community-acquired pneumonia in children- clinical features and diagnosis

11/11/2015 Community-acquired pneumonia in children: Clinical features and diagnosis

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Official reprint from UpToDate

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AuthorWilliam J Barson, MD

Section EditorsSheldon L Kaplan, MDGeorge B Mallory, MD

Deputy EditorMary M Torchia, MD

Communityacquired pneumonia in children: Clinical features and diagnosis

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Oct 2015. | This topic last updated: Oct 07, 2015.

INTRODUCTION — Communityacquired pneumonia (CAP) is defined as signs and symptoms of an acuteinfection of the pulmonary parenchyma in a previously healthy patient who acquired the infection in thecommunity, as distinguished from hospitalacquired (nosocomial) pneumonia [1,2]. CAP is a common andpotentially serious illness with considerable morbidity.

The clinical features and diagnosis of CAP in children will be reviewed here. The epidemiology,pathogenesis, and treatment of pneumonia in children are discussed separately. (See "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology" and "Communityacquired pneumonia in children:Outpatient treatment" and "Pneumonia in children: Inpatient treatment".)

CLINICAL PRESENTATION — The clinical presentation of childhood pneumonia varies depending uponthe responsible pathogen, the particular host, and the severity. The presenting signs and symptoms arenonspecific; no single symptom or sign is pathognomonic for pneumonia in children.

Symptoms and signs of pneumonia may be subtle, particularly in infants and young children. Thecombination of fever and cough is suggestive of pneumonia; other respiratory findings (eg, tachypnea,increased work of breathing) may precede cough. Cough may not be a feature initially since the alveoli havefew cough receptors. Cough begins when the products of infection irritate cough receptors in the airways.The longer fever, cough, and respiratory findings are present, the greater the likelihood of pneumonia [3].

Neonates and young infants may present with difficulty feeding, restlessness, or fussiness [4]. Youngchildren (ie, <5 to 10 years of age) may present with fever and leukocytosis [3,5]. Older children maycomplain of pleuritic chest pain (pain with respiration), but this is an inconsistent finding. Occasionally, thepredominant manifestation may be abdominal pain (because of referred pain from the lower lobes) or nuchalrigidity (because of referred pain from the upper lobes). "Walking pneumonia" is a term that is sometimesused to describe pneumonia in which the respiratory symptoms do not interfere with normal activity.

CLINICAL EVALUATION — The evaluation of the child with cough and potential lower respiratory tractdisease has two goals: the identification of the clinical syndrome (eg, pneumonia, bronchiolitis, asthma) andan assessment of the severity of the illness [4]. The severity of illness determines the need for additionalevaluation.

History — Important aspects of the history for children with possible communityacquire pneumonia arelisted in the table (table 1) [4,6,7]. Historical features can be helpful in determining the etiologic agent, thelikelihood of infection with an organism that is resistant to antibiotics, and the severity of illness. (See"Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)

Examination — Important aspects of the examination are summarized in the table (table 2) and discussedin greater detail below.

General appearance — In the young infant, assessment of general appearance includes the ability toattend to the environment, to feed, to vocalize, and to be consoled. The state of awareness and presence ofcyanosis should be assessed in all children, although children may be hypoxemic without cyanosis [8]. Mostchildren with radiographically confirmed pneumonia appear ill [9].

Fever — Fever is a common manifestation of pneumonia in children [10]. However, it is nonspecific and

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variably present. Young infants may have afebrile pneumonia related to Chlamydia trachomatis or otherpathogens. (See "Chlamydia trachomatis infections in the newborn", section on 'Pneumonia' and"Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'In infants'.)

Fever may be the only sign of occult pneumonia in highly febrile young children. In one report, 26 percent of146 children (<5 years) with fever ≥39ºC (102.2°F), no clinical evidence of pneumonia or other localizingsigns, and peripheral white blood cell count ≥20,000/microL had radiographic evidence of pneumonia [5].

Tachypnea — Tachypnea is the most sensitive and specific sign of radiographically confirmedpneumonia in children [4,1113]. In a systematic review of studies evaluating the correlation between clinicalexamination findings and radiographic pneumonia, tachypnea was twice as frequent in children with thanwithout radiographic pneumonia, and the absence of tachypnea was the single most valuable sign forexcluding pneumonia [4]. Tachypnea in infants with pneumonia (respiratory rate >70 breaths/min) also hasbeen associated with hypoxemia [14]. Tachypnea may be less useful early in the course of illness (eg, lessthan three days) [11].

The World Health Organization agerelated definitions of tachypnea are as follows [15,16]:

The respiratory rate varies with activity in infants and young children, and in these patients is best assessedby counting for a full 60 seconds [4,1719]. Observation of chest wall movements is preferable toauscultation because auscultation may stimulate the child, falsely elevating the rate [4]. The respiratory ratemay increase by as many as 10 breaths per minute per degree (Celsius) of fever in children withoutpneumonia [20]; the effect of fever on respiratory rate in children with pneumonia has not been investigated[4].

Respiratory distress — Signs of respiratory distress include tachypnea, hypoxemia (peripheral arterialoxygen saturation [SpO ] <90 percent on room air at sea level), increased work of breathing (intercostal,subcostal, or suprasternal retractions; nasal flaring; grunting; use of accessory muscles), apnea, and alteredmental status [1].

Oxygen saturation should be measured in any child with increased work of breathing, particularly if he or shehas a decreased level of activity or agitation [1,2,21]. Infants and children with hypoxemia may not appearcyanotic [8]. Hypoxemia is a sign of severe disease and an indication for admission [1,2].

Signs of respiratory distress are more specific than fever or cough for lower respiratory tract infection. In areview of 192 febrile infants younger than three months of age, the specificity of at least one sign ofrespiratory distress for radiographic pneumonia (respiratory rate >60 breaths/min, retractions, flaring,crackles, grunting, apnea, or cyanosis) was 93 percent, but the sensitivity was only 59 percent [22].

Signs of respiratory distress that are predictive of pneumonia include hypoxemia (defined differently indifferent studies, usually oxygen saturation <94 to 96 percent in room air), retractions, head bobbing, andnasal flaring [7,9,12,23]. Unlike tachypnea, the absence of these findings does not exclude a diagnosis ofpneumonia.

Younger than two months: >60 breaths/minTwo to 12 months: >50 breaths/minOne to 5 years: >40 breaths/min≥5 years: >20 breaths/min

2

In a review of children 2 to 59 months of age, oxygen saturation ≤96 percent in room air was 2.8 timesmore frequent among children with pneumonia than without [12]

In a systematic review, retractions were 2.5 times more frequent in infants with pneumonia than without[4]

Nasal flaring is approximately three times more frequent in children <5 years with pneumonia thanwithout [4], and five times more frequent in infants 2 to 12 months with pneumonia than without [12]



Lung examination — Examination of the lungs may provide clues to the diagnosis of pneumonia and/orpotential complications.

Auscultation is an important component of the examination of the child who presents with findings indicativeof pneumonia. However, auscultatory findings have less interobserver agreement than observable findings,such as retractions [4]. Auscultation of all lung fields should be performed.

Examination findings consistent with radiographically confirmed pneumonia include [13]:

Severity assessment — An assessment of pneumonia severity is necessary to determine the need forlaboratory and imaging studies and the appropriate treatment setting. The severity of pneumonia isassessed by the child's overall clinical appearance and behavior, including an assessment of his or herdegree of awareness and willingness to eat or drink (table 3) [7].

