1. Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age
Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD
Department of Pediatrics, Boonshoft School of Medicine, Wright State University, The Children’s Medical Center of Dayton

2. Clin Infect Dis 2011; 53 (7):

3. Objectives
List common pathogens causing community-acquired pneumonia (CAP) in infants and children.
Discuss appropriate use of diagnostic laboratory and imaging tests in a child with CAP in an outpatient or inpatient setting.
Review choice of anti-infective therapy and duration of treatment provided to a child with suspected CAP in the outpatient or inpatient setting.

4. “Teasers are docile male horses, usually
old and past prime with undesirable
genes, who set up aggressive just
off-the-track mares to be bred by the
wild testosterone crazed prize stallions
whose only job is to deliver the goods,
which they do. “

5. A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient?
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above

6. A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient?
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above

7. A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria?
Able to tolerate outpatient meds, greater level of activity, improving appetite.
Afebrile for over 24 hours
Pulse oximetry measurements >90% in room air at least 12 hours
A and C
A, B, and C

8. Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient?
A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided 2 times a day for 10 days
Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5
Combined treatment with both amoxicilln and azithromycin as noted above
No anti-infective therapy indicated

9. A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s
A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended?
A third-generation parenteral cephalosporin (e.g., cefotaxime or ceftriaxone)
Intravenous clindamycin
A third-generation parenteral cephalosporin plus azithromycin
Intravenous ampicillin
Intravenous vancomycin

10. A 5 yr old is admitted with a right upper lobe pneumonia
A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of:
Ceftriaxone intravenously at 100mg/kg/day
Levofloxacin intravenously at 20 mg/kg/day
Ampicillin intravenously at 400 mg/kg/day
A or C
A, B, or C

11. Introduction
The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple subspecialists and expert consultants to create and review guidelines
Guidelines endorsed by AAP, American College of Emergency Physicians, Society of Critical Care Medicine….
The guidelines grade method of recommendation, low or very low evidence situations require clinical judgment

12. Strength of Recommendations

13. Strength of Recommendations

14. Inpatient Criteria
Age 3-6 months with a suspicion of bacterial pneumonia
Suspicion or documentation of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia
Concern for follow up or administration of home therapy

15. Patients Requiring Hospitalization

16. Diagnostic approach to
the child with pneumonia

17. Outpatient Diagnostics
Chest radiography, blood culture, CBC, ESR/CRP not necessary
Pulse oximetry should be obtained in all patients
If available a rapid test for influenza and for other viral pathogens should be obtained
Testing for Mycoplasma pneumoniae should be obtained if suspicious
If no improvement on antibiotics for hrs, a CXR and blood culture should be obtained

18. Inpatient Workup All pt’s should have CXR Blood culture CBC ESR/CRP
Urinary antigen for Pneumococcal infection is not recommended
Sputum samples if able (weak; low evidence)
Rapid tests for Influenza and viruses should be used
Mycoplasma pneumoniae should be tested for if suspicious
No reliable test for Chlamydophila pneumoniae

19. Inpatient Diagnostics
A routine repeat CXR is not necessary
Repeat CXR should be obtained if no clinical improvement is demonstrated by hrs
If blood culture yields MRSA, a repeat culture is mandatory todocument sterility of the blood.
If blood culture is positive for another organism, repeat culture of blood is not mandatory
Tracheal aspirate should be obtained in patient with endotracheal intubation

20. Criteria for admission to an ICU

21. Criteria for admission to an ICU

22. Criteria for admission to an ICU
Intubation, continuous CPAP or BIPAP
Sustained tachycardia or hypotension
<92% SpO2 on >50% FiO2
Altered mental status
Clinical judgment should be used regardless of scores

23. Discharge Criteria Improved Clinical Status >12 hrs
RA with Sp02 >90% >12 hrs
No increased work of breathing , tachypnea or tachycardia
Able to tolerate outpatient therapy
Chest tube out for >12 hrs

24. Outpatient Treatment of Pneumonia
Antibiotics not routinely required for preschool-aged children
High-dose amoxicillin should be considered first line for presumed bacterial pneumonia in all ages
90 mg/kg/day divided bid
TID dosing is required for Pen-resistant pneumococcus (MIC > 2 µg/mL)
Macrolides (azithromycin) should be considered in school-aged and adolescents with illness consistent with atypical pneumonia

25. Atypical vs. Bacterial Gradual onset
Malaise, headache, sore throat, ear infections
Lower fevers ( )
Usually nonproductive, persistent cough
May or may not have rales
Gradual or acute onset
Fatigue, dyspnea, chest pain
Fevers often higher (>103)
Cough more often productive
Decreased or bronchial breath sounds, rales, dullness to percussion, egophony

26. Manifestations of Mycoplasma pneumonia

27. Outpatient Treatment of Pneumonia
For presumed atypical pneumonia, azithromycin is first-line
10 mg/kg on day 1; 5 mg/kg on days 2-5
In season, treat influenza presumptively until a sensitive test is negative
10-day course of antibiotics is usually adequate
Azithromycin: 5 day course
MRSA will require a longer course (and hospitalization!)

