SIGNS AND SYMPTOMS 
- General (in all ages):
- Cough
- Rales
- Fever
- Hypoxia
- Tachycardia
- Tachypnea, retractions, grunting
- Rash (up to 10% of cases); usually maculopapular
- Nonspecific symptoms of toxicity
- Pulmonary exam:
- Decreased breath sounds, ventilation
- Dullness to percussion
- Wheezing, ronchi, rales
- Infants < 6 mo:
- Altered behavior: Listless, irritable
- Apnea (esp. RSV in premature infants)
- Conjunctivitis (Chlamydia < 1 mo old)
- Cyanosis
- Grunting
- Poor feeding
- Temperature instability (hypothermia/hyperthermia)
- Vomiting, often with coughing
- Cough
- Nasal congestion
- Nasal flaring
- Wheezing
- Staccato cough (Chlamydia)
- Children > 5 yr:
- Pleuritic chest pain
- Productive cough
- Rigors, chills
History
- Immunization history
- Past medical history include immune status
- Exposures
- Progression of signs and symptoms
Physical Exam
- Pulmonary exam may be helpful, particularly in children > 5 yr.
- Peripheral and central cyanosis should be assessed.
- Evidence of respiratory compromise, distress, failure
ESSENTIAL WORKUP
- Pulse oximetry
- Chest radiograph:
- Gold standard for diagnosis
- Should be ordered for patients with signs of lower respiratory tract infection and patients < 36 mo old with marked leukocytosis or neutrophilia (WBC > 15,000 or absolute neutrophil count [ANC] > 9,000).
- Much overlap between viral and bacterial findings
- Viral and M. pneumoniae tend to show interstitial infiltrates, often perihilar and peribronchial.
- Bacterial pneumonias may show focal lobar consolidation, focal alveolar infiltrates, and possibly effusion or pneumatocele.
- Round pneumonia pathognomonic of S. pneumonia
- Lateral decubitus films may aid in demonstrating effusion.
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC with differential:
- Patients with bacteremia tend to have leukocytosis with left shift.
- Sensitivity and specificity are poor.
- Patients with WBC ≥20,000 or ANC > 9,000 are at increased risk of pneumococcal bacteremia.
- B. pertussis usually has elevated WBC with lymphocytosis.
- Blood culture:
- Low yield (< 10–20%)
- Recommended in children < 36 mo
- Probably worthwhile in toxic patients requiring hospitalization
- Arterial blood gas may be useful in determining degree of respiratory insufficiency in critically ill patients.
- Electrolytes to exclude syndrome of inappropriate antidiuretic hormone secretion and in hypotensive children
- Sputum for Gram stain and culture may be obtained in older children with suspected bacterial infection.
- Mycoplasma IgM or cold agglutinin titers:
- Useful if suspecting this organism
- More likely positive with severe illness
- Nasopharyngeal washes for direct fluorescent antibody and culture:
- Identify RSV, C. trachomatis, and B. pertussis infections
Imaging
Chest radiographs are still the imaging modality of choice:
- Posteroanterior and lateral films should be obtained whenever possible.
- CT provides additional detail and better identification of underlying lung pathology but adds little as an initial testing modality.
Diagnostic Procedures/Surgery
Pleural fluid (if present) for culture, Gram stain, protein, glucose, and cell counts
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
- Pulse oximetry
- Administer high-flow oxygen for respiratory distress.
- IV fluids (0.9% normal saline [NS] 20 mL/kg initial bolus) for volume depletion, hypotension
- Support and intubation for respiratory failure
INITIAL STABILIZATION/THERAPY
- If moderately or severely ill:
- Secure airway, as appropriate; intubate for clinical respiratory failure. Children with severe sepsis or septic shock benefit from aggressive airway management.
- High-flow oxygen
- IV hydration (0.9% NS 20 mL/kg initial bolus) and resuscitation if in shock or hypovolemia
- Monitor
- Ongoing pulse oximetry
- Arterial blood gas if inadequate ventilation
- Check bedside glucose in severely ill-appearing infants and toddlers:
- If hypoglycemic, administer glucose D25 at 2 mL/kg IV for toddlers or D10 at 5 mL/kg IV for neonates.