Clues to etiology — Clinical features classically taught to be characteristic of bacterial pneumonia, atypicalbacterial pneumonia, or viral pneumonia are summarized in the table (table 4). However, the featuresfrequently overlap and cannot be used reliably to distinguish between the various etiologies [26,27]. Inaddition, as many as 50 percent of infections may be mixed bacterial/viral infections. (See "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology", section on 'Communityacquired pneumonia'.)

Grunting, when present, is a sign of severe disease and impending respiratory failure [24]

Crackles, also called rales or crepitations; in a systematic review, crackles were 3.5 times morefrequent in infants with radiographic pneumonia than without [4]

Findings consistent with consolidated lung parenchyma, including:

Decreased breath sounds•

Bronchial breath sounds (louder than normal, with short inspiratory and long expiratory phases,and higherpitched during expiration), egophony (E to A change)

•

Bronchophony (the distinct transmission of sounds such as the syllables of “ninetynine”)•

Whispered pectoriloquy (transmission of whispered syllables)•

Tactile fremitus (eg, when the patient says “ninetynine”)•

Dullness to percussion•

Wheezing is more common in pneumonia caused by atypical bacteria and viruses [25] than bacteria(see 'Clues to etiology' below)

Findings suggestive of pleural effusion include chest pain with splinting, dullness to percussion, distantbreath sounds, and a pleural friction rub (see "Epidemiology; clinical presentation; and evaluation ofparapneumonic effusion and empyema in children", section on 'Clinical presentation')

Bacterial – Classically, bacterial ("typical") pneumonia, usually resulting from Streptococcuspneumoniae and less commonly from Staphylococcus aureus and group A Streptococcus, which mayfollow days of upper respiratory tract infection symptoms, is considered abrupt in onset, with the febrilepatient appearing ill and sometimes toxic. Respiratory distress is moderate to severe; auscultatoryfindings may be few and focal, limited to the involved anatomic segment. Signs and symptoms ofsepsis and localized chest pain (signifying pleural irritation) are more suggestive of bacterial etiology[10], as they are rarely present in nonbacterial pneumonia. Complications, discussed below, also aremore suggestive of bacterial etiology (see 'Complications' below) On the other hand, primary bacterialpneumonia is unlikely in children older than five years if wheezing is present [28].

Pneumococcal pneumonia is the most common typical bacterial pneumonia in children of all ages. Inone retrospective review of 254 children and young adults (age <1 month to 26 years) with



Pneumococcal pneumonia in children is discussed in greater detail separately. (See "Pneumococcalpneumonia in children".)

pneumococcal pneumonia, the most common signs and symptoms and their approximate frequenciesare listed below [29]:

Fever: 90 percent•

Cough: 70 percent; productive cough: 10 percent•

Tachypnea: 50 percent•

Malaise/lethargy: 45 percent•

Emesis: 43 percent•

Hypoxemia (oxygen saturation ≤95 percent): 50 percent•

Decreased breath sounds: 55 percent•

Crackles: 40 percent•

Atypical bacterial – "Atypical" bacterial pneumonia resulting from Mycoplasma pneumoniae orChlamydia pneumoniae usually presents abruptly with constitutional findings of fever, malaise andmyalgia, headache, photophobia, sore throat, and gradually worsening nonproductive cough despiteimprovement of other symptoms [25,28]. Although hoarseness may be seen in disease caused by bothagents, it is more frequently seen with C. pneumoniae infection. Wheezing is a frequent finding inatypical bacterial and viral pneumonias [10]. (See "Pneumonia caused by Chlamydia species inchildren" and "Mycoplasma pneumoniae infection in children", section on 'Clinical features'.)

M. pneumoniae may be associated with a variety of extrapulmonary manifestations. Dermatologicmanifestations may range from a mild erythematous maculopapular rash or urticaria to the StevensJohnson syndrome. Other extrapulmonary manifestations include hemolytic anemia, polyarthritis,pancreatitis, hepatitis, pericarditis, myocarditis, and neurologic complications [30]. (See "Mycoplasmapneumoniae infection in children", section on 'Clinical features'.)

Infants younger than one year of age may develop "afebrile pneumonia of infancy". Afebrile pneumoniaof infancy is a syndrome generally seen between two weeks and three to four months of life. It isclassically caused by C. trachomatis, but other agents, such as cytomegalovirus, M. hominis, andUreaplasma urealyticum, also are implicated. The clinical presentation is one of insidious onset ofrhinorrhea and tachypnea followed by a staccato cough pattern (individual coughs separated byinspirations). Physical examination typically reveals diffuse inspiratory crackles. Conjunctivitis may bepresent, or there may have been a past history of conjunctivitis [31]. (See "Chlamydia trachomatisinfections in the newborn", section on 'Pneumonia'.)

Viral – The onset of viral pneumonia is gradual and associated with preceding upper airway symptoms(eg, rhinorrhea, congestion). The child does not appear toxic. Auscultatory findings are usually diffuseand bilateral. In one study of 98 ambulatory children with pneumonia, wheezing was more frequent inpatients with viral than bacterial pneumonia (43 versus 16 percent), but other clinical features oftenassociated with viral illness, such as rhinorrhea, myalgia, and ill contacts, were not [32].

Some viral causes of pneumonia are associated with characteristic dermatologic findings:

Measles (picture 1AB) (see "Clinical manifestations and diagnosis of measles")•

Varicella (picture 2) (see "Clinical features of varicellazoster virus infection: Chickenpox")•

Herpes simplex virus (picture 3AB) (see "Clinical manifestations and diagnosis of herpes simplex•



RADIOLOGIC EVALUATION — An infiltrate on chest radiograph is often used to define pneumonia,particularly in clinical research [23,33]. The radiographic definition is necessary because of the difficulty inobtaining appropriate specimens from the lower respiratory tract for culture or microbiologic evaluation. Thispeculiarity makes it difficult to assess the degree to which chest radiographs are actually needed todiagnose pneumonia in the clinical setting, as the likelihood ratio of a standard cannot be measured [4,7].

Indications — Routine chest radiographs are not necessary to confirm the diagnosis of suspectedcommunityacquired pneumonia (CAP) in children with mild, uncomplicated lower respiratory tract infectionwho are well enough to be treated as outpatients [1,2,7]. Indications for radiographs in children with clinicalevidence of pneumonia include [1,2,7]:

There are a number of caveats to consider when deciding whether to obtain radiographs and whetherradiographs will alter management. These include:

Views — When radiographs are indicated, the recommended views depend upon the age of the child [43].In children older than four years, the frontal posteroanterior (PA) upright chest view is usually obtained tominimize the cardiac shadow [44]. In younger children, position does not affect the size of the cardiothoracicshadow, and the anteroposterior (AP) supine view is preferred because immobilization is easier and thelikelihood of a better inspiration is improved [44].

