Management of Community Acquired
Pneumonia in Infants and Children
Older than 3 Months of Age
Daniel Urschel, MD, Charles Pace,
MD, Sherman Alter, MD
Department of Pediatrics, Boonshoft School
of Medicine, Wright State University, The
Children’s Medical Center of Dayton
Clin Infect Dis 2011; 53 (7): 617-630
Objectives
1. List common pathogens causing community-acquired
pneumonia (CAP) in infants and children.
2. Discuss appropriate use of diagnostic laboratory and
imaging tests in a child with CAP in an outpatient or
inpatient setting.
3. Review choice of anti-infective therapy and duration of
treatment provided to a child with suspected CAP in the
outpatient or inpatient setting.
“Teasers are docile male horses, usually
old and past prime with undesirable
genes, who set up aggressive just
off-the-track mares to be bred by the
wild testosterone crazed prize stallions
whose only job is to deliver the goods,
which they do. “
A 3yr old female presents to your office in November with cough
and tachypnea. You hear crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had good fluid intake.
Previously healthy and immunizations up to date. You believe
33%
33%
33%
patient may be well enough to manage as
an outpatient.
Which
diagnostic tests should be performed on this patient?
1.
2.
3.
4.
5.
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above
0%
1
0%
2
3
4
5
A 3yr old female presents to your office in November with cough
and tachypnea. You hear crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had good fluid intake.
Previously healthy and immunizations up to date. You believe
33%
33%
33%
patient may be well enough to manage as
an outpatient.
Which
diagnostic tests should be performed on this patient?
1.
2.
3.
4.
5.
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above
0%
1
0%
2
3
4
5
A school aged child hospitalized with community-acquired
pneumonia can be safely discharged if he meets which of the
following criteria?
1.
2.
3.
4.
5.
Able to tolerate outpatient
meds, greater level of
activity, improving appetite.
Afebrile for over 24 hours
Pulse oximetry
measurements >90% in
room air at least 12 hours
A and C
A, B, and C
67%
33%
0%
1
2
3
0%
0%
4
5
Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in
the right base) in late October. Respiratory rate is 30 breaths/minute
and temperature is 38.5° C. She has received all recommended
immunizations. She attends a day care on daily basis. She is interactive
and drinking well. Which oral anti-infective therapy should be provided
33%
33%
33%
to this child managed as an outpatient?
1.
2.
3.
4.
5.
A second-or third-generation
cephalosporin (e.g., cefdinir,
cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided
2 times a day for 10 days
Azithromycin 10 mg/kg on day 1,
5 mg/kg on days 2-5
Combined treatment with both
amoxicilln and azithromycin as
noted above
No anti-infective therapy
indicated
0%
1
2
0%
3
4
5
A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s.
Radiography demonstrates left lower lobe consolidation without an
effusion. He has a 92% SpO2 on 30% FiO2, some retractions and
poor oral fluid intake. A blood culture is obtained. What first-line
67%
antibiotic therapy is recommended?
1.
2.
3.
4.
5.
A third-generation
parenteral cephalosporin
(e.g., cefotaxime or
ceftriaxone)
Intravenous clindamycin
A third-generation
parenteral cephalosporin
plus azithromycin
Intravenous ampicillin
Intravenous vancomycin
33%
0%
1
2
3
0%
0%
4
5
A 5 yr old is admitted with a right upper lobe pneumonia. Child is
not fully immunized. His blood cultures yield Streptococcus
pneumoniae. Susceptibility testing on the blood isolate demonstrates
a penicillin MIC of > 4 ug/mL. Appropriate
100% antibiotic therapy
directed at this pathogen consists of:
1.
2.
3.
4.
5.
Ceftriaxone intravenously at
100mg/kg/day
Levofloxacin intravenously
at 20 mg/kg/day
Ampicillin intravenously at
400 mg/kg/day
A or C
A, B, or C
0%
1
0%
2
3
0%
0%
4
5
Introduction



The Pediatric Infectious Diseases Society (PIDS) and
the Infectious Diseases Society of America (IDSA)
convened multiple subspecialists and expert consultants
to create and review guidelines
Guidelines endorsed by AAP, American College of
Emergency Physicians, Society of Critical Care
Medicine….
The guidelines grade method of recommendation, low
or very low evidence situations require clinical
judgment
Strength of Recommendations
Strength of Recommendations
Inpatient Criteria



Age 3-6 months with a suspicion of bacterial
pneumonia
Suspicion or documentation of methicillinresistant Staphylococcus aureus (MRSA) pneumonia
Concern for follow up or administration of
home therapy
Patients Requiring Hospitalization
Diagnostic approach to
the child with pneumonia
Outpatient Diagnostics