ED TREATMENT/PROCEDURES
- Continue pre-hospital and initial stabilization therapy.
- Early antibiotic therapy should be broad enough to address local resistance patterns in your area.
- Often have concurrent reactive airway disease that needs specific treatment with bronchodilator (albuterol or levalbuterol)
- Perform thoracentesis if pleural effusion is compromising respiratory function or for diagnostic tests.
MEDICATION
- Empiric therapy with oral antibiotics for most well-appearing children ≥6 mo:
- Infants < 2 mo:
- Outpatient treatment generally not recommended unless child has no respiratory distress or associated conditions or issues.
- Children 3 mo–5 yr:
- Children 5–18 yr:
- Macrolide (azithromycin or clarithromycin)
- Initiate IV antibiotic therapy for moderate to severely ill children who require admission:
- Neonate:
- Ampicillin, and cefotaxime or gentamicin
- Azithromycin for suspected C. trachomatis or B. pertussis pneumonia
- Infants 1–2 mo:
- Ampicillin and cefotaxime
- Azithromycin or erythromycin for suspected C. trachomatis or B. pertussis
- Children ≥3 mo:
- Cefotaxime, cefuroxime, or ceftriaxone
- Vancomycin for suspected or confirmed penicillin-resistant S. pneumoniae
- Macrolide (i.e., azithromycin) for suspected M. pneumoniae
- Clindamycin if group A strep suspected in patient with severe disease
- Unusual organisms require specific therapy in coordination with infectious disease consultation.
- Albuterol (0.5% solution or 5 mg/mL): Nebulizer 0.015 mg (0.03 mL)/kg per dose up to 5 mg per dose q10–20min as needed; metered dose inhaler (with spacer; 90 mg per puff) 2 puffs q10–20min up to total of 10 puffs
- Amoxicillin: 80 mg/kg/24 h q12h PO
- Amoxicillin–clavulanate: 30 mg/kg/24 h q12h PO
- Ampicillin: 100–150 mg/kg/24 h q6h IV
- Azithromycin: 10 mg/kg/24 h daily for 1 day, then 5 mg/kg/24 h daily for 4 days
- Cefotaxime: 50–75 mg/kg/24 h q8h IV, max. 2 g q8h
- Ceftriaxone: 100 mg/kg/24 h q12–24 h IV, max. 2 g q12h
- Cefuroxime: 100 mg/kg/24 h q8h IV, max. 2 g q8h
- Clarithromycin: 15 mg/kg/24 h q12h PO, max. 500 g q12h
- Clindamycin 30–40 mg/kg/24 h q6–8h IV
- Erythromycin–sulfisoxazole: 40 mg/kg/24 h as erythromycin q8h PO, max. 2 g/d
- Gentamicin: 5–7.5 mg/kg/24 h q8–12h IV
- Trimethoprim–sulfamethoxazole: 8–10 mg/kg/24 h as TMP q12h PO
- Vancomycin: 10–15 mg/kg/24 h q8–12h IV; max. 1,000 mg
[Outline]
DISPOSITION
Admission Criteria
- Toxic appearance
- Respiratory distress or failure
- Dehydration/vomiting
- Apnea
- Infants < 2 mo
- Infants < 6 mo with lobar pneumonia
- Hypoxia (O2 saturation < 92% on room air [sea level])
- Pleural effusion
- Poor response to outpatient oral therapy
- Immunocompromised children
- Concern about noncompliant parents
Discharge Criteria
- Most cases are mild and can be discharged home if no evidence of hypoxia, significant work-of-breathing, dehydration, vomiting, or noncompliance.
- Ensured follow-up within 1–2 days
Issues for Referral
Respiratory failure, effusion, toxicity
FOLLOW-UP RECOMMENDATIONS
Clinical resolution should be ensured through follow-up.
[Outline]
- Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr. 2009;168(12):1429–1436.
- Kronman MP, Hersh AL, Feng R, et al: Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics 2011;127:411–418.
- Michelow IC, Olsen K, Loranzo J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004;113(4):701–707.
- Murphy CG, van de Pol AC, Harper MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243–249.
- Shah SS, Dugan MH, Bell LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia. Pediatr Infect Dis J. 2011;30:475–479.
See Also (Topic, Algorithm, Electronic Media Element)
Asthma