29. Inpatient Treatment of Pneumonia
For the fully immunized child in regions that do not demonstrate high-level pneumococcal penicillin resistance:
Ampicillin or Penicillin G are first-line
Azithromycin for suspected atypical pneumonia (with a beta-lactam if diagnosis is in question)
Vancomycin or clindamycin should be added when S. aureus is suspected by labs, clinical findings or imaging
Ceftriaxone or cefotaxime are alternatives

30. Inpatient Treatment of Pneumonia
For a not fully immunized child or in regions that demonstrate high-level pneumococcal penicillin resistance:
Ceftriaxone or cefotaxime is preferred
Add azithromycin if considering atypical pneumonia
Add vancomycin or clindamycin for S. aureus
Ceftriaxone or cefotaxime also preferred for life-threatening infections and empyema

31. Empiric Inpatient Treatment of CAP

32. Pneumococcal Penicillin Resistance
MIC < 0.06 µg/mL: very susceptible
Standard-dose oral amoxicillin effective
MIC µg/mL: susceptible
High-dose oral amoxicillin effective
MIC 1-2: somewhat resistant
High-dose oral amoxicillin >90% effective
MIC 2-4: resistant
Oral therapy likely to fail; IV ampicillin or penicillin
MIC >4: very resistant
Standard-dose ampicillin likely to fail; ceftriaxone effective

34. Specific Treatment for CAP

35. Specific Treatment of CAP

36. Specific Treatment of CAP

37. Specific Treatment of CAP

38. Specific Treatment of CAP

39. Viral Pneumonia in Children
Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia (except influenza)
Hamano-Hasegawa, J Infect Chemother (2008)
Younger children more likely to have viral pneumonia
Evidence of bacterial co-infection in 33%
Michelow, Pediatrics (2004)
Bacterial co-infections seen in 54% of viral pneumonias
67% of influenza pneumonia
55% of RSV pneumonia

40. Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics Apr;113(4):701-7.

41. Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics Apr;113(4):701-7.

42. Viral Pneumonia in Children
A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pneumonia
27% developed influenza-associated pneumonia
Of these, 2% had a bacterial co-infection
18 identified by blood cultures; 3 by pleural fluid
The actual incidence of secondary bacterial pneumonia with influenza is likely much higher
Dagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized With Laboratory-Confirmed Influenza, ” Pediatr Infect Dis J Jul;29(7):

43. Adjunctive Therapy CXR should be obtained if suspicious for effusion
US or CT if CXR is inconclusive
Size of effusion and respiratory compromise will determine treatment

45. Pleural Fluid Tests Gram stain (+25-50%)
Antigen or PCR if available (S. pneumoniae, S.aureus)
Pleural fluid analysis rarely changes management and is not recommended
WBC count with differntial helps differentiate source
Majority of cultures will be negative

46. Effusion/Empyema
Total antibiotic therapy 2-4 weeks or 10 days after resolution of fever
If abscess or necrosis is identified tx should begin with IV antibiotics
If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV antibiotics
Abscess secondary to congenital malformation requires surgery consultation
Necrosis should not routinely be managed surgically given high rates of broncho-pleural fistulas

47. A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient?
Complete blood count
Chest radiograph
Pulse oximetry
Blood culture
All of the above

48. A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria?
Able to tolerate outpatient meds, greater level of activity, improving appetite.
Afebrile for over 24 hours
Pulse oximetry measurements >90% in room air at least 12 hours
A and C
A, B, and C

49. Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient?
A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided 2 times a day for 10 days
Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5
Combined treatment with both amoxicilln and azithromycin as noted above
No anti-infective therapy indicated

50. Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient?
A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days.
Amoxicillin 90mg/kg/day divided 2 times a day for 10 days
Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5
Combined treatment with both amoxicilln and azithromycin as noted above
No anti-infective therapy indicated

51. A 5 yr old is admitted with a right upper lobe pneumonia
A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of:
Ceftriaxone intravenously at 100mg/kg/day
Levofloxacin intravenously at 20 mg/kg/day
Ampicillin intravenously at 400 mg/kg/day
A or C
A, B, or C

52. BMJ 2003; 327: