Pediatric Pneumonia

 3-year-old boy presents to the ED with a 4-day history of cough and 1-day history of fever. Per family patient has been having rigors and chills with vomiting. He also reports chest pain with coughing. His immunizations are UTD. The child does not appear toxic,

VS: Temp 103.3F,  BP 90/65,  HR 100,  RR 30,  96% O2 Saturation on RA.
Patient has some intercostal retractions, with decreased air entry on the right side with audible crackles.

Questions for EM physician

• How do you make the diagnosis of pneumonia?
• Distinguishing patients with bacterial pneumonia, who would benefit from antibiotics, from those with nonbacterial pneumonia who would not.
• Who requires inpatient management vs. patients that can be safely discharged home on oral antibiotics.
• Pneumonia is the number 1 killer of children worldwide.
• Pneumonia occurs more often in early childhood than at any other age and causes significant morbidity and mortality.
• Identifying the cause of pneumonia in children is difficult due to a lack of rapid, accurate, commercially available laboratory tests for most pathogens. Empirical therapy based on patient’s age, clinical scenario and risk factor is the most common course in most cases.

Age-specific causes of pneumonia in otherwise healthy children. Pathogen listed in order of frequency
Neonates	GBS, E. Coli, Listeria Monocytogenes, Staphylococcus
1 month – 2 years	RSV, Parainfluenza virus, Metapneumovirus, Influenza virus, Adenovirus, S. Pneumoniae  **3 weeks to 3 months of age (Pneumonitis syndrome/Afebrile Pneumonia Syndrome (APS))*: Chlamydia trachomatis, RSV, Parainfluenza virus, Bordetella pertussis
2 – 5 years	RSV, S. Pneumoniae, Non-typeable H. Influenzae (NTHi), Group A Streptococcus, Mycoplasma pneumonia, Chlamydia pneumonia
6 – 18 years	Mycoplasma pneumonia, Chlamydophila pneumonia, Streptococcus pneumonia, NTHi, Influza virus A , other respiratory viruses
	*Infants (1 – 3 months of age) may present with a characteristic syndrome of cough, tachypnea, progressive respiratory distress, and radiographic evidence of bilateral diffuse pulmonary infiltrates with air trapping. Most are afebrile. This syndrome is also called APS. The most common pathogen included Chlamydia trachomatis and respiratory viruses. Infection of Bordetella pertussis should also be considered due to recent dec. in immunization. Acutely, APS is generally benign and self-limiting disease. In such cases, infants often have viral illness, which does not respond to antibiotic therapy, but differentiating bacterial from viral illness is often difficult. Consider empiric antibiotic therapy.

Diagnosis of pneumonia:

• • Definition: Essentially it is infection of lower respiratory tract in the presence of radiographic abnormalities on CXR.
  • WHO guidelines for pneumonia in children is cough and tachypnea
    • Age < 2 months: Tachypnea is >60 RR
    • Age 2 months to 5 months: Tachypnea is >50 RR
    • Age >12 months: Tachypnea is > 40 RR

• • Clinical features
    • Fever and tachypnea are sensitive but not specific
    • Cough
    • Productive cough is rarely seen before late childhood
    • Consider pneumonia in any child presenting with prolonged fever, prolonged cough, high fever, as well as focal respiratory findings not including wheezing, especially with the presence of multiple symptoms.

Evaluation
Absence of tachypnea, respiratory distress, and rales/decreased breath sound rules-out pneumonia with 100% sensitivity

• CXR: Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
  • • Consider for:
      • Age 0-3mo (as part of sepsis work up)
      • <5yr with temperature >102.2, WBC >20K and no clear source of infection
      • Ambiguous clinical findings
      • Pneumonia that is prolonged or not responsive to antibiotics
  • Consider RSV, Influenza 

Treatment

Empiric Antimicrobial Therapy For Children with Pneumonia by Age group
Age group	Outpatient	Inpatient
Neonates	NOT RECOMMENDED	Ampicillin 200 mg/kg/d IV divided Q6H + Gentamycin 7.5 mg/kg/d IV divided Q8H OR + Cefotaxime 150mg/kg/day IV divided Q8H Consider Cloxacillin and Nafcillin for patient with S. aureus infection or Vancomycin for MRSA
3 wk – 3 mo	NOT RECOMMENDED	Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days
3 mo – 5 yr*	Amoxicillin 80 – 100mg/kg/day in 2 divided doses	Ampicillin 200 mg/kg/d IV divided Q6H OR Ceftriaxone 50 mg/kg Q24hrs Consider Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days Consider Vancomycin for seriously ill patients
6yr – 18yr*	Azithromycin 10 mg/kg for first dose, then 5 mg/kg daily for 4 days	Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days PLUS Ceftriaxone 50 mg/kg Q24hrs Consider Vancomycin for seriously ill patients
*Refer to AAP guideline on management of pediatric pneumonia below

Disposition

• Consider Admission For
  • Age: <2-3 months old (Consider up to 6 months)
  • History of severe or relevant congenital disorders (Cystic fibrosis)
  • Suspected complication (Empyema)
  • Vomiting, dehydration, unable to tolerate PO
  • Immune suppression (HIV, SCD, malignancy)
  • Toxic appearance/respiratory distress
  • SpO2 <90-93%
  • Social circumstances

Post by Dr. Michael Hong