There is a lack of consensus regarding the need for lateral radiographs to demonstrate infiltrates behind thedome of the diaphragm or the cardiac shadow that may not be visualized on AP or PA views [45]. In a

virus type 1 infection", section on 'Respiratory tract infections' and "Neonatal herpes simplex virusinfection: Clinical features and diagnosis", section on 'Disseminated disease')

Severe disease (table 3) (see 'Severity assessment' above)

Confirmation of the diagnosis when clinical findings are inconclusive

Hospitalization (to document the presence, size, and character of parenchymal infiltrates and evaluatepotential complications)

Exclusion of alternate explanations for respiratory distress (eg, foreign body aspiration, heart failure),particularly in patients with underlying cardiopulmonary or medical conditions (see 'Differentialdiagnosis' below)

Assessment of complications, particularly in children whose pneumonia is prolonged and unresponsiveto antimicrobial therapy [7] (see "Communityacquired pneumonia in children: Outpatient treatment",section on 'Treatment failure' and 'Complications' below)

Exclusion of pneumonia in young children (3 to 36 months) with fever >39ºC (102.2°F) andleukocytosis (≥20,000 white blood cell [WBC]/microL) and older children (<10 years) with fever >38ºC(100.4°F), cough, and leukocytosis (≥15,000 WBC/microL) [3,5] (see "Fever without a source inchildren 3 to 36 months of age")

Radiographic findings are poor indicators of the etiologic diagnosis and must be used in conjunctionwith other clinical features to make therapeutic decisions [2,3437] (see "Communityacquiredpneumonia in children: Outpatient treatment", section on 'Treatment failure')

Radiographic findings may lag behind the clinical findings [38]

Patients who are hypovolemic may have normalappearing chest radiography before volume repletion

There is variation in intraobserver and interobserver agreement [2,39]

Radiographic interpretation may be influenced by the clinical information that is provided to theradiologist [40]

Obtaining outpatient chest radiographs does not affect outcome [41,42]



review of chest radiographs in 201 children with pneumonia, the lateral film was abnormal in 91 percent of

109 children with definite pneumonia [46]. However, it was the sole basis for the diagnosis in only three

cases.

We suggest that a lateral view be obtained in settings where the radiographs are interpreted by

nonradiologists. The Pediatric Infectious Diseases Society and Infectious Diseases Society of America

suggest PA and lateral views for all children who are hospitalized for management of CAP [1]. The British

Thoracic Society guidelines recommend against lateral radiographs [2].

A lateral decubitus radiograph (with the affected side down) may be needed to identify pleural effusion. (See

"Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children",

section on 'Radiologic evaluation'.)

Highresolution computed tomography and ultrasonography are available for patients who require more

extensive imaging or clarification of plain radiographic findings [47].

Etiologic clues — Certain radiographic features that are more often associated with bacterial, atypical

bacterial, or viral etiologies are listed below. However, none can reliably differentiate between a bacterial,

atypical bacterial, and viral pneumonia (table 4) [26,4850].

LABORATORY EVALUATION — The laboratory evaluation of the child with communityacquired

pneumonia (CAP) depends on the clinical scenario, including the age of the child, severity of illness,

complications, and whether the child requires hospitalization [1]. More aggressive evaluation is required

when it is necessary to determine a microbiologic etiology (eg, in children with severe disease, potential

complications, and who require hospital admission) [2]. An etiologic diagnosis in such children helps to direct

pathogenspecific therapy and permits cohorting of children if necessary to prevent the spread of nosocomial

Segmental consolidation is reasonably specific for bacterial pneumonia but lacks sensitivity [36,51].

Radiologic features of segmental consolidation are not always easy to distinguish from segmental

collapse (atelectasis), which is apparent in about 25 percent of children with bronchiolitis [52,53].

In clinical practice it is common to consider alveolar infiltrates to be caused by bacteria and bilateral

diffuse interstitial infiltrates to be caused by atypical bacterial or viral infections. However, this is not

supported in the literature. In a study of 254 children with radiographically defined pneumonia, the

etiology was determined in 215 [35]. The sensitivity and specificity of alveolar infiltrate for bacterial

pneumonia were 72 and 51 percent, respectively; the sensitivity and specificity of interstitial infiltrates

for viral pneumonia were 49 and 72 percent, respectively. A lobar infiltrate is reasonably specific for a

bacterial pneumonia but lacks sensitivity [29,54].

Pulmonary consolidation in young children sometimes appears to be spherical (ie, "round pneumonia")

[55,56]. Round pneumonias tend to be >3 cm, solitary, and posteriorly located [56,57]. The most

common bacterial etiology for round pneumonia is S. pneumoniae; additional bacterial causes include

other streptococci, Haemophilus influenzae, S. aureus, and M. pneumoniae [36,58].

Pneumatoceles, cavitations, large pleural effusions (image 1AB), and necrotizing processes (image 2)

are supportive of a bacterial etiology.

M. pneumoniae and viruses are most likely to spread diffusely along the branches of the bronchial tree,

resulting in a bronchopneumonic pattern (image 3). However, S. pneumoniae have been associated

with a similar radiographic pattern in children. (See "Pneumococcal pneumonia in children", section on

'Radiographic features'.)

In young infants, hyperinflation with an interstitial process is characteristic of afebrile pneumonia of

infancy, typically caused by C. trachomatis. (See "Chlamydia trachomatis infections in the newborn",

section on 'Pneumonia'.)

Significant mediastinal/hilar adenopathy suggests a mycobacterial or fungal etiology.



infection.

Young infants in whom pneumonia is suspected, particularly those who are febrile and toxic appearing,

require a full evaluation for sepsis and other serious bacterial infections. (See "Evaluation and management

of the febrile young infant (7 to 90 days of age)".)

Blood tests — Complete blood count (CBC) with differential and acute phase reactants may provide

supportive evidence for bacterial or viral pneumonia, but should not be used as the only criteria in

determining the need for antimicrobial therapy. Serum electrolytes may be useful in assessing the degree of

dehydration and the presence of hyponatremia, which may indicate the syndrome of inappropriate

antidiuretic hormone secretion (SIADH). (See "Pathophysiology and etiology of the syndrome of

inappropriate antidiuretic hormone secretion (SIADH)", section on 'Pulmonary disease'.) Blood polymerase

chain reaction (PCR) for pneumococcus is discussed below. (See 'Rapid diagnostic tests' below.)

Complete blood count – CBC usually is not necessary for children with mild lower respiratory tract

infection who will be treated as outpatients, unless the CBC will determine the need for antibiotic

therapy. CBC typically is performed in infants and children who require hospital admission. Certain

CBC findings, described below, are more characteristic of bacterial, atypical bacterial, or viral

pneumonias. However, the findings overlap and cannot reliably differentiate between the etiologic

agents.

White blood cell (WBC) count <15,000/microL suggests a nonbacterial etiology, except in the

severely ill patient, who also may be neutropenic and have a predominance of immature cells.

•

WBC count >15,000/microL is suggestive of pyogenic bacterial disease [59]. However, children

with M. pneumoniae, influenza, or adenovirus pneumonia also may have WBC count

>15,000/microL [6062].

•

Peripheral eosinophilia may be present in infants with afebrile pneumonia of infancy, typically

caused by C. trachomatis. (See "Chlamydia trachomatis infections in the newborn", section on'Pneumonia'.)

•

Acute phase reactants – Acute phase reactants, such as the erythrocyte sedimentation rate, Creactive

protein (CRP), and serum procalcitonin (PCT), need not be routinely measured in fully immunized

children (table 5) with CAP managed as outpatients [1]. However, for those with more serious disease

requiring hospitalization, measurement of acute phase reactants may provide useful information to

assist clinical management.

