PneumoniaBacterial

Basics
DESCRIPTION
Acute infection of the pulmonary parenchyma, which is associated with consolidation of alveolar spaces
EPIDEMIOLOGY
Incidence
Highest incidence in children <5 years of age (annual incidence 34%)
RISK FACTORS

Asthma

Cystic fibrosis

Sickle cell anemia

Cerebral palsy

Immunocompromised status

Altered mental status

Tracheoesophageal fistula

Congenital pulmonary malformations

Bronchopulmonary dysplasia

Seizure disorder

ETIOLOGY
Etiology of bacterial pneumonia differs by age:

Neonates: Group B streptococcus, Enterococcus, Listeria monocytogenes, Escherichia coli,

Ureaplasma urealyticum

13 months: Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Bordetella

pertussis, Chlamydia trachomatis, U. urealyticum

4 months to 4 years: S. pneumoniae, S. aureus, H. influenzae

>5 years of age: S. pneumoniae, Mycoplasma pneumoniae, Mycoplasma tuberculosis

Diagnosis
SIGNS AND SYMPTOMS
History

Fever and/or chills

Rapid breathing is a sensitive, but nonspecific finding in bacterial pneumonia.

Difficulty breathing or shortness of breath is common and can lead to difficulty feeding in infants.

Cough is often seen in bacterial pneumonia. B. pertussis pneumonia often presents after a catarrhal
phase with a paroxysmal cough and posttussive vomiting.

Pleuritic chest pain

Abdominal pain and/or vomiting: Lower-lobe pneumonia can present with abdominal pain.

Irritability, lethargy, and/or malaise

Poor feeding or apnea in young infants

Birth history, including maternal infections (e.g., C. trachomatis can be transmitted to an infant through
a mothers genital tract at delivery)

Immunization status: In a fully immunized child, H. influenzae type B, B. pertussis, and S.

pneumoniae infections are less common.

Recent history of upper respiratory tract infection (URI) can predispose to bacterial pneumonia.

History of repeated bacterial infections suggest immunodeficiency or cystic fibrosis, which are risk
factors for bacterial pneumonia.

Exposure to contacts with pertussis, tuberculosis, or history of recent travel:

1. Travelers, health care workers, and persons working in prisons or institutional settings are
at greater risk for tuberculosis.

Physical Exam

Ill appearance:
1. General examination can range from mildly ill- appearing to toxic in appearance.
2. Infants may have a paucity of exam findings disproportionate to their appearance and
tachypnea.
3. Patients can be dehydrated or in shock.

Fever:
1. Most children with bacterial pneumonia have fever.
2. Patients with atypical bacterial pneumonia and pertussis are sometimes afebrile.

Tachypnea or increased work of breathing: Nasal flaring, grunting, and/or retracting

Decreased oxygen saturation; therefore, oxygen saturation should be obtained by pulse oximetry in
children with tachypnea or other signs of distress.

Localized rales, rhonchi, decreased breath sounds, or wheezing:

1. These are all significant clinical findings of pneumonia. Crackles suggest the diagnosis of
pneumonia.
2. With increasing consolidation, dullness to percussion and decreased breath sounds may be
noted.
3. In patients who are actively wheezing, it may be difficult to distinguish rales from other
auscultated sounds.

TESTS

Not indicated for patients with uncomplicated pneumonia

In toxic-appearing infants, blood, urine, and CSF cultures (i.e., a sepsis work-up) should be
considered.

LABORATORY

Blood culture:
1. Not usually indicated in healthy children with uncomplicated pneumonia
2. Rarely leads to identification of pathogen causing pneumonia
3. Should be obtained in toxic-appearing patients and infants <1 month old
4. Bacteremia has been noted in up to 30% of patients with pneumococcal pneumonia.

Elevated peripheral WBC or range 15,00040,000/mm 3 is associated with bacterial pneumonia, but
should not be relied upon to distinguish etiology of pneumonia.

Cold agglutinin test:

1. A positive test suggests M. pneumoniae. This test is usually not indicated because empiric
treatment of this pathogen is typically safe and effective.

Purified protein derivative (PPD) test: Should be obtained in all patients in whom M. tuberculosis is
suspected

IMAGING

Chest radiograph (CXR), upright:

1. A CXR is not required for diagnosis if clinical symptoms and examination findings are
consistent with pneumonia.
2. A CXR is typically obtained if pneumonia is suspected but clinical findings are unclear, if the
patient has evidence of respiratory distress and if a complication, (e.g., a pleural effusion) is
suspected, or if the patient is not responding to treatment.
3. Characteristic CXR patterns include alveolar or lobar infiltrate with air bronchograms.
Round infiltrates may be seen with S. pneumococcus. Diffuse interstitial infiltrates and
hyperinflation may be seen with atypical pneumonia such as M. pneumoniae or chlamydial
pneumonias.
4. More commonly, CXR cannot be reliably used to distinguish between viral and bacterial
disease.
5. An infiltrate may not be seen (negative CXR) if the disease is diagnosed early or if the
patient is dehydrated.

CXR, lateral decubitus: More sensitive than an upright radiograph in detecting pleural effusions or
foreign body aspiration

Computed tomography (CT) scan: Not recommended as 1st-line imaging for suspected pneumonia.
CT is mainly used as adjunct imaging for patients who are worsening (not improving) despite
treatment, or have complications.

DIAGNOSTIC PROCEDURES
If diagnosis is unclear, consider the following:

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage or lung biopsy

Thoracentesis if plural fluid is present

For empyema, drainage by aspiration or chest tube may be required.