Chest radiography, blood culture, CBC,
ESR/CRP not necessary
Pulse oximetry should be obtained in all patients
If available a rapid test for influenza and for
other viral pathogens should be obtained
Testing for Mycoplasma pneumoniae should be
obtained if suspicious
If no improvement on antibiotics for 48-72 hrs,
a CXR and blood culture should be obtained
Inpatient Workup









All pt’s should have CXR
Blood culture
CBC
ESR/CRP
Urinary antigen for Pneumococcal infection is not
recommended
Sputum samples if able (weak; low evidence)
Rapid tests for Influenza and viruses should be used
Mycoplasma pneumoniae should be tested for if suspicious
No reliable test for Chlamydophila pneumoniae
Inpatient Diagnostics





A routine repeat CXR is not necessary
Repeat CXR should be obtained if no clinical
improvement is demonstrated by 48-72 hrs
If blood culture yields MRSA, a repeat culture is
mandatory todocument sterility of the blood.
If blood culture is positive for another organism,
repeat culture of blood is not mandatory
Tracheal aspirate should be obtained in patient
with endotracheal intubation
Criteria for admission to an ICU
Criteria for admission to an ICU
Criteria for admission to an ICU





Intubation, continuous CPAP or BIPAP
Sustained tachycardia or hypotension
<92% SpO2 on >50% FiO2
Altered mental status
Clinical judgment should be used regardless of
scores
Discharge Criteria





Improved Clinical Status >12 hrs
RA with Sp02 >90% >12 hrs
No increased work of breathing , tachypnea or
tachycardia
Able to tolerate outpatient therapy
Chest tube out for >12 hrs
Outpatient Treatment of Pneumonia



Antibiotics not routinely required for preschool-aged
children
High-dose amoxicillin should be considered first line
for presumed bacterial pneumonia in all ages
 90 mg/kg/day divided bid
 TID dosing is required for Pen-resistant
pneumococcus (MIC > 2 µg/mL)
Macrolides (azithromycin) should be considered in
school-aged and adolescents with illness consistent with
atypical pneumonia
Atypical





Gradual onset
Malaise, headache, sore
throat, ear infections
Lower fevers (101-102)
Usually nonproductive,
persistent cough
May or may not have
rales
vs.





Bacterial
Gradual or acute onset
Fatigue, dyspnea, chest
pain
Fevers often higher (>103)
Cough more often
productive
Decreased or bronchial
breath sounds, rales,
dullness to percussion,
egophony
Manifestations of Mycoplasma pneumonia
Outpatient Treatment of Pneumonia

For presumed atypical pneumonia, azithromycin
is first-line



10 mg/kg on day 1; 5 mg/kg on days 2-5
In season, treat influenza presumptively until a
sensitive test is negative
10-day course of antibiotics is usually adequate
Azithromycin: 5 day course
 MRSA will require a longer course (and
hospitalization!)

Inpatient Treatment of Pneumonia

For the fully immunized child in regions that do
not demonstrate high-level pneumococcal
penicillin resistance:
Ampicillin or Penicillin G are first-line
 Azithromycin for suspected atypical pneumonia
(with a beta-lactam if diagnosis is in question)
 Vancomycin or clindamycin should be added when
S. aureus is suspected by labs, clinical findings or
imaging
 Ceftriaxone or cefotaxime are alternatives

Inpatient Treatment of Pneumonia

For a not fully immunized child or in regions
that demonstrate high-level pneumococcal
penicillin resistance:
Ceftriaxone or cefotaxime is preferred
 Add azithromycin if considering atypical pneumonia
 Add vancomycin or clindamycin for S. aureus


Ceftriaxone or cefotaxime also preferred for lifethreatening infections and empyema
Empiric Inpatient Treatment of CAP
Pneumococcal Penicillin Resistance

MIC < 0.06 µg/mL: very susceptible


MIC 0.12-1 µg/mL: susceptible


High-dose oral amoxicillin >90% effective
MIC 2-4: resistant


High-dose oral amoxicillin effective
MIC 1-2: somewhat resistant


Standard-dose oral amoxicillin effective
Oral therapy likely to fail; IV ampicillin or penicillin
MIC >4: very resistant

Standard-dose ampicillin likely to fail; ceftriaxone effective
Specific Treatment for CAP
Specific Treatment of CAP
Specific Treatment of CAP
Specific Treatment of CAP
Specific Treatment of CAP
Viral Pneumonia in Children


