Pneumonia is still the leading killer of children worldwide (29% of pediatric deaths worldwide, 158 million cases per year; 3 million deaths per year). The death rates in underdeveloped countries is 2000x that of children in developed countries.
Viral causes (particulalry RSV) predominate before school age. Upto 30% of children with viral pneumonia develop coexisting bacterial pneumonia
| Age | Pathogen |
|---|---|
| Newborn (0-1 mo) | GBS, Gram negatives, Listeria |
| 3 wks. – 3mos. | RSV, Parainfluenza, S. pneumoniae, S. aureus, C. trachomatis, B- pertussis |
| 4 mos. – 4yrs | RSV, other viruses, S. pneumoniae, M. pneumoniae |
| 5 yrs. – 15 yrs. | M. pneumoniae, S. pneumoniae, C. pneumoniae |
In newborn and very young infants, the presentation of pneumonia is different and the situation is much more severe.
- Common Symptoms
- Productive cough (from onset, diff from acute bronchitis where cough is unproductive and becomes more productive with time)
- Fever
- Viral Signs and Symptoms
- Low-grade fever
- URTI symptoms
- Mild tachypnea
- Crackes/wheezing
- Bacterial Signs and Symptoms
- High-grade fever
- Chills
- Severe, hacking cough
- Chest pain
- More sick looking
- Tachypnea
- Adventitious lung sounds
- Local dullness to percussion (important to ask the child to inhale and percuss to find areas of dullness)
- Respiratory distress
- Cyanosis
- Diminshed breath sounds (indicates respiratory fatigue)
- Mycoplasma/Chalamydia Signs and Symptoms
- Gradual onset of constitutional symptoms
- Worsening cough and Hoarseness
- URTI symptoms
- Dyspnea
- Rales
- CXR out of proportion to presentation
- Differentials
- Acute bronchitis: absent to low-grade fever, less severe presentation; CXR unremarkable
- Bronchioloitis: Young pt (<2-3 yoa); wheezing, hyperinflation, positive RSV swab, prolonged expiratory phase
- Cystic fibrosis: repeated episodes, no newborn screening, FHx, FTT
- Investigations
- Respiratory evaluation: RR, SpO2, supp. O2, apnea monitor if necessary
- CBC w/differential
- <20 WBCs, Lymphocytes high**: Viral process**
- 20, WBC left-shift: Bacterial process
- Sputum/Blood Cx (bacterial process, sepsis related) or NP swab (viral process)
- CXR (AP and Lateral views)
- CXR viral: Hyperinflation, Generalized infiltrates, Peribronchial cuffing
- CXR pneumococcal: Lobar consolidation
- CXR S. aureus: Abscess/Cavitating lesions (suspect when child has been hospitalized)
- *CXR Mycoplasma and Chlamydia:*No CXR is pathognomic for Mycoplasma or Chlamydia pneumonia, Unilateral lower lobe interstitial pneumonia, CXR out of proportion to presentation
- How do you make a definitive diagnosis of Pneumonia?
- Viral: isolate from respiratory swabbing
- Bacterial: isolate from blood cx (high false negative rate in S. pneumoniae infection)
- Mycoplasma: IgM titres
- When to hospitalise patients with pneumonia
- Age <6mos (more likely to have respiratory distress)
- Respiratory distress
- Requires supplemental O2
- Dehydrated
- Vomiting (can’t tolerate PO fluids or meds, needs IV Tx)
- Multiple lobar involvement
- Toxic appearance
- Immunocompromised
- No response to PO Antibiotics
- Social/care issues
- Treatment of viral pneumonia
- Supportive care
- Monitor
- Return for any deterioration
- Treatment of bacterial pneumonia
- Outpatient: Amoxicillin PO or Amoxicilin/Clavulanate, Cefuroxime
- Inpatient: Ceftriaxone or Cefotaxime
- If developed pneumonia in hopsital or CXR suggests S. aureus add Vancomycin or Clindamycin (Tx for MRSA)
- Treatment of Mycoplasma/Chamydia pneumoniae
- Azithromycin or Erithromycin or Respiratory FQs (Levofloxacin, Gatifloxacin, Moxifloxacin)
| Clinical Findings | Viral | Bacterial |
|---|---|---|
| Temperature | Low-grade | High |
| URTI sx | + | – |
| Toxicity | + | +++ |
| Crackles | Scattered | Localized |
| Dullness to percussion | – | Localized |
| WBC | Normal | Elevated, left shift |
| CXR | Streaking | Lobar consolidaition |
| Definitive dx | NP swab | Sputum/Blood cx |