DIFFERENTIAL DIAGNOSIS

Infectious:
1. Sepsis
2. Viral pneumonia:

In infants: Cytomegalovirus (CMV), herpes simplex virus (HSV)

From 1 month3 months: CMV, respiratory syncytial virus (RSV)

From 4 months to 4 years: RSV, adenovirus, influenza

3. Bronchiolitis
4. URI
5. Croup (laryngotracheobronchitis)
6. Fungal infection
7. Parasitic infection

Pulmonary:
1. Asthma
2. Atelectasis
3. Pneumonitis (i.e., chemical)
4. Pneumothorax
5. Pulmonary edema
6. Pulmonary hemorrhage
7. Pulmonary embolism

Congenital:
1. Pulmonary sequestration
2. Congenital cystic adenomatoid malformation

Genetic: Cystic fibrosis

Tumors:
1. Lymphoma
2. Primary lung tumor
3. Metastatic tumor

Cardiac: CHF

GI: Gastroesophageal reflux disease

Miscellaneous:
1. Foreign body aspiration
2. Sarcoidosis

Treatment
GENERAL MEASURES
Outpatient: Empiric treatment:

Unlike adults, there is no validated tool to identify those patients at low risk who can be treated as
outpatients. In general, neonates should be managed as inpatients.

24 months; if afebrile:
1. Erythromycin: 50 mg/kg/d divided q6h or for infants <6 weeks consider azithromycin 10
mg/kg/d 1 day then 5 mg/kg/d 4 days due to concerns regarding hypertrophic pyloric
stenosis
2. If febrile, hypoxic, or dehydrated, then admit (see FAQ)

5 months to 5 years:
1. Amoxicillin 80100 mg/kg/d divided q812h
2. Consider for additional coverage of H. influenzae, nontype B:

Amoxicillin/clavulanate 2545 mg/kg/d divided b.i.d. or t.i.d.

Cefuroxime 30 mg/kg/d divided b.i.d., cefprozil 30 mg/kg/d divided

b.i.d., cefdinir 14 mg/kg/d divided daily or b.i.d., or cefpodoxime 10 mg/kg/d
divided b.i.d.

May consider use of ceftriaxone50 mg/kg intramuscular (IM) to initiate therapy

For penicillin-allergic patients, may use macrolide or cephalosporin

3. Age >5 years (unless organism other than atypical pathogen suspected; atypical pathogens
are much more common in this age group):

Erythromycin 3050 mg/kg/d divided q6h to q8h or other macrolide

Azithromycin 10 mg/kg/d 1 day (max dose 500 mg) then 5 mg/kg/d (max dose
250 mg) 4 days

May consider doxycyline 4 mg/kg/d divided by 2 doses in patients 9 years of age

or older. Not to exceed 200 mg/d.

May consider fluoroquinolones in patients 16 years of age

4. If specific pathogen is known or suspected, use appropriate antibiotic therapy.

5. For patients with more severe disease, may consider combining -lactam antibiotic and
macrolide

Inpatient:

Oxygen as needed to keep oxygen saturations >9495%

Intubation and positive pressure ventilation if clinically indicated

Empiric antibiotic treatment:

1. <1 month:

Ampicillin 200 mg/kg/d divided q68h

2. Age 13 months:

Erythromycin: 10 mg/kg IV q6h or azithromycin 2.5 mg/kg IV q12h. For infants <6
weeks, consider azithromycin due to concerns regarding hypertrophic pyloric
stenosis.

If febrile, add cefotaxime 200 mg/kg/d divided q8h.

3. Age 4 months to 5 years (if atypical pathogens are not suspected):

Ceftriaxone 5075 mg/kg/d q1224h or cefotaxime 200 mg/kg/d divided q8h

4. Age 5 years: Add macrolide to above therapy.

5. For seriously ill patients, add vancomycin 60 mg/kg/d divided q6h.
6. For antistaphylococcal coverage, add vancomycin 15 mg/kg/dose q68h
or clindamycin 2540 mg/kg/d divided q68h.
7. If atypical pneumonia also suspected, may add macrolide
8. May also consider macrolides or clindamycin IV as alternative for cephalosporin-allergic
patients
Follow-up Recommendations
EXPECTED COURSE/PROGNOSIS
Otherwise healthy children with uncomplicated pneumonia typically have rapid improvement with treatment (35
days).
POSSIBLE COMPLICATIONS

Pleural effusion

Empyema

Lung abscess

Pneumatoceles

Pneumothorax

Bacteremia/sepsis

PATIENT MONITORING

If treated as outpatient, follow up within 13 days.

If worsening or not responding to treatment, consider repeated or additional diagnostic studies. For

example, persistent fever may be due to loculated pleural fluid or an empyema.

CXR may be abnormal for up to 10 weeks after successful treatment. Consider follow-up CXR only if
indicated for severe disease or complications (e.g., effusion, empyema).

For children with recurrent bacterial pneumonia, consider an underlying anatomical or immunologic
disorder (e.g., abnormal antibody production, cystic fibrosis, tracheoesophageal fistula, pulmonary
sequestration).

Frequently Asked Questions

Q: What are the indications for admission and inpatient treatment of pneumonia in children?

A: Failure of outpatient therapy, hypoxemia, inability to maintain hydration orally or dehydration,

respiratory distress, apnea, toxic appearance, presence of complications such as effusion or
empyema and risk factors that predispose to complications, such as age <2 months, or
immunocompromised status

Q: What is the most common causative organism of pulmonary abscess, and what is the appropriate
treatment?

A: S. aureus is the most common causative organism. Treatment includes ampicillin/sulbactam (200
mg/kg divided by 6 hours) or cefuroxime (150 mg/kg/d divided by 8 hours)

Q: What is the case fatality rate for pneumonia in hospitalized children?

A: Based on data from 19951997, case fatality rates for children differ by age and are as high as 4%
for children <2 years of age, and 2% for children aged 217 years.