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Community-Acquired Pneumonia in Children KIMBERLY STUCKEY-SCHROCK, MD, Memphis, Tennessee BURTON L

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Community-Acquired Pneumonia in Children KIMBERLY STUCKEY-SCHROCK, MD, Memphis, Tennessee BURTON L Community-Acquired Pneumonia in Children KIMBERLY STUCKEY-SCHROCK, MD, Memphis, Tennessee BURTON L. HAYES, MD, and CHRISTA M. GEORGE, PharmD University of Tennessee Health Science Center, Memphis, Tennessee Community-acquired pneumonia is a potentially serious infection in children and often results in hospitalization. The diagnosis can be based on the history and physical examination results in children with fever plus respiratory signs and symptoms. Chest radiography and rapid viral testing may be helpful when the diagnosis is unclear. The most likely etiology depends on the age of the child. Viral and Streptococcus pneumoniae infections are most common in preschool-aged children, whereas Mycoplasma pneumoniae is common in older children. The decision to treat with antibiotics is challenging, especially with the increasing prevalence of viral and bacterial coinfections. Preschool-aged children with uncomplicated bacterial pneumonia should be treated with amoxicillin. Macrolides are first-line agents in older children. Immunization with the 13-valent pneumococcal conjugate vaccine is important in reducing the severity of childhood pneumococcal infections. (Am Fam Physician. 2012;86(7):661-667. Copyright © 2012 American Academy of Family Physicians.) ommunity-acquired pneumonia infection accounts for 30 to 50 percent of CAP (CAP) is a significant cause of infections in children.7 respiratory morbidity and mor- Streptococcus pneumoniae is the most com- tality in children, especially in mon bacterial cause of CAP. The widespread C developing countries.1 Worldwide, CAP is the use of pneumococcal immunization has leading cause of death in children younger reduced the incidence of invasive disease.8 than five years.2 Factors that increase the Children with underlying conditions and incidence and severity of pneumonia in chil- those who attend child care are at higher risk dren include prematurity, malnutrition, low of invasive pneumococcal disease. Breast- socioeconomic status, exposure to tobacco feeding seems to be protective. Penicillin- smoke, and child care attendance.3 resistant S. pneumoniae infections can occur in children with recent antibiotic use.9 Etiology Mycoplasma pneumoniae, Chlamydophila Viruses cause a significant percentage of CAP pneumoniae, and S. pneumoniae are the infections, especially in children younger predominant etiologies of CAP in school- than two years (Table 1).3,4 The prevalence of aged children.3 Haemophilus influenzae and viral pneumonia decreases with age.3 Respi- group A streptococcus are less common ratory syncytial virus, influenza A, and para- causes. Staphylococcus aureus, especially influenza types 1 through 3 are the most methicillin-resistant S. aureus (MRSA), is common viral agents. Other viral pathogens increasingly common and causes significant include adenovirus, rhinovirus, influenza B, morbidity and mortality.10 Identification of and enteroviruses.5 Human metapneumo- S. pneumoniae and S. aureus as pathogens virus has been identified as can be problematic because they can be car- a common cause of CAP in ried asymptomatically.4 Mycoplasma pneumoniae, cases previously classified as Chlamydophila pneumoniae, virus-negative. The spectrum STAPHYLOCOCCUS AUREUS and S. pneumoniae are the of illness caused by metapneu- S. aureus accounts for 3 to 5 percent of CAP predominant etiologies of movirus is similar to that of infections and is a complication of seasonal CAP in school-aged children. respiratory syncytial virus.6 and pandemic influenza in children and Mixed viral and bacterial young adults.11 Reports of S. aureus infection Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2012 American Academy of Family Physicians. For the private, noncom- Octobermercial 1, use 2012 of one◆ Volume individual 86, user Number of the Web 7 site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or Family permission Physician requests. 661 Community-Acquired Pneumonia in Children associated with influenza-related deaths in Table 1. Age-Based Etiologies of Childhood children have raised concerns that this syn- Community-Acquired Pneumonia drome is increasing in frequency.10,12 In the past decade, case series have estimated that Age Common etiologies Less common etiologies 41 to 88 percent of patients with S. aureus pneumonia have MRSA isolates.10,13 2 to 24 months Respiratory syncytial virus Mycoplasma pneumoniae The potential severity of community- Human metapneumovirus Haemophilus influenzae acquired staphylococcal pneumonia in Parainfluenza viruses (type B and nontypable) children is illustrated by a study of admis- Influenza A and B Chlamydophila pneumoniae Rhinovirus sions to three children’s hospitals during 10 Adenovirus the autumn and winter of 2006 and 2007. Enterovirus Of 30 patients, 25 (83 percent) required Streptococcus pneumoniae intensive care unit treatment, 21 (70 per- Chlamydia trachomatis cent) required mechanical ventilation, five (17 