Guidelines suggest not treating a preschool-aged child
with suspected viral pneumonia (except influenza)
Hamano-Hasegawa, J Infect Chemother (2008)



Younger children more likely to have viral pneumonia
Evidence of bacterial co-infection in 33%
Michelow, Pediatrics (2004)



Bacterial co-infections seen in 54% of viral pneumonias
67% of influenza pneumonia
55% of RSV pneumonia
Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired
pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.
Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired
pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.
Viral Pneumonia in Children

A 2010 retrospective cohort study of 4015
pediatric patients hospitalized with pneumonia
27% developed influenza-associated pneumonia
 Of these, 2% had a bacterial co-infection
 18 identified by blood cultures; 3 by pleural fluid
 The actual incidence of secondary bacterial
pneumonia with influenza is likely much higher

Dagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized With Laboratory-Confirmed
Influenza, 2003-2008.” Pediatr Infect Dis J. 2010 Jul;29(7):585-90.
Adjunctive Therapy



CXR should be obtained if suspicious for
effusion
US or CT if CXR is inconclusive
Size of effusion and respiratory compromise will
determine treatment
Pleural Fluid Tests





Gram stain (+25-50%)
Antigen or PCR if available (S. pneumoniae,
S.aureus)
Pleural fluid analysis rarely changes management
and is not recommended
WBC count with differntial helps differentiate
source
Majority of cultures will be negative
Effusion/Empyema





Total antibiotic therapy 2-4 weeks or 10 days after
resolution of fever
If abscess or necrosis is identified tx should begin with
IV antibiotics
If abscess is peripheral may attempt to drain, most will
resolve spontaneously with IV antibiotics
Abscess secondary to congenital malformation requires
surgery consultation
Necrosis should not routinely be managed surgically
given high rates of broncho-pleural fistulas
A 3yr old female presents to your office in November with cough
and tachypnea. You hear crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had good fluid intake.
Previously healthy and immunizations up to date. You believe
33%
33%
33%
patient may be well enough to manage as
an outpatient.
Which
diagnostic tests should be performed on this patient?
1.
2.
3.
4.
5.
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above
0%
1
0%
2
3
4
5
A school aged child hospitalized with community-acquired
pneumonia can be safely discharged if he meets which of the
following criteria?
1.
2.
3.
4.
5.
Able to tolerate outpatient
meds, greater level of
activity, improving appetite.
Afebrile for over 24 hours
Pulse oximetry
measurements >90% in
room air at least 12 hours
A and C
A, B, and C
100%
0%
1
0%
2
3
0%
0%
4
5
Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in
the right base) in late October. Respiratory rate is 30 breaths/minute
and temperature is 38.5° C. She has received all recommended
immunizations. She attends a day care on daily basis. She is interactive
and drinking well. Which oral anti-infective therapy should be provided
67%
to this child managed as an outpatient?
1.
2.
3.
4.
5.
A second-or third-generation
cephalosporin (e.g., cefdinir,
cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided
2 times a day for 10 days
Azithromycin 10 mg/kg on day 1,
5 mg/kg on days 2-5
Combined treatment with both
amoxicilln and azithromycin as
noted above
No anti-infective therapy
indicated
33%
0%
1
0%
2
3
0%
4
5
Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in
the right base) in late October. Respiratory rate is 30 breaths/minute
and temperature is 38.5° C. She has received all recommended
immunizations. She attends a day care on daily basis. She is interactive
and drinking well. Which oral anti-infective therapy should be provided
67%
to this child managed as an outpatient?
1.
2.
3.
4.
5.
A second-or third-generation
cephalosporin (e.g., cefdinir,
cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided
2 times a day for 10 days
Azithromycin 10 mg/kg on day 1,
5 mg/kg on days 2-5
Combined treatment with both
amoxicilln and azithromycin as
noted above
No anti-infective therapy
indicated
33%
0%
1
0%
2
0%
3
4
5
A 5 yr old is admitted with a right upper lobe pneumonia. Child is
not fully immunized. His blood cultures yield Streptococcus
pneumoniae. Susceptibility testing on the blood isolate demonstrates
a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy
33%
33%
directed at this pathogen consists
of: 33%
1.
2.
3.
4.
5.
Ceftriaxone intravenously at
100mg/kg/day
Levofloxacin intravenously
at 20 mg/kg/day
Ampicillin intravenously at
400 mg/kg/day
A or C
A, B, or C
0%
1
0%
2
3
4
5
BMJ 2003; 327:1459-1461