Childhood pneumonia: clinical features It is not possible to distinguish between bacterial and viral pneumonia on clinical grounds alone! Suggestive of bacteria: • Rapid onset (tachypnea, cough, retractions) • Likely to appear very sick • Higher temperatures (>39º C) Suggestive of virus: • Low-grade fever, irritable but not toxic (usually!) • Associated complaints: HA, sore throat, myalgias, GI complaints • Longer prodrome (2-3 days or longer) • Concomitant URI symptoms at times
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Childhood pneumonia: clinical features It is not possible to distinguish between bacterial and viral pneumonia on clinical grounds alone! Suggestive of.
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Childhood pneumonia: clinical features
It is not possible to distinguish between bacterial and viral pneumonia on clinical grounds alone!
Suggestive of bacteria:• Rapid onset (tachypnea, cough, retractions)• Likely to appear very sick• Higher temperatures (>39º C)
Suggestive of virus:• Low-grade fever, irritable but not toxic (usually!)• Associated complaints: HA, sore throat, myalgias, GI complaints• Longer prodrome (2-3 days or longer)• Concomitant URI symptoms at times
Indications for hospitalization in pediatric pneumonia
• Considered for most infants <4 months of age (unless viral etiology/Chlamydia trachomatis and child relatievly asymptomatic)
• Hypoxemia (oxygen saturation <92%)• Dehydration, poor oral intake• Moderate to severe respiratory distress: RR> 70 breaths/min in infanst <12
months or >50 breaths/min in older children, difficulty breathing, apnea, grunting
• Toxic appearance (tends to be more common with bacterial etiologies)• Underlying conditions predisposing to a more serious course
(cardiopulmonary disease, immunocompromised, metabolic disorders)• Presence of complications – effusions/empyema• Failure of outpatient therapy (worsening or no response in 24-72 hours)
Indications for treatment in an intensive care unit in pediatric pneumonia
• Failure to maintain O2 saturation >92% in FiO2 >0.5-0.6• Signs of impending respiratory failure (lethargy, increasing work of
breathing, and/or fatigue with or without hypercarbia)• Recurrent apneic episodes or slow, irregular respirations• Cardiovascular compromise with progressive tachycardia and/or
Remember to consider tuberculosis, endemic fungal disease (histoplamosis), aspiration pneumonitis, Pneumocystis jiroveci, pertussis, CMV, and other etiologic agents in
certain age groups and in specific clinical settings!
Childhood pneumonia: clinical features
Suggestive of Mycoplasma pneumoniae• Older children• Multiple organ systems may also be involved• Rapid and progressive disease in sickle cell anemia
Suggestive of Chlamydia trachomatis (in young infant):• Afebrile pneumonia with tachypnea and crackles• May be associated with conjunctivitis, FTT
“… we have found that studies assessing the diagnostic accuracy of clinical, radiological, and laboratory tests for bacterial childhood pneumonia have used a heterogeneous group of gold standards, and found, at least in part because of this, the index tests have widely different accuracies. These findings highlight the need for identifying a widely accepted gold standard for diagnosis of bacterial pneumonia in children.”
Lynch T, et al. A systematic review on the diagnosis of pediatric bacterial pneumonia: When gold is bronze. Plos ONE 2010; 5(8): e11989. doi:10.1371/journal.pone.0011989
Michelow IC, et al. Pediatrics 2004; 113:701-707
Michelow IC, et al. Pediatrics 2004; 113:701-707
Michelow IC, et al. Pediatrics 2004; 113:701-707
Michelow IC, et al. Pediatrics 2004; 113:701-707
Parenteral empiric antibiotics for inpatient treatment of pediatric pneumonia
Remember: Most community-acquired pneumonia in children <5 years is caused by a virus!
Age group Empiric regimen
Birth to 3 weeks
Bacteria – Group B streptococcus, Ampicillin 200mg/kg/d + gentamicin 5 mg/kg/d