Measurement of serum CRP may be helpful in distinguishing bacterial from viral pneumonia. A meta

analysis of eight studies including 1230 patients suggested that children with bacterial pneumonia were

more likely to have serum CRP concentrations greater than 35 to 60 mg/L (3.5 to 6 mg/dL) than

children with nonbacterial pneumonia (odds ratio 2.6, 95% CI 1.25.6) [63]. Given a 41 percent

prevalence of bacterial pneumonia, the positive predictive value for CRP values of 40 to 60 mg/L (4 to

6 mg/dL) was 64 percent. An elevated serum PCT concentration may be as sensitive as but more

specific than an increased CRP level for differentiating a bacterial from a viral process [26,64,65].

However, predictable utility has not been documented [1,66,67].

Acute phase reactants should not be used as the sole determinant to distinguish between viral and

bacterial etiologies of CAP but may be helpful in following the disease course, response to therapy, and

in determining when therapy can be discontinued [1,66,6870]. (See "Pneumonia in children: Inpatient

treatment", section on 'Duration of treatment'.)

Serum electrolytes – Measurement of serum electrolytes may be helpful in assessing the degree of

dehydration in children with limited fluid intake and whether hyponatremia is present (as pneumonia

may be complicated by SIADH). (See 'Complications' below.)



Microbiology

Indications — If possible, a microbiologic diagnosis should be established in children with severedisease (table 3), potential complications, and those who require hospitalization. Accurate and rapiddiagnosis of the responsible pathogen helps to determine the appropriate antimicrobial therapy [1]. (See"Pneumonia in children: Inpatient treatment", section on 'Overview'.)

A microbiologic diagnosis also should be established if there appears to be a community outbreak [71] or ifan unusual pathogen is suspected, particularly if it requires treatment that differs from standard empiricregimens (eg, S. aureus including methicillinresistant strains, Mycobacterium tuberculosis). (See 'Criticalmicrobes' below.)

Children with mild disease who are treated as outpatients usually can be treated empirically, based on ageand other epidemiologic features, without establishing a microbiologic etiology [2,72]. (See "Communityacquired pneumonia in children: Outpatient treatment", section on 'Empiric therapy'.)

Microbiologic diagnosis can be established with culture, rapid diagnostic testing (enzyme immunoassay,immunofluorescence, PCR, or serology).

Cultures

Blood cultures – We suggest that blood cultures be performed in children with CAP who requireadmission to the hospital and in children with parapneumonic effusion or other complication [1,2,73].Although blood cultures are positive in at most 10 to 12 percent of children with pneumonia, whenpositive they help to confirm the etiologic diagnosis [7478]. The yield of blood cultures increases to 30to 40 percent in patients with a parapneumonic effusion or empyema [76,79,80]. The utility of bloodculture is limited when antibiotics are administered before obtaining the specimen. (See "Blood culturesfor the detection of bacteremia".)

Blood cultures are not necessary in children with CAP who will be treated as outpatients [1,7,74,81]. Inthe outpatient setting, the likelihood of a positive blood culture in children with CAP is less than 3percent [74,75].

Nasopharyngeal cultures – We do not suggest obtaining nasopharyngeal (NP) cultures for etiologicdiagnosis in children with pneumonia. Bacterial organisms recovered from the nasopharynx do notaccurately predict the etiology of pneumonia because bacteria that cause pneumonia also may benormal upper respiratory flora. The results of NP cultures for viruses and atypical bacterial althoughhelpful may not be available soon enough to assist with management decisions [7]. Rapid diagnostictests for viruses and atypical bacteria are discussed below. (See 'Rapid diagnostic tests' below.)

Sputum cultures – We suggest that sputum samples for Gram stain and culture be obtained in childrenwho require hospital admission if they are able to produce sputum [1]. Children younger than five yearsusually swallow sputum, so it is rarely available for examination. Goodquality sputum samples can beobtained by sputum induction [82]. However, sputum induction is unpleasant and not routinelynecessary because most children respond to empiric antimicrobial therapy. It may be beneficial inchildren who require intensivecare therapy, have a pleural effusion, or fail to respond to empirictherapy [82,83]. (See "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)

As a general guide, an appropriate sputum specimen for examination is one with ≤10 epithelial cellsand ≥25 polymorphonuclear leukocytes (PMN) under low power (x100) [84]. A predominantmicroorganism and/or intracellular organisms suggest the etiologic agent. When the following criteriaare used, the specificity of the Gram stain for identifying pneumococci has been shown to be 85percent, with a sensitivity of 62 percent: predominant flora or more than 10 Grampositive, lancetshaped diplococci per oil immersion field (x1000) (picture 4) [85].

Pleural fluid cultures – Diagnostic (and possibly therapeutic) thoracentesis generally is warranted for



Rapid diagnostic tests — When available, rapid diagnostic tests, such as molecular testing using PCRtechniques and immunofluorescence, on NP specimens and blood can be helpful in the management ofinfants and children who are admitted to the hospital with probable pneumococcal, mixed bacterial/viral,viral, atypical bacterial CAP. The results of rapid diagnostic tests can be used to make decisions abouttreatment and cohorting of patients [1].

In prospective studies, PCR of blood and respiratory samples had a higher yield than culture for S.pneumoniae [8688]. Quantitative S. pneumoniae PCR testing of a nasopharyngeal specimen may behelpful if mixed viral/bacterial pneumonia is a concern [89].

The rapid diagnostic tests that are available for the following viral pathogens are discussed separately:

The use of rapid diagnostic tests for identification of pathogens in children with parapneumonic effusion isdiscussed separately. (See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusionand empyema in children", section on 'Pleural fluid analysis'.)

Serology — We do not suggest routine serologic testing for specific pathogens (eg, S. pneumoniae, M.pneumoniae, C. pneumoniae) because the results usually do not influence management [7,90,91]. Serologicdiagnosis of viral pathogens is not practical because acute and convalescent specimens are needed. S.pneumoniae has too many potential infecting serotypes to make antibody determinations practical. Serologictests for Chlamydia spp are not readily available.

Although most older children with atypical pneumonia can be treated empirically for M. pneumoniae,serologic and PCR testing can be helpful in evaluating the younger child. These tests also may be helpful inestablishing the diagnosis of M. pneumoniae in patients with extrapulmonary manifestations, particularlycentral nervous system manifestations. (See "Mycoplasma pneumoniae infection in children", section on'Clinical features'.)

Other tests — Other tests that may be helpful in establishing less common microbiologic etiologies ofCAP in children include:

children with more than minimal pleural effusion. Specimens for culture of pleural fluid ideally should beobtained before administration of antibiotics. The evaluation of pleural fluid is discussed separately.(See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema inchildren", section on 'Pleural fluid analysis'.)

