Community Acquired Pneumonia
Definition
Acute infection of lung parenchyma in previously healthy child, acquired outside of the hospital settings, and not hospitalized within 14 days prior to onset of symptoms. This excludes children with immunodeficiency, severe malnutrition, and postmeasles state.
Etiological Types
TABLE 1: Etiological types and characteristic differentiating features. | |||
Viral pneumonia Streptococcal | Viral pneumonia Streptococcal | Viral pneumonia Streptococcal | Viral pneumonia Streptococcal |
· Follows short upper respiratory tract infection (URTI) · Gradual onset cough · Less toxic look · Wheeze may be associated (bronchiolitis like features) · Usually, bilateral affecting all lobes · Lasts 3–5 days and resolves spontaneously | · More toxic · Rapid progression · Lobar pneumonia · Gastrointestinal manifestations (lower lobe pneumonia) | · Empyema · Cellulitis/ abscess · Necrotizing pneumonia · Pneumatocele formation | · More like viral pneumonia · Wheezing · May not be sick (walking pneumonia) · Diffuse lung involvement |
Classification
TABLE 2: Revised World Health Organization (WHO) classification (2014) in children aged 2–59 months. | |
Classification | Clinical findings |
No pneumonia | Cough and cold |
Pneumonia | Fast breathing: ≥ 50/min (2 months to 1 year) ≥ 40/min (>1–5 years) ≥ 30/min (>5 years) |
| and/or Chest indrawing | |
Severe/very severe | General danger signs | |
pneumonia | · Not able to drink/feed | |
| · Persistent vomiting | |
| · Convulsions, cyanosis | |
| · Lethargy/Unconscious | |
| · Stridor in a calm child | |
| · Severe malnutrition | |
Persistent single cardinal clinical sign which is very sensitive and specific to diagnose pneumonia is rapid breathing or tachypnea. Auscultatory features are not sensitive.
Triaging
Fig. 1: Triaging of a pneumonia case (2–59 months) in the emergency. (IV: intravenous; SpO2: oxygen saturation)
Source: Pneumonia in Children (PIC) Module of IAP Respiratory Chapter, 2021.
Initial Approach
· Community-acquired pneumonia (CAP) is a clinical diagnosis and no investigations are required in outpatient department (OPD) setting.
· Investigations required in hospitalized children—complete blood count (CBC), blood culture, chest X-ray, inflammatory markers [C-reactive protein (CRP) and procalcitonin], and molecular methods [multiplex reverse transcription– polymerase chain reaction (RTPCR) and BioFire).
· A combination of CRP, procalcitonin, and CBC—better understanding the response to the treatment.
· Isotype enzyme-linked immunosorbent assay (ELISA) for antibody detection against Mycoplasma—better than cold agglutinins.
· Pulse oximetry is helpful in assessing the severity and monitoring response to treatment in hospitalized children or those with severe disease.
Indications for Admission or Referral
TABLE 3: Indications for admission or referral. | ||
Age < 3 months Oxygen saturation (SpO2) | Age < 3 months Oxygen saturation (SpO2) | Age < 3 months Oxygen saturation (SpO2) |
< 92% | < 92% | < 92% |
Treatment
TABLE 4: Outpatient treatment (oral therapy). | |||
Age | First line | Second | If Staphylococcus aureus suspected |
<3 months Always admit and treat in the hospital | |||
3 months to 5 years | Amoxicillin (80 mg/ kg/d), BD for 5 days (in India, 40–50 mg/ kg/d is sufficient as penicillin- resistant pneumococci prevalence is <10%) | Co-amoxiclav (dose schedule same as that of amoxicillin) Or Cefpodoxime (10 mg/kg/d), BD for 5 days Or Cefuroxime (30 mg/kg/d), BD for 5 days | Co-amoxiclav (dose schedule same as that of Amoxicillin) Or Cefuroxime (30 mg/kg/d), BD for 5 days Or Linezolid* (10 mg/kg/d), TID for 5 days |
>5 years | Same as above | Co-amoxiclav or cefpodoxime (as above) Or Azithromycin (10 mg/kg/d), | Same as above |
|
| OD for 5 days (empty stomach |
|
* Linezolid is a reserve drug for tuberculosis (TB), so the National Tuberculosis Elimination Programme (NTEP) has advised to use it with caution.