percent) required extracorporeal mem- 2 to 5 years Respiratory syncytial virus Staphylococcus aureus brane oxygenation, and five (17 percent) died. Human metapneumovirus (including methicillin- resistant S. aureus) The diagnosis of staphylococcal pneumo- Parainfluenza viruses Group A streptococcus nia is challenging. No specific symptoms, Influenza A and B clinical signs, or imaging or laboratory Rhinovirus findings have been identified as having Adenovirus high specificity for staphylococcal pneu- Enterovirus monia. Cavitation on chest imaging, a pos- S. pneumoniae M. pneumoniae sible marker for staphylococcal pneumonia 14 H. influenzae (B and in adults, was identified in only two of 30 10 nontypable) children hospitalized for CAP. Physicians C. pneumoniae should have a high index of suspicion for S. aureus infection in children with CAP, Older than M. pneumoniae H. influenzae (B and especially those who are severely ill, have 5 years C. pneumoniae nontypable) current or recent influenza, or whose symp- S. pneumoniae S. aureus (including methicillin- resistant S. aureus) toms do not improve with beta-lactam or Rhinovirus Group A streptococcus Adenovirus macrolide antibiotic therapy. Respiratory syncytial virus Influenza A and B Parainfluenza viruses Diagnosis Human metapneumovirus First impressions are important in the clini- Enterovirus cal diagnosis of CAP in children. Common physical findings include fever, tachypnea, NOTE: Etiologies listed in approximate order of prevalence in the community. increasingly labored breathing, rhonchi, Information from references 3 and 4. crackles, and wheezing. Hydration status, activity level, and oxygen saturation are important and may indicate the need for hospitalization.7 Table 2. World Health Organization Tachypnea Thresholds Tachypnea seems to be the most significant for Diagnosing Pneumonia in the Presence of Cough clinical sign. To be measured accurately, the respiratory rate must be counted over a full Normal respiratory rate Tachypnea threshold minute when the child is quiet.15 In febrile Age (breaths per minute) (breaths per minute) children, the absence of tachypnea has a high 2 to 12 months 25 to 40 50 negative predictive value (97.4 percent) for 1,15,16 1 to 5 years 20 to 30 40 pneumonia. Conversely, the presence of tachypnea in febrile children has a low posi- Information from reference 18. tive predictive value (20.1 percent).15 Fever alone can increase the respiratory rate by 662 American Family Physician www.aafp.org/afp Volume 86, Number 7 ◆ October 1, 2012 Table 3. Recommended Empiric Outpatient Treatment of Childhood Community-Acquired Pneumonia Age Alberta guideline 25 Cincinnati guideline 7 10 breaths per minute per degree Celsius.16 In febrile children with tachypnea, findings 60 days to Preferred regimens 5 years* Amoxicillin Amoxicillin of chest retractions, grunting, nasal flaring, † 40 mg per kg per day for 80 to 90 mg per kg per day, and crepitation increase the likelihood of 7 to 10 days in two divided doses, for 16 pneumonia. The World Health Organiza- or 7 to 10 days tion uses tachypnea in the presence of cough 90 mg per kg per day, as the diagnostic criterion of pneumonia in in three divided doses, developing countries where chest radiogra- for 7 to 10 days phy is not readily available 17,18 (Table 2 18). Alternative regimens for patients allergic to penicillin or beta-lactam antibiotics Chest radiography is often used to diag- Azithromycin (Zithromax) Azithromycin nose CAP. Many studies use chest radiog- Day 1: 10 mg per kg Day 1: 10 mg per kg raphy as the preferred diagnostic modality, Days 2 through 5: 5 mg Days 2 through 5: 5 mg per kg but positive findings have not been shown per kg per day per day to improve clinical outcomes or significantly Clarithromycin (Biaxin) Clarithromycin 17 change treatment. Chest imaging is most 15 mg per kg per day, 15 mg per kg per day, in two useful when the diagnosis is uncertain or in two divided doses, divided doses, for 7 to 10 days when the findings from the history and phys- for 7 to 10 days ical examination are inconsistent. Antigenic Erythromycin Cefprozil (Cefzil) tests are available to aid in the detection of 40 mg per kg per day, 30 mg per kg per day, in two in four divided doses, divided doses, for 7 to 10 days respiratory syncytial virus and influenza for 7 to 10 days A and B. The Infectious Diseases Society of Cefuroxime (Ceftin) America recommends that all persons with 30 mg per kg per day, in two fever and respiratory symptoms be tested for divided doses, for 7 to 10 days influenza when it is present in the commu- Ceftriaxone (Rocephin)‡ nity.19 The American Academy of Pediatrics Single dose of 50 mg per kg, recommends testing for respiratory syncytial administered intramuscularly virus only when the diagnosis is unclear.20 5 to 16 years Azithromycin§ Azithromycin|| Bacterial pneumonia may be suspected Day 1: 10 mg per kg Day 1: 10 mg per kg Days 2 through 5: 5 mg Days 2 through 5: 5 mg per kg based on radiographic findings; however, per kg per day per day these findings are not highly specific. Pleu- ral effusion on chest radiography is the most *—Age range in Alberta guideline is three months to five years.
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