Respiratory syncytial virus (see "Respiratory syncytial virus infection: Clinical features and diagnosis",section on 'Diagnosis')

Influenza viruses (see "Seasonal influenza in children: Clinical features and diagnosis", section on'Diagnosis')

Parainfluenza viruses (see "Parainfluenza viruses in children", section on 'Diagnosis')

Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on'Pneumonia')

M. pneumoniae (see "Mycoplasma pneumoniae infection in children", section on 'Diagnosis')

Chlamydia spp (see "Pneumonia caused by Chlamydia species in children", section on 'Diagnosis')

Human metapneumovirus (see "Human metapneumovirus infections", section on 'Diagnosis')

Tuberculin skin and interferon gamma release assay if pulmonary tuberculosis is a consideration;additional diagnostic testing for tuberculosis in children is discussed separately (see "Tuberculosisdisease in children", section on 'Diagnosis')

Urine antigen testing for legionellosis due to serogroup 1 (see "Clinical manifestations and diagnosis ofLegionella infection", section on 'Urinary antigen testing')


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Invasive studies — Invasive procedures may be necessary to obtain lower respiratory tract specimensfor culture and other studies in children in whom an etiologic diagnosis is necessary and has not beenestablished by other means [1,9295]. These procedures are typically reserved for seriously ill patientswhose condition is worsening despite empiric therapy, or individuals with significant comorbidities (eg,immune compromise). They include [1,9294]:

Critical microbes — Some microbes are critical to detect because they require treatment that differsfrom standard empiric regimens or have public health implications. Diagnostic testing for these pathogens isdiscussed separately.

DIAGNOSIS — The diagnosis of pneumonia requires historical or physical examination evidence of anacute infectious process with signs or symptoms of respiratory distress or radiologic evidence of an acute

Serum and urine antigen testing for histoplasmosis (see "Diagnosis and treatment of pulmonaryhistoplasmosis", section on 'Antigen detection')

Urine antigen testing for S. pneumoniae in children should not be performed because of false positivereactions, some of which may merely indicate colonization with S. pneumoniae [1,2]

Bronchoscopy with bronchoalveolar lavage (BAL). Because the accurate identification of bacterialpathogens via bronchoscopy is hampered by specimen contamination with upper airway normal flora,quantitative culture techniques are utilized in many centers to differentiate true infection from upperairway contamination [9698].

Percutaneous needle aspiration of the affected lung tissue guided by computed tomography orultrasonography. A small study from Finland found that needle aspiration determined an infectiousetiology (21 bacteria and 2 viruses) in 20 of 34 patients (59 percent) studied and in 18 of 26 (69percent) of those in whom an adequate specimen was obtained [92]. Six patients developed apneumothorax, which spontaneously resolved over two to three days without intervention.

Lung biopsy either by a thoracoscopic or thoracotomy approach. Open biopsy yields diagnosticinformation that may affect medical management in up to 90 percent of patients [94]. In oneretrospective review, an infectious etiology was determined by open lung biopsy in 10 of 33 patientswith respiratory failure, eight of whom had a prior nondiagnostic BAL [93]. In another retrospectivereview, lung biopsy provided a definitive diagnosis in 25 of 50 immunocompromised patients, nine ofwhom had a prior nondiagnostic BAL [99].

Influenza A and B (see "Seasonal influenza in children: Clinical features and diagnosis", section on'Diagnosis')

Communityassociated methicillinresistant S. aureus (see "Methicillinresistant Staphylococcus aureusin children: Treatment of invasive infections", section on 'Pneumonia' and "MethicillinresistantStaphylococcus aureus infections in children: Epidemiology and clinical spectrum", section on'Epidemiology and risk factors')

M. tuberculosis (see "Tuberculosis disease in children")

Fungal etiologies (Coccidioides immitis, Blastomyces dermatitidis, Histoplasma capsulatum) (see"Primary coccidioidal infection" and "Mycology, pathogenesis, and epidemiology of blastomycosis" and"Treatment of blastomycosis" and "Diagnosis and treatment of pulmonary histoplasmosis")

Legionella species (see "Clinical manifestations and diagnosis of Legionella infection", section on'Specific laboratory diagnosis')

Avian influenza (see "Clinical manifestations and diagnosis of avian influenza", section on 'Diagnosis')

Hantavirus (see "Hantavirus cardiopulmonary syndrome")

Agents of bioterrorism (see "Identifying and managing casualties of biological terrorism")



pulmonary infiltrate [7,30].

The diagnostic approach depends, to some extent, upon the setting and the severity of illness. In theappropriate clinical setting, the diagnosis can be made without radiographs. In children with severe illness,and in those who require hospital admission, the diagnosis should be confirmed with radiographs. Ifpossible, etiologic diagnosis should be established in children who require admission to the hospital and inthose who fail to respond to initial therapy. (See "Pneumonia in children: Inpatient treatment", section on'Overview'.)

Clinical diagnosis — The diagnosis of pneumonia should be considered in infants and children withrespiratory complaints, particularly cough, tachypnea, retractions, and abnormal lung examination [2,3,7].

The diagnosis of pneumonia can be made clinically in children with fever and historical or physicalexamination evidence of an infectious process with symptoms or signs of respiratory distress [7].Tachypnea, nasal flaring, grunting, retractions, crackles, and decreased breath sounds increase thelikelihood of pneumonia [4,9,30,100]. The absence of tachypnea is helpful in excluding pneumonia; theabsence of the other signs is not. (See 'Tachypnea' above.)

In developing countries where there is a high prevalence of pneumonia, a single positive respiratory signincreases the certainty of pneumonia [4]. The World Health Organization uses tachypnea (>60 breaths/minin infants <2 months; >50 breaths/min in infants 2 to 12 months; and >40 breaths/min in children 1 to 5years; and >20 breaths/min in children ≥5 years) as the sole criterion to define pneumonia in children withcough or difficulty breathing [15]. In developed countries with a lower prevalence of pneumonia, multiplerespiratory signs are necessary to increase the certainty of pneumonia [4,101].

Radiographic confirmation — An infiltrate on chest radiograph confirms the diagnosis of pneumonia inchildren with compatible clinical findings. Radiographs should be obtained in children in whom the diagnosisis uncertain and in those with severe, complicated, or recurrent pneumonia [1,2,102]. Radiographicconfirmation is not necessary in children with mild, uncomplicated lower respiratory tract infection who will betreated as outpatients. (See 'Indications' above.)

Radiographic findings cannot reliably distinguish between bacterial, atypical bacterial, and viral etiologies ofpneumonia. Radiographic findings should be used in conjunction with clinical and microbiologic data to maketherapeutic decisions [2,4]. (See "Communityacquired pneumonia in children: Outpatient treatment", sectionon 'Empiric therapy' and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)

Etiologic diagnosis — The etiologic agent is suggested by host characteristics, clinical presentation,epidemiologic considerations, and, to some degree, the results of nonspecific laboratory tests and chestradiographic patterns (table 4). (See 'Clues to etiology' above and 'Etiologic clues' above and "Pneumonia inchildren: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)

Specific microbiologic tests can be used to confirm the etiologic diagnosis. Confirmation of etiologicdiagnosis is not necessary in mildly ill patients who can be treated empirically in the outpatient setting.Confirmation of etiologic diagnosis should be attempted in children who are admitted to the hospital or aresuspected to be infected with an unusual pathogen, or a pathogen that requires treatment that differs fromstandard empiric regimens, so that therapy can be directed toward the appropriate pathogen. Etiologicdiagnosis also is necessary in children who fail to respond to initial therapy. (See 'Microbiology' above and'Critical microbes' above and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)

DIFFERENTIAL DIAGNOSIS — Although pneumonia is highly probable in a child with fever, tachypnea,cough, and infiltrate(s) on chest radiograph, alternate diagnoses and coincident conditions must beconsidered in children who fail to respond to therapy or have an unusual presentation/course [7].

