Etiologies by Age 3wk to 3mo Chlamydia trachomatis (vertical transmission, afebrile, interstitial infiltrates, hx conjunctivitis) Respiratory syncytial virus [RSV] (bronchiolitis with wheezing most common but focal pneumonia possible, onset usually late fall or early winter) Parainfluenza (bronchiolitis or pneumonia, typically fall through spring) Streptococcus pneumoniae (major bacterial causes throughout childhood) Bordetella pertussis (tracheobronchitis with severe paroxysms of cough, no fever; pneumonia occasionally seen, usually related to aspiration)
3mo to 4yo RSV, parainfluenza, human metapneumovirus, influenza, rhinovirus, bocavirus S. pneumoniae MSSA or MRSA (especially following influenza) Hemophilus influenzae type B (Hib) Mycoplasma pneumoniae (possible in all ages, increased incidence in children approaching school age)
5yo to adolescence M. pneumoniae (major treatable cause in school-age children and adolescents)
Presentation Bacterial (suppurative) from pneumococcus and others: abrupt onset, high fever, ill/toxic appearance, more focal findings on exam, chest/abdominal pain, focal infiltrates on CXR Atypical - infancy from Chlamydia trachomatis: tachypnea, mild hypoxemia, lack of fever, wheezing, interstitial infiltrates on CXR Atypical - older children from Mycoplasma or C. pneumoniae: gradual onset, low-grade fever, diffuse examination findings, diffuse infiltrates on CXR Viral: prominent URI sx, low-grade or absent fever, diffuse findings/wheezes on examination, possible diffuse interstitial infiltrates on CXR
Triage Assess hydration status and respiratory status Assess need for inpatient management: strongly consider for 3mo-3yr with fever, hypoxia, respiratory distress, or dehydration, or any child in significant respiratory distress, dehydration, high fever, toxic appearance, failed outpatient therapy, or underlying medical disease
Inpatient management Supportive care: O2 (simple NC, high-flow NC, mask) for hypoxemia, suctioning, IVF, analgesics, antipyretics Inpatient: CBC + diff, BMP, blood cx, sputum cx (if possible) and CXR (PA+lat if stable and cooperative, AP/portable if not). Consider respiratory virus DFA or serologies on a case-by-case basis Antibiotics: ceftriaxone, ampicillin, vancomycin, clindamycin, azithromycin, doxycycline, levofloxacin, nafcillin/oxacillin, piperacillin/tazobactam, meropenem Transition to PO antibiotics when afebrile and tolerating PO Total antibiotics course typically 7-10 days
Complications Purulent effusion or empyema (especially after Staph aueres or streptococcus). Evaluate with ultrasound and/or upright + decubitus CXR to assess character (freedom to flow, loculation, thickness, fibrinous, streaking) Abscess (especially after aspiration; often streptococcus and anerobes)
Pearls Blood cultures are positive <10% time for Strep pneumoniae cases Tachypnea is the most sensitive sign for all pneumonias Always culture parapneumonic pleural fluid and consider additional testing on a case-by-case basis (e.g. albumin, LDH, AFB, fungal cx) Strongly consider expanding coverage with clindamycin or vancomycin for MRSA coverage in children who fail antipneumococcal therapy (cephalosporins) and have fulminant or extensive disease VATS has been shown to reduce mortality, length of stay, and duration of antibiotic therapy compared with antibiotics and/or thoracentesis alone Never forget about TB Never forget about atypical pathogens (fungus, PCP, CMV, non-TB mycobacteria) Consider asthma, and then immunodeficiency, HIV, and CF in recurrent pneumonias (>3/year)
