
Choking episodes
Previous episodes
Previous antibiotics
 WHAT ELSE TO CONSIDER
Noninfectious pulmonary disease
Asthma
Gastric aspiration
Foreign body aspiration
Atelectasis
Congenital malformations
CHF
Malignancy
Interstitial lung disease
collagen diseases
Neoplasm
 NEONATES
0 4 weeks old

Group B streptococcus
Chlamydia trachomatis
Gram negative rods
Listeria monocytogenes

E. coli now MCC in very low birth weight infants

Can be viral, but much less common. If viral RSV and more likely in
preemie who had less transfer of immunoglobulins from mom
 NEONATES
0 4 weeks old

Tachypnea, resp. distress signs esp. grunting

Fever may not be present in newborns but temperature instability

(hypothermia)

Nonspecific complaints are more common poor feeding,

inconsolable, irritability

Cough may be absent in the newborn period

 If onset is within hours of birth to <1week likely part
of a generalized SEPSIS from congenital infection
Respiratory distress shock death
Broad spectrum Abx organism specific ASAP

Chest x-ray, pulse oximetry, blood cultures, gram stain +

culture of tracheal aspirates
Full sepsis workup

IV Ampicillin + Gentamicin +/- Vancomycin (MRSA)

10-21 days (treats sepsis plus pneumonia)
 CHLAMYDIAL PNEUMONIA
Exposure during delivery 2 weeks 4 months
+/I history of conjunctivitis
Usually not critically ill but are tachypneic
Staccato cough
Afebrile and no wheezing *** helps to distingish from RSV
CBC = Eosinophilia
Chest xray = Bilateral interstitial infiltrates + hyperinflation

Treatment erythromycin / azithromycin

6 week old male
w/ wheezing
Chlamydia
trachomatis
pneumonia
- Diffuse
interstitial
infiltrates
- hyperinflation
 OTHER SIGNS TO LOOK FOR
Toddlers + Older children +
Infants
Preschool adolescents
cough congestion headache
history of URI vomiting pleuritic chest
symptoms chest pain pain
wheezing abdominal vague abdominal
pain/tenderness pain
vomiting
diarrhea
pharyngitis
otitis
 RSV
Human metapneumovirus
Infants/Toddle Parainfluenza
rs VIRAL
Influenza A + B
2 months - 2 (80%)
Rhino, Entero, Adeno
years
S. Pneumoniae
C. trachomatis

(same viruses as
above)
Preschool VIRAL + S. Pneumoniae
(2 -5 years) BACTERIAL
M. Pneumoniae
H. Flu (nontypable)

M. Pneumoniae
School aged to
BACTERIAL + S. Pneumoniae
adolescents
ATPICAL C. Pneumoniae
(5+ years)
MRSA
 VIRAL PNEUMONIA
More often associated with cough or wheezing

Fever less common than with bacterial

Chest x-ray: diffuse, streaky infiltrates of bronchopneumonia / interstitial

pneumonia

WBC count: low, normal, or mildly elevated + lymphocytes

 VIRAL PNEUMONIA
RSV
Parainfluenza
Influenza
Adenovirus

KEY WORDS: insidious, low grade fever, wheeze, URI symptoms, mild dyspnea

Initial test: chest x-ray

Accuracy: resp. secretions or antigen isolation

Depends: Tamiflu for influenza, Ribavirin for RSV

If suspected bacterial co-infection, treat with high dose amoxicillin
RSV pneumonia in a
1.5 year old male
VIRAL BACTERIAL CO-INFECTION
 BACTERIAL PNEUMONIA
More often associated with high fever, cough, dyspnea, chills