The Table lists a number of other conditions that can mimic an infectious pneumonia (table 6). History and/orassociated clinical features usually help to distinguish the conditions in the table from infectious pneumonia.In some cases, laboratory studies or additional imaging may be necessary.



Foreign body aspiration must be considered in young children. The aspiration event may not have beenwitnessed. (See "Airway foreign bodies in children", section on 'Presentation'.)

Other causes of tachypnea, with or without fever and cough, in infants and young children include [103]:

These conditions usually can be distinguished from pneumonia by history, examination, and laboratory tests.

Lemierre syndrome (jugular vein suppurative thrombophlebitis) is an important consideration in adolescentsand young adults whose illness began with pharyngitis. In Lemierre syndrome, the vessels of the carotidsheath become infected (typically with Fusobacterium spp), leading to bacteremia and metastatic spread ofinfection to the lungs and mediastinum. (See "Suppurative (septic) thrombophlebitis", section on 'Jugularvein'.)

Communityacquired pneumonia (CAP) can be misdiagnosed in young children with asthma who have viralrespiratory infections [104]. Many such children have respiratory distress and may have hypoxemia. Thediagnosis of CAP and treatment with antibiotics must be carefully considered in young children who have aprodrome compatible with a viral respiratory infection and wheezing, even if there are pulmonary infiltrates(versus atelectasis) on chest radiograph. (See "Asthma in children younger than 12 years: Initial evaluationand diagnosis", section on 'Respiratory tract infections'.)

Rare, noninfectious lung diseases may present with an intercurrent infectious illness. Pulmonary alveolarproteinosis, eosinophilic pneumonia, acute interstitial pneumonitis, and cryptogenic organizing pneumoniaare entities that should be considered, especially if the acute illness is atypical or the radiographic andclinical findings do not resolve as expected with uncomplicated CAP. (See "Clinical manifestations andetiology of pulmonary alveolar proteinosis in adults" and "Idiopathic acute eosinophilic pneumonia" and"Acute interstitial pneumonia (HammanRich syndrome)" and "Cryptogenic organizing pneumonia".)

COMPLICATIONS — Bacterial pneumonias are more likely than atypical bacterial or viral pneumonias to beassociated with complications involving the respiratory tract. Complications of bacterial pneumonia includepleural effusion (image 1AB), empyema, pneumatoceles, necrotizing pneumonia (image 2), and lungabscesses.

Pleural effusion and empyema — The clinical features, evaluation, and management of parapneumoniceffusion and empyema in children are discussed separately. Hypoalbuminemia is common in children withparapneumonic effusions and hypogammaglobulinemia may be encountered. (See 'Blood tests' above and"Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children"and "Management and prognosis of parapneumonic effusion and empyema in children".)

Necrotizing pneumonia — Necrotizing pneumonia, necrosis, and liquefaction of lung parenchyma, is aserious complication of communityacquired pneumonia (CAP). Necrotizing pneumonia usually followspneumonia caused by particularly virulent bacteria [102]. S. pneumoniae (especially serotype 3 andserogroup 19) is the most common cause of necrotizing pneumonia (image 2) [105110]. Necrotizingpneumonia also may occur with S. aureus and group A Streptococcus and has been reported due to M.pneumoniae, Legionella, and Aspergillus. [110115].

Clinical manifestations of necrotizing pneumonia are similar to those of uncomplicated pneumonia, but theyare more severe [115117]. Necrotizing pneumonia should be considered in a child with prolonged fever orseptic appearance [102]. The diagnosis can be confirmed by chest radiograph (which demonstrates a

Bronchiolitis (see "Bronchiolitis in infants and children: Clinical features and diagnosis", section on'Clinical features')

Heart failure

Sepsis

Metabolic acidosis (see "Approach to the child with metabolic acidosis", section on 'Clinical evaluationand diagnosis')



radiolucent lesion) (image 4) or contrastenhanced computed tomography (image 2) [118]; the findings onchest radiograph may lag behind those of computed tomography [113].

Pleural effusion/empyema generally accompanies necrotizing pneumonia whereas bronchopleural fistula,pneumatocele, or abscess formation (which typically is insidious) is much less common. Drainage of thepleural fluid collection is frequently required but pneumonectomy is rarely needed. (See 'Pneumatocele'below and 'Lung abscess' below.)

Treatment of necrotizing pneumonia is discussed separately. (See "Pneumonia in children: Inpatienttreatment", section on 'Complicated CAP'.)

Lung abscess — A lung abscess is an accumulation of inflammatory cells, accompanied by tissuedestruction or necrosis that produces one or more cavities in the lung [45]. Aspiration is the most importantpredisposing factor for lung abscess, which may develop one to two weeks after the aspiration event; otherpredisposing factors include airway obstruction and congenitally abnormal lung [45]. S. aureus is theorganism most frequently involved [103].

Clinical manifestations of lung abscess are nonspecific and similar to those of pneumonia [45]. They includefever, cough, dyspnea, chest pain, anorexia, hemoptysis, and putrid breath [45,102,119121]. The coursemay be indolent.

The diagnosis is suggested by a chest radiograph demonstrating a thickwalled cavity with an airfluid level(image 4) [45], and confirmed by contrastenhanced computed tomography [118]. Lung abscess is oftenaccompanied by parapneumonic effusion [122,123]. Lung abscess should be suspected when consolidationis unusually persistent, when pneumonia remains persistently round or masslike, and when the volume ofthe involved lobe is increased (as suggested by a bulging fissure) [45,124].

Interventional radiology may be helpful in obtaining a specimen from the abscess cavity for diagnosticstudies. Treatment of lung abscess is discussed separately. (See "Pneumonia in children: Inpatienttreatment", section on 'Complicated CAP'.)

The most common complication of lung abscess is intracavitary hemorrhage. This can cause hemoptysis orspillage of the abscess contents with spread of infection to other areas of the lung [116]. Other complicationsof lung abscess include empyema, bronchopleural fistula, septicemia, cerebral abscess, and inappropriatesecretion of antidiuretic hormone [116].

Pneumatocele — Pneumatoceles are thinwalled, aircontaining cysts of the lungs. They are classicallyassociated with S. aureus, but may occur with a variety of organisms [125,126]. Pneumatoceles frequentlyoccur in association with empyema [125]. In most cases, pneumatoceles involute spontaneously, and longterm lung function is normal [125,127,128]. However, on occasion, pneumatoceles result in pneumothorax[126].

Hyponatremia — Hyponatremia (serum sodium concentration ≤135 meq/L) occurs in approximately 45percent of children with CAP and onethird of children hospitalized with CAP, but is usually mild [129131].Inappropriate secretion of antidiuretic hormone (ADH) is the most frequent cause [129,130]. Hyponatremia isassociated with increased length of hospital stay, complications, and mortality. (See "Pathophysiology andetiology of the syndrome of inappropriate antidiuretic hormone secretion (SIADH)", section on 'Pulmonarydisease'.)

INDICATIONS FOR HOSPITALIZATION — Indications for hospitalization are discussed separately. (See"Pneumonia in children: Inpatient treatment", section on 'Indications'.)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or emailthese topics to your patients. (You can also locate patient education articles on a variety of subjects bysearching on “patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

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Basics topic (see "Patient information: Pneumonia in children (The Basics)")

The presenting signs and symptoms of communityacquired pneumonia (CAP) are nonspecific; nosingle symptom or sign is pathognomonic for pneumonia in children. The combination of fever andcough is suggestive of pneumonia, but the presentation may be subtle, or misleading (eg, abdominalpain or nuchal rigidity). (See 'Clinical presentation' above.)

