Community Acquired Pneumonia
in Children
June 2014
Pediatric Continuity Clinic Curriculum
Created by: Cecile Besingi
Objectives
• Describe clinical manifestations of
CAP.
• Discuss outpatient treatment options
for CAP.
• Discuss indications for hospitalization.
Case # 1
A 5 yr. old female presents to the outpatient acute clinic
with a 10 day history of cough and rhinorrhea.
Rhinorrhea has been improving but cough is getting
worse and patient has been febrile for the past 2 days.
She also reports abdominal pain since yesterday.
Discussion Questions:
• What other findings on exam, if present would help
rule in a diagnosis of pneumonia?
• What is the most likely organism causing this patient’s
symptoms?
What other findings on exam, if present would help
rule in a diagnosis of pneumonia?
• In general, signs and symptoms of pneumonia are nonspecific, and vary depending on the patient’s age,
responsible pathogen and severity of infection.
• Fever and cough are the hallmark of pneumonia in all
age groups.
• Other signs and symptoms that are highly specific but
not sensitive for pneumonia include:
– Crackles (rales)
– Rhonchi
– Retractions (and nasal flaring in young infants)
What other findings on exam, if present would help
rule in a diagnosis of pneumonia?
• The WHO uses tachypnea and retractions to
diagnose pneumonia in children < 5 yrs. old.
• Tachypnea becomes less sensitive and specific
as age increases.
• Upper Lobe pneumonias may mimic meningitis
due to radiating neck pain.
• Lower Lobe pneumonias may mimic
appendicitis due to vague abdominal pain
What is the most likely organism causing this
patient’s symptoms?
Answer: Streptococcus pneumoniae
Rationale: Our patient had fever, cough, and abdominal
pain which is suggestive of a lower lobe pneumonia.
• Pneumococcal pneumonia is typically lobar, presenting
with fever, nonproductive cough, tachypnea and
decreased breath sounds (or crackles) over the
affected lobe.
• It is often difficult to differentiate between Atypical
bacterial pneumonia and viral pneumonia.
Viral and atypical pneumonias
• Viral pneumonia:
–
–
–
–
–
More common in children less than 5 yrs. old
Usually a gradual insidious onset
Usually with URI symptoms
Auscultatory findings are more likely to be diffuse.
Wheezing is more frequent in viral vs. bacterial pneumonia
• Atypical pneumonia:
–
–
–
–
More common in school aged children (< 5 yrs. old)
Usually caused by Mycoplasma or Chlamydia pneumoniae.
Symptoms may include abrupt onset of fever, malaise, myalgia,
headache, sore throat, hoarseness and gradually worsening
prolonged non-productive cough.
Diffuse auscultatory findings including wheezing
Case # 2-1
Case # 2-2
7 yr. old female presents with
nonproductive cough and
fever of three days duration.
You note crackles on
auscultation of right middle
lobe area and diagnose a lobar
pneumonia. She is otherwise
well appearing.
Your patient has been on the 1st
line antimicrobial therapy for >
72 hours and is still febrile with
no significant improvement in
her cough. She now reports
mild intermittent shortness of
breath with activity but no
other new symptoms.
Discussion Question:
• What antimicrobial therapy
is appropriate for empiric
treatment of this infection?
Discussion question:
• What are possible reasons
for presumed treatment
failure?
What antimicrobial therapy is appropriate for
empiric treatment of this infection?
Answer: 1st line therapy with Amoxicillin or amoxicillinclavulanate.
Rationale: S. pneumoniae remains the most common
implicated pathogen.
• Clavulanate adds the benefit of action against B-lactamase
producing organisms such as H. influenza and Moraxella
catarrhalis.
• For patients with penicillin allergy, 2nd line options include
2nd or 3rd generation cephalosporins (e.g. cefdinir),
clindamycin, macrolides (e.g. azithromycin) and levofloxacin.
Antibiotic Choice—Outpatient
(Table from pediatric care online – AAP)
What are possible reasons for presumed treatment
failure (in patient already on 1st line therapy for lobar
pneumonia)?
1. Ineffective antibiotic coverage
a. Lack of coverage for actual etiology, e.g. organism is atypical
b. Resistant organism
2. Pneumonia complications (more likely with bacterial
rather than atypical or viral pneumonias)
a) Pleural effusion or empyema (distant breath sounds, friction
rub on exam)
3. Alternative or coincident diagnosis e.g. Foreign body
aspiration.
Additional information – diagnostic testing
• Pulse oximetry is recommended in all children with pneumonia
and suspected hypoxemia.
• Initial Chest X-Ray (Table from pediatric care online – AAP)
Case #3
A 14 month old male presents to your outpatient acute
clinic with a 2 day history of cough and fever. Vital signs
reveal RR 52, HR 175, O2 sat of 88% on room air. On
exam, you note crackles in the right lower lobe area,
intercostal retractions, but no wheezing. You start the
patient on oxygen via nasal cannula and O2 saturation
increases to 94%.
Discussion question:
• What is your next course of action?
What is your next course of action?
Answer:
Call the ED and transfer patient to the hospital
for further evaluation and possible admission.
Indications for Hospitalization
• Hypoxia (oxygen saturations < 90 to 92%)
• Infants < 3 months with suspected bacterial infection.
• Respiratory distress (grunting, difficulty breathing, poor
feeding).
• Tachypnea (< 12 months w/ RR > 70 or children with RR >
50).
• Inability to maintain hydration or oral intake
• Failure of outpatient therapy (48 to 72 hours with no
response).
• Caretaker unable to provide appropriate observation or
comply with prescribed home therapy.
General approach to childhood pneumonia
Gereige R S , and Laufer P M Pediatrics in Review
2013;34:438-456
PREP Question
Prevention of pneumonia in children includes
active immunization of adult caretakers of
infants younger than 6 months against which of
the following pathogens?
A. Bordetella pertussis.
B. Haemophilus influenzae type b.
C. Neisseria meningitidis.
D. Respiratory syncytial virus.
E. Tuberculosis.
PREP Question
Prevention of pneumonia in children includes
active immunization of adult caretakers of
infants younger than 6 months against which of
the following pathogens?
A. Bordetella pertussis.
B. Haemophilus influenzae type b.
C. Neisseria meningitidis.
D. Respiratory syncytial virus.
E. Tuberculosis.
PREP Question
A 10-year-old boy presents with a history of fever,
headache, malaise, mild sore throat, and worsening
nonproductive cough. Lung examination reveals
diffuse crackles. Chest radiographs reveal bilateral
diffuse patchy infiltrates. The next step in
management is to prescribe:
A.
B.
C.
D.
E.
Amoxicillin.
Amoxicillin-clavulanate.
Azithromycin.
Cephalexin.
Penicillin.
PREP Question
A 10-year-old boy presents with a history of fever,
headache, malaise, mild sore throat, and worsening
nonproductive cough. Lung examination reveals diffuse
crackles. Chest radiographs reveal bilateral diffuse patchy
infiltrates. The next step in management is to prescribe:
A.
B.
C.
D.
E.
Amoxicillin.
Amoxicillin-clavulanate.
Azithromycin.
Cephalexin.
Penicillin.
References and Future Reading
• Pneumonia: Pediatrics in Review October
2013
• Current diagnosis & Treatment of CAP in
children - Highlights of the PIDS/IDSA
National guidelines: Pediatric Care Online
AAP