Ausculatory findings more common rales, dullness to percussion,

diminished breath sounds

Chest x-ray: lobar consolidation +/- pleural effusion

WBC count: markedly elevated >20,000/mm3 + neutrophils

HIGH FEVER + TACHYPNEA + COUGH = hallmarks of community

acquired pneumonia
 2 months - 5
TREATMENT
>5 years
years BACTERIAL PNEUMONIA
S. Pneumoniae
Inpatient: Inpatient:
Hib
IV Cefuroxime 10-14 days plus IV Cefuroxime 10-14 days plus
Erythromycin po/IV for 10-14 S. aureus /Azithromycin
days po/IErythromycinV for 10-14 days

KEY WORDS: rales, rhonchi, high fever, productive cough, severe, acute,
decreased breath sounds, chest pain, dyspnea
OUTPATIENT: OUTPATIENT:
Initial:
high chest-xray 7-10 days
dose Amoxicillin Azithromycin (z-pack)

Accuracy: sputum culture + sputum, pleural fluid culture, blood culture

Strep. Pneumo in
a 5.5 yo F
- Left sided back
pain and fever
 ATYPICAL (WALKING)
PNEUMONIA
Mycoplasma pneumoniae & Chlamydophila pneumonia
Hacking cough
Sore throat
headache
+/- nonspecific rash
Long incubation period

Chest x-ray: interstitial, usually lower lobes. Looks worse than patient

KEY WORDS: insidious, URI symptoms with cough that worsens over weeks, rales are
most common physical finding

TREATMENT: Macrolide antibiotics 7-10 days (or ciprofloxacin)+ hydration, bed rest,
antipyretics
 Mycoplasma
pneumonaie
Alveolar
consolidation
in LLL and RLL
 DIAGNOSIS
Clinical diagnosis
Tachypnea is the most important clinical sign (must be counted over 1 full
minute)
In febrile children, look for chest retractions, grunting, nasal flaring, crepitation's
Hydration status, activity level, and oxygen saturation are important and may
indicate the need for hospitalization

Chest x-ray is confirmatory (for the boards)

u/s may be replacing this in the future (sensitivity=86%; specificity=89%)
 (IN PRACTICE) WHEN DO WE DO
A CHEST X-RAY?
Severe infection
Diagnosis is otherwise inconclusive
Complications of pneumonia unresponsive to treatment (pleural effusion,
empyema)
Exclude other causes of dyspnea (heart failure, foreign body aspiration,
etc.)
To exclude pneumonia in an infant less than 3 months with a fever

The chest x-ray is often NORMAL in early pneumonia

 Prevention
APA GUIDELINES
Children should be vaccinated for bacterial pathogens S. pneumo, Hib,
pertussis to prevent CAP
All infants 6 months or older + adolescents should be given the influenza vaccine
yearly
Parents and caretakers (incl. pregnant adolescents) of infants younger than 6
months should be vaccinated for influenza and pertussis to protect infants from
exposure
High risk infants should be provided immune prophylaxis with RSV-specific
monoclonal antibody to decrease risk of severe RSV pneumonia

Diagnosis
Chest x-ray IF resp. distress present, documented hypoxemia, or failed initial abx
therapy
For outpatient simple CAP, routine chest x-rays are not recommended to confirm
CAP, treat empirically
CBC and blood cultures also not recommended
 TREATMENT
APA GUIDELINES
Amoxicillin is first line therapy for bacterial pneumonia
Stronger antibiotics are often not needed
Should consider MRSA in cases of pneumonia where first-line treatment fails

Overtreatment is a critical concern

Most cases of pneumonia in preschool-aged children are VIRAL in origin and
will not develop into life-threatening bacterial pneumonia!
 SPECIAL POPULATIONS
Immunocompromised
Mycobacteria (m. avium complex)
Fungi (aspergillosis, histoplasmosis) esp. post antibiotic use
Viruses (CMV, herpes, VZV, adenovirus)
Pneumocystis jirovecii pneumonia
Gram negative enteric bacteria TB pneumonia *
High index of suspicion
1-6 months post primary
CF infection
Infancy S. aureus Travel / exposure history
>1 year Pseudomonas

Sickle cell patients

Encapsulated organisms (S. pneumoniae, Hib, mycoplasma)
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