The history should focus on features that can help to define the clinical syndrome (eg, pneumonia,bronchiolitis) and narrow the list of potential pathogens (table 1). (See 'History' above and "Pneumoniain children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)

Examination findings that have been correlated with radiographic pneumonia include tachypnea,increased work of breathing (retractions, nasal flaring, grunting, use of accessory muscles), hypoxemia,and adventitious lung sounds. Combinations of findings are more predictive than single findings. Theabsence of tachypnea is useful in excluding pneumonia. (See 'Examination' above.)

The history and examination are used to determine the severity of illness (table 3), which determines,in part, the need for radiologic and laboratory evaluation. (See 'Severity assessment' above.)

Neither clinical nor radiologic features reliably distinguish between bacterial, atypical bacterial, and viralpneumonia. (See 'Clues to etiology' above and 'Etiologic clues' above.)

Radiographs are not necessary for children with pneumonia who are well enough to be treated asoutpatients. We suggest that chest radiographs be obtained for the following indications:

Severe disease (table 3) (see 'Severity assessment' above)•

Confirmation of the diagnosis when clinical findings are inconclusive•

Exclusion of alternate explanations for respiratory distress (see 'Differential diagnosis' above)•

Evaluation for complications (see 'Complications' above)•

Exclusion of occult pneumonia in young children (3 to 36 months) with fever >39ºC (102.2°F),leukocytosis (white blood cell count >20,000/microL), and no obvious focus of infection (see'Radiologic evaluation' above)

•

Routine laboratory evaluation is not necessary for children with clinical evidence of mild uncomplicatedlower respiratory tract infection who will be treated as outpatients unless the findings will help indeciding whether antimicrobial therapy is necessary. (See 'Laboratory evaluation' above.)

We recommend that attempts be made to establish an etiologic diagnosis in children with CAP whorequire hospital admission. A complete blood count with differential and blood culture should beobtained in all such patients. If produced, a good quality sputum should be submitted for Gram stainand culture. Other specimens for microbiologic testing should be obtained as indicated by the clinicalscenario. (See 'Microbiology' above.)

Attempts also should be made to establish (or exclude) an etiologic diagnosis in patients suspected tohave CAP caused by pathogens that require treatment regimens that differ from standard empiricregimens (eg, influenza, communityassociated methicillinresistant Staphylococcus aureus,Mycobacterium tuberculosis, fungi, Legionella, hantavirus). (See 'Critical microbes' above.)



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REFERENCES

1. Bradley JS, Byington CL, Shah SS, et al. The management of communityacquired pneumonia ininfants and children older than 3 months of age: clinical practice guidelines by the Pediatric InfectiousDiseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.

2. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of communityacquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1.

3. Murphy CG, van de Pol AC, Harper MB, Bachur RG. Clinical predictors of occult pneumonia in thefebrile child. Acad Emerg Med 2007; 14:243.

4. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA1998; 279:308.

5. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children withleukocytosis. Ann Emerg Med 1999; 33:166.

6. Bradley JS. Management of communityacquired pediatric pneumonia in an era of increasing antibioticresistance and conjugate vaccines. Pediatr Infect Dis J 2002; 21:592.

7. Community acquired pneumonia guideline team, Cincinnati Children's Hospital Medical Center.Evidencebased care guidelines for medical management of community acquired pneumonia inchildren 60 days to 17 years of age. Guideline 14. www.cincinnatichildrens.org/svc/alpha/h/healthpolicy/evbased/pneumonia.htm (Accessed on September 22, 2011).

8. Jadavji T, Law B, Lebel MH, et al. A practical guide for the diagnosis and treatment of pediatricpneumonia. CMAJ 1997; 156:S703.

9. Pereira JC, Escuder MM. The importance of clinical symptoms and signs in the diagnosis ofcommunityacquired pneumonia. J Trop Pediatr 1998; 44:18.

10. McIntosh K. Communityacquired pneumonia in children. N Engl J Med 2002; 346:429.11. Palafox M, Guiscafré H, Reyes H, et al. Diagnostic value of tachypnoea in pneumonia defined

radiologically. Arch Dis Child 2000; 82:41.12. MahabeeGittens EM, GruppPhelan J, Brody AS, et al. Identifying children with pneumonia in the

emergency department. Clin Pediatr (Phila) 2005; 44:427.13. Lynch T, Platt R, Gouin S, et al. Can we predict which children with clinically suspected pneumonia will

have the presence of focal infiltrates on chest radiographs? Pediatrics 2004; 113:e186.14. Smyth A, Carty H, Hart CA. Clinical predictors of hypoxaemia in children with pneumonia. Ann Trop

Paediatr 1998; 18:31.15. World Health Organization. The management of acute respiratory infections in children. In: Practical

guidelines for outpatient care. World Health Organization, Geneva 1995.16. Russell G. Community acquired pneumonia. Arch Dis Child 2001; 85:445.17. Simoes EA, Roark R, Berman S, et al. Respiratory rate: measurement of variability over time and

accuracy at different counting periods. Arch Dis Child 1991; 66:1199.18. Gadomski AM, Khallaf N, el Ansary S, Black RE. Assessment of respiratory rate and chest indrawing

in children with ARI by primary care physicians in Egypt. Bull World Health Organ 1993; 71:523.19. Berman S, Simoes EA, Lanata C. Respiratory rate and pneumonia in infancy. Arch Dis Child 1991;

66:81.20. Gadomski AM, Permutt T, Stanton B. Correcting respiratory rate for the presence of fever. J Clin

Alternate diagnoses and coincident conditions must be considered in children who fail to respond totherapy or who have an unusual presentation or course (table 6). (See 'Differential diagnosis' aboveand "Communityacquired pneumonia in children: Outpatient treatment", section on 'Treatment failure'and "Pneumonia in children: Inpatient treatment".)

Complications of CAP in children include pleural effusion and empyema, necrotizing pneumonia, lungabscess, pneumatocele, and hyponatremia. (See 'Complications' above.)



Epidemiol 1994; 47:1043.21. Margolis PA, Ferkol TW, Marsocci S, et al. Accuracy of the clinical examination in detecting hypoxemia

in infants with respiratory illness. J Pediatr 1994; 124:552.22. Heulitt MJ, Ablow RC, Santos CC, et al. Febrile infants less than 3 months old: value of chest

radiography. Radiology 1988; 167:135.23. Harari M, Shann F, Spooner V, et al. Clinical signs of pneumonia in children. Lancet 1991; 338:928.24. Campbell H, Byass P, Lamont AC, et al. Assessment of clinical criteria for identification of severe

acute lower respiratory tract infections in children. Lancet 1989; 1:297.25. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.26. Korppi M, Don M, Valent F, Canciani M. The value of clinical features in differentiating between viral,

pneumococcal and atypical bacterial pneumonia in children. Acta Paediatr 2008; 97:943.27. Wang K, Gill P, Perera R, et al. Clinical symptoms and signs for the diagnosis of Mycoplasma

pneumoniae in children and adolescents with communityacquired pneumonia. Cochrane DatabaseSyst Rev 2012; 10:CD009175.