Inpatient Treatment and Switch to Oral Therapy
TABLE 5: Inpatient treatment (parenteral therapy). | |||
Age | First line | Second | If Staphylococcus aureus suspected |
<3 months | Cefotaxime ± gentamicin (5–7 mg/kg/d, OD) Or Amikacin (15 mg/kg/d, OD) Or Ceftriaxone (75–100 mg/kg/d), BD | Piperacillin-tazobactam ± gentamicin or amikacin Or Cefoperazone-sulbactam ± gentamicin or amikacin | Ceftriaxone + cloxacillin (50–100 mg/kg/d, QID) Or Cefuroxime/or co- amoxiclav* + gentamicin or amikacin Second line Ceftriaxone + vancomycin (40–60 mg/kg/d, QID) or linezolid** (same as oral dose) |
3 months to 5 years | Ampicillin (100 mg/ kg/d, TID or QID)*** | Co-amoxiclav* Or Cefotaxime Or Ceftriaxone | Ceftriaxone + Cloxacillin Or Cefuroxime or Co- amoxiclav or cefazolin (50 mg/kg/d, BD or TID) Second line Ceftriaxone + vancomycin or clindamycin (20 mg/kg/d, TID or QID) |
|
|
| or linezolid** (same as oral dose) |
>5 years | Ampicillin (dose same as above) | Co-amoxiclav* Or Cefotaxime (150 mg/kg/d, TID) Or Ceftriaxone Or Azithromycin | Same as above |
* Co-amoxiclav injectable dose: 100 mg/kg/d, TID.
** Linezolid is a reserve drug for tuberculosis (TB), so the National Tuberculosis Elimination Programme (NTEP) has advised to use it with caution.
***Ampicillin dose in severe infection: 200 mg/kg/d, TID or QID.
TABLE 6: Oral therapy in hospitalized children. | |||
Etiological agents | Parenteral therapy | Oral therapy | Total duration |
Bacteria other than Staphylococcus aureus | b-lactam antibiotics | Amoxicillin OR cefpodoxime OR cefdinir (14 mg/kg/d, BD) | 7–10 days |
Methicillin- susceptible Staphylococcus aureus (MSSA) | b-lactam antibiotics | Cephalexin (50 mg/kg/d, BD or TID) Or Co-amoxiclav | 7–10 days |
Methicillin- resistant Staphylococcus aureus (MRSA) | b-lactam antibiotics + vancomycin/ clindamycin | Linezolid* Or Clindamycin | 14 days (if no complications) Or 4–6 weeks (if complications) |
* Linezolid is a reserve drug for tuberculosis (TB), so the National Tuberculosis Elimination Programme (NTEP) has advised to use it with caution.
Treatment
Macrolides in CAP (used in following situations):
· In a child immunized against Hemophilus influenzae type b (Hib)/pneumococcal conjugate vaccine (PCV): If no response to first-line antibiotics or suppurative complications of CAP are absent.
· Persistence of the following: Low-grade fever, cough, few clinical signs, and chest X-ray showing bilateral perihilar streaky infiltrates.
· Extrapulmonary manifestations not suggestive of Staphylococcus aureus or no response to antistaphylococcal antibiotics.
For Viral Pneumonia
· Only symptomatic and supportive treatment
· Oseltamivir can be given if H1N1 infection is suspected but that should be initiated within 3 days of symptoms. The details of dose schedule are provided in Table 7 [recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention CDC)].
TABLE 7: Indication and dose schedule. | |
Indications | Dose schedule |
Treatment | Infants (<1 year old): 3 mg/kg/dose twice daily Children (≥1 year old): ≤15 kg: 30 mg twice daily >15–23 kg: 45 mg twice daily >23–40 kg: 60 mg twice daily >40 mg: 75 mg twice daily |
Prophylaxis (7 days) | Not indicated in infants <3 months of age (limited data) Infants ≥3 months and <1 year of age: 3 mg/kg/dose once daily Children (≥1 year old): The doses mentioned above under different weight band should be given as once daily dosing |
Further Reading
· Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:617-30.
· Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 Suppl 2:ii1-23.
· Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2013;6:CD004874.
· Rudan I, O’Brien KL, Nair H, Liu L, Theodoratou E, Qazi S, et al. Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health. 2013;3:010401.
· World Health Organization. Integrated Management of Childhood Illness (IMCI) (revised). Geneva: World Health Organization/The United Nation Children’s Fund (UNICEF); 2014.
· World Health Organization (WHO). Antibiotic Dosing for Children: Expert Recommendations for Children Ages 2 months to 12 years. [online] Available from https://www.who.int/selection_medicines/committees/expert/21/applications/s6_ab_paed_dosing_re v.pdf. [Last accessed January, 2022].
References
- Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:617-30.
- Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 Suppl 2:ii1-23.
- Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2013;6:CD004874.
- Rudan I, O’Brien KL, Nair H, Liu L, Theodoratou E, Qazi S, et al. Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health. 2013;3:010401.
- World Health Organization. Integrated Management of Childhood Illness (IMCI) (revised). Geneva: World Health Organization/The United Nation Children’s Fund (UNICEF); 2014.
- World Health Organization (WHO). Antibiotic Dosing for Children: Expert Recommendations for Children Ages 2 months to 12 years. [online] Available from https://www.who.int/selection_medicines/committees/expert/21/applications/s6_ab_paed_dosing_re v.pdf. [Last accessed January, 2022].