Pneumonia (peds)

Background

• Most common site of infection in neonates
• Fever and tachypnea are Sensitive but not Specific

Causes

Neonatal Pneumonia

Etiology	Clinical Presentation	Management Approach
Bacterial Group B Streptococcus (most common), Escherichia coli, Listeria monocytogenes, Haemophilus influenzae, S. pneumoniae Klebsiella species, Enterobacter aerogenes	Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment.	Full evaluation for sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative. Two culture samples may increase diagnostic yield fourfold.
	Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present.	A lumbar puncture should be done if there are no contraindications.
		Hospitalization, supportive care (O2), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available).
Nosocomial infections in premature infants (Staphylococcus aureus,Pseudomonas aeruginosa)	Same as for common bacterial etiology.	Same as for common bacterial etiology.
Chlamydia	Develops in 3%–16% of exposed neonates (in colonized mothers).	Sepsis evaluation as indicated.
		CXR may show hyperinflation with interstitial infiltrates.
	Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon.	Definitive diagnosis by nasopharyngeal swab PCR or cultures.
		Eosinophilia may be seen on peripheral blood count.
		Treatment: macrolide (erythromycin, clarithromycin, or azithromycin).
Bordetella pertussis	In addition to pneumonia, may causes paroxysms of cough, ± cyanosis and post-tussive emesis in otherwise well-looking infant. Characteristic whoop is not present in neonates. Apnea may be the only symptom. Suspect when adult caregiver also has persistent cough.	Sepsis evaluation as indicated.
		Diagnosis via nasopharyngeal swab for PCR and/or culture.
		Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis.
		Macrolides are efficient against B. pertussis but is not approved by the U.S. Food and Drug Administration for infants <6 mo.
		No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin.
		Neonates need to be admitted during treatment and monitored for severe adverse effects.
Mycobacterium tuberculosis	Half of infants born to actively infected mothers develop TB if not immunized or treated.	Sepsis evaluation as for bacterial pneumonia.
		CXR, culture of urine, gastric and tracheal aspirates.
	May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission.	Skin testing not sensitive in neonates.
		Routine anti-TB treatment.
		Supportive treatment as needed.
	Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly).
Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza)	Initial upper respiratory illness progressing to respiratory distress and feeding difficulty.	Sepsis evaluation as indicated.
		Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab).
	Hypoxia and apnea may be present.
	Often indistinguishable from bronchiolitis.	Rate of concurrent bacterial infections in confirmed viral infection is low.
		CXR for significant respiratory distress.
		Supportive therapy; monitoring for apnea in young and premature infants.

Infants and Children

• More likely to have viral cause
  • Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
    • Pneumococus, H. flu, staph, pertussis
  • If age >5 consider mycoplasma (treat w/ macrolide)

Bugs by Age Group

Age Group	Bacterial Pathogens	Hospitalized Patients	Outpatients
Newborn	Group B streptococci	Ampicillin	Initial outpatient management not recommended
	Gram-negative bacilli	plus
	Listeria monocytogenes	Gentamicin or cefotaxime
1–3 mo	Streptococcus pneumoniae	Afebrile pneumonitis	Initial outpatient management not recommended
	Chlamydia trachomatis	Erythromycin or clarithromycin
	Haemophilus influenzae	Febrile pneumonia:
	Bordetella pertussis	Cefuroxime
	Staphylococcus aureus	± erythromycin IV or clarithromycin PO
		Severe: choose one of
		Cefuroxime + erythromycin or clarithromycin
		Cefotaxime + erythromycin
		Cloxacillin + clarithromycin
3 mo–5 y (majority of PNA in this group is viral)	S. pneumoniae	Ampicillin IV or cefuroxime IV	Amoxicillin
	S. aureus	or amoxicillin if PO	or amoxicillin-clavulanate
	H. influenzae type b	or amoxicillin-clavulanate if PO	or cefuroxime axetil x7-10d
	Nontypeable H. influenzae	Moderate to severe
	C. trachomatis	Add erythromycin or clarithromycin
	Mycoplasma pneumoniae
5–18 y	M. pneumoniae	Ampicillin IV	Erythromycinor clarithromycin
	S. pneumoniae	plus	or amoxicillin ± clavulanate
	C. pneumoniae	Erythromycin or clarithromycin	or cefuroxime axetil x7-10d
	H. influenzae type b	Alternative
	S. aureus	Cefuroxime
		or amoxicillin-clavulanate
		or erythromycin
		or clarithromycin
		Moderate to severe:
		Cefuroxime + erythromycin or clarithromycin

Diagnosis

• Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
  • Productive cough is rarely seen before late childhood
• Imaging
  • CXR is not the gold standard!
  • Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
  • Consider for:
    • Age 0-3mo (part of w/u for sepsis)
    • <5yr w/ temp >102.2, WBC >20K and no clear source of infection
    • Ambiguous clinical findings
    • PNA that is prolonged or not responsive to abx
• Consider rapid assays for RSV, influenza
• Blood/nasal culture are low yield

Treatment

Newborn

• Hospitalized
  • Ampicillin (80-90mg/kg/day) + (gentamicin OR cefotaxime)
• Outpatient
  • Initial outpatient management not recommended

1-3 Month

• Hospitalized
  • Afebrile pneumonitis
    • Erythromycin or clarithromycin
  • Febrile pneumonia
    • Cefuroxime ± (erythromycin IV or clarithromycin PO)
  • Severe: choose one of
    • Cefuroxime + (erythromycin or clarithromycin)
    • Cefotaxime + erythromycin
    • Cloxacillin + clarithromycin
• Outpatient
  • Initial outpatient management not recommended

3mo - 5 year

• Hospitalized
  • Ampicillin IV or cefuroxime IV
  • or amoxicillin if PO
  • or amoxicillin-clavulanate if PO
  • Moderate or severe
    • Add erythromycin or clarithromycin
• Outpatient
  • Amoxicillin
  • or amoxicillin-clavulanate
  • or cefuroxime axetil x7-10d

5yr - 18yr

• Hospitalized
  • Ampicillin IV + (erythromycin OR clarithromycin)
  • Alternative
    • Cefuroxime or amoxicillin-clavulanate or erythromycin or clarithromycin
  • Moderate to severe
    • Cefuroxime + (erythromycin or clarithromycin)
• Outpatient
  • Erythromycinor clarithromycin
  • or amoxicillin ± clavulanate
  • or cefuroxime axetil x7-10d

Comments

• High dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice for uncomplicated outpatient community acquired pneumonia
• For Inpatient treatment of pneumonia preference is to Vancomycin along with a second- or third- generation Cephalosporins.

Disposition

• All Children less than 2 months should be hospitalized
• Consider admission for:
  • Age of birth to 3mo
  • History of severe or relevant congenital disorders
  • Immune suppression (HIV, SCD, malignancy)
  • Toxic appearance/resp distress
  • SpO2 <90-93%