Pneumonia, Community-Acquired

Key Features

Essentials of Diagnosis

• Fever, cough, dyspnea

• Abnormal chest examination (crackles or decreased breath sounds)

• Abnormal chest radiograph (infiltrates, hilar adenopathy, pleural effusion)

General Considerations

• Streptococcus pneumoniae is most common cause of bacterial pneumonia in children of all ages

• Bacterial pneumonia usually follows a viral lower respiratory tract infection

• Children with compromised pulmonary defense systems are at high risk for bacterial pneumonia

Clinical Findings

Symptoms and Signs

• Fever (over 39°C)

• Tachypnea

• Cough

• Chest auscultation may reveal crackles or decreased breath sounds in the setting of consolidation or an associated pleural effusion

• Extrapulmonary findings caused by pneumonia

  • Meningismus

  • Abdominal pain

• Organism causing pneumonia may be responsible for other infections

  • Meningitis

  • Otitis media

  • Sinusitis

  • Pericarditis

  • Epiglottitis

  • Abscesses

Differential Diagnosis

• Noninfectious pulmonary disease should be considered in the differential diagnosis of localized or diffuse infiltrates

  • Gastric aspiration

  • Foreign body aspiration

  • Atelectasis

  • Congenital malformations

  • Heart failure

  • Malignancy, tumors such as plasma cell granuloma

  • Chronic interstitial lung disease

  • Pulmonary hemosiderosis

• When effusions are present, additional noninfectious disorders should be considered

  • Collagen diseases

  • Neoplasm

  • Pulmonary infarction

Diagnosis

Laboratory Findings

• An elevated peripheral white blood cell count with a left shift may be a marker of bacterial pneumonia

• A low white blood cell count (< 5000/μL) can be an ominous finding

• Blood cultures should be obtained in children admitted to the hospital with pneumonia

• Sputum cultures may be helpful in older children capable of providing a satisfactory sample

Imaging

• Radiography

  • Air space disease or consolidation in a lobar distribution suggests bacterial pneumonia

  • Interstitial or peribronchial infiltrates suggest a viral infection

Diagnostic Procedures

• Bronchial brushing or washing, lung puncture, or open or thoracoscopic lung biopsy should be undertaken in critically ill patients when other means do not adequately identify the cause

• Viral antigen immunofluorescent staining (DFA) and polymerase chain reactivity (PCR) technology has improved the ability to detect a wide variety of viral infections

• Thoracocentesis should also be performed in a child with a pleural effusion

Treatment

• Empiric antibiotic therapy should be considered if bacterial pneumonia is suspected

• Children younger than 4 weeks should be treated with ampicillin and an aminoglycoside

• Infants 4–12 weeks of age should be treated with intravenous ampicillin for 7–10 days

• Children 3 months to 5 years of age should be treated with oral amoxicillin (50–90 mg/kg/dose) for 7–10 days

• Children older than 5 years should also be treated with amoxicillin (50–90 mg/kg/dose) for 7–10 days

• Macrolide antibiotics should be used if an atypical infection is suspected

• Additional therapeutic considerations

  • Oxygen

  • Humidification of inspired gases

  • Hydration

  • Electrolyte supplementation

  • Nutrition

Outcome