Pneumonia (peds)

Background

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

Causes

Neonatal

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

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%