28. British Thoracic Society Standards of Care Committee. British Thoracic Society Guidelines for theManagement of Community Acquired Pneumonia in Childhood. Thorax 2002; 57 Suppl 1:i1.

29. Tan TQ, Mason EO Jr, Barson WJ, et al. Clinical characteristics and outcome of children withpneumonia attributable to penicillinsusceptible and penicillinnonsusceptible Streptococcuspneumoniae. Pediatrics 1998; 102:1369.

30. Leventhal JM. Clinical predictors of pneumonia as a guide to ordering chest roentgenograms. ClinPediatr (Phila) 1982; 21:730.

31. Tipple MA, Beem MO, Saxon EM. Clinical characteristics of the afebrile pneumonia associated withChlamydia trachomatis infection in infants less than 6 months of age. Pediatrics 1979; 63:192.

32. Turner RB, Lande AE, Chase P, et al. Pneumonia in pediatric outpatients: cause and clinicalmanifestations. J Pediatr 1987; 111:194.

33. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically relevant standards for tachypneain febrile children younger than 2 years. Arch Pediatr Adolesc Med 1995; 149:283.

34. Alario AJ, McCarthy PL, Markowitz R, et al. Usefulness of chest radiographs in children with acutelower respiratory tract disease. J Pediatr 1987; 111:187.

35. Virkki R, Juven T, Rikalainen H, et al. Differentiation of bacterial and viral pneumonia in children.Thorax 2002; 57:438.

36. Korppi M, Kiekara O, HeiskanenKosma T, Soimakallio S. Comparison of radiological findings andmicrobial aetiology of childhood pneumonia. Acta Paediatr 1993; 82:360.

37. Bettenay FA, de Campo JF, McCrossin DB. Differentiating bacterial from viral pneumonias in children.Pediatr Radiol 1988; 18:453.

38. Bruns AH, Oosterheert JJ, El Moussaoui R, et al. Pneumonia recovery: discrepancies in perspectivesof the radiologist, physician and patient. J Gen Intern Med 2010; 25:203.

39. Davies HD, Wang EE, Manson D, et al. Reliability of the chest radiograph in the diagnosis of lowerrespiratory infections in young children. Pediatr Infect Dis J 1996; 15:600.

40. Kramer MS, RobertsBräuer R, Williams RL. Bias and 'overcall' in interpreting chest radiographs inyoung febrile children. Pediatrics 1992; 90:11.

41. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chestradiograph in ambulatory acute lowerrespiratory infection in children. Lancet 1998; 351:404.

42. Cao AM, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory tractinfections. Cochrane Database Syst Rev 2013; 12:CD009119.

43. Ablin DS, Newell JD 2nd. Diagnostic imaging for evaluation of the pediatric chest. Clin Chest Med1987; 8:641.

44. Gaisie G, Dominguez R, Young LW. Comparison of AP supine vs PA upright methods of chestroentgenography in infants and young children. J Natl Med Assoc 1984; 76:171.

45. Miller MA, BenAmi T, Daum RS. Bacterial pneumonia in neonates and older children. In: PediatricRespiratory Medicine, Taussig LM, Landau LI (Eds), Mosby, St. Louis 1999. p.595.

46. Kiekara O, Korppi M, Tanska S, Soimakallio S. Radiological diagnosis of pneumonia in children. Ann



Med 1996; 28:69.47. Kuhn JP, Brody AS. Highresolution CT of pediatric lung disease. Radiol Clin North Am 2002; 40:89.48. Courtoy I, Lande AE, Turner RB. Accuracy of radiographic differentiation of bacterial from nonbacterial

pneumonia. Clin Pediatr (Phila) 1989; 28:261.49. McCarthy PL, Spiesel SZ, Stashwick CA, et al. Radiographic findings and etiologic diagnosis in

ambulatory childhood pneumonias. Clin Pediatr (Phila) 1981; 20:686.50. Clements H, Stephenson T, Gabriel V, et al. Rationalised prescribing for community acquired

pneumonia: a closed loop audit. Arch Dis Child 2000; 83:320.51. Lahti E, Peltola V, Virkki R, Ruuskanen O. Influenza pneumonia. Pediatr Infect Dis J 2006; 25:160.52. Simpson W, Hacking PM, Court SD, Gardner PS. The radiological findings in respiratory syncytial virus

infection in children. II. The correlation of radiological categories with clinical and virological findings.Pediatr Radiol 1974; 2:155.

53. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J PaediatrChild Health 1990; 26:209.

54. Finnegan OC, Fowles SJ, White RJ. Radiographic appearances of mycoplasma pneumonia. Thorax1981; 36:469.

55. Griscom NT. Pneumonia in children and some of its variants. Radiology 1988; 167:297.56. McLennan MK. Radiology rounds. Round pneumonia. Can Fam Physician 1998; 44:751, 757.57. Kim YW, Donnelly LF. Round pneumonia: imaging findings in a large series of children. Pediatr Radiol

2007; 37:1235.58. Redd SC, Patrick E, Vreuls R, et al. Comparison of the clinical and radiographic diagnosis of paediatric

pneumonia. Trans R Soc Trop Med Hyg 1994; 88:307.59. Shuttleworth DB, Charney E. Leukocyte count in childhood pneumonia. Am J Dis Child 1971; 122:393.60. Peltola V, Mertsola J, Ruuskanen O. Comparison of total white blood cell count and serum Creactive

protein levels in confirmed bacterial and viral infections. J Pediatr 2006; 149:721.61. Tabain I, LjubinSternak S, CepinBogović J, et al. Adenovirus respiratory infections in hospitalized

children: clinical findings in relation to species and serotypes. Pediatr Infect Dis J 2012; 31:680.62. Chen SP, Huang YC, Chiu CH, et al. Clinical features of radiologically confirmed pneumonia due to

adenovirus in children. J Clin Virol 2013; 56:7.63. Flood RG, Badik J, Aronoff SC. The utility of serum Creactive protein in differentiating bacterial from

nonbacterial pneumonia in children: a metaanalysis of 1230 children. Pediatr Infect Dis J 2008; 27:95.64. Moulin F, Raymond J, Lorrot M, et al. Procalcitonin in children admitted to hospital with community

acquired pneumonia. Arch Dis Child 2001; 84:332.65. Schützle H, Forster J, SupertiFurga A, Berner R. Is serum procalcitonin a reliable diagnostic marker in

children with acute respiratory tract infections? A retrospective analysis. Eur J Pediatr 2009; 168:1117.66. Toikka P, Irjala K, Juvén T, et al. Serum procalcitonin, Creactive protein and interleukin6 for

distinguishing bacterial and viral pneumonia in children. Pediatr Infect Dis J 2000; 19:598.67. van Rossum AM, Wulkan RW, OudesluysMurphy AM. Procalcitonin as an early marker of infection in

neonates and children. Lancet Infect Dis 2004; 4:620.68. Korppi M. Nonspecific host response markers in the differentiation between pneumococcal and viral

pneumonia: what is the most accurate combination? Pediatr Int 2004; 46:545.69. Korppi M, Remes S, HeiskanenKosma T. Serum procalcitonin concentrations in bacterial pneumonia

in children: a negative result in primary healthcare settings. Pediatr Pulmonol 2003; 35:56.70. Williams DJ, Hall M, Auger KA, et al. Association of White Blood Cell Count and CReactive Protein

with Outcomes in Children Hospitalized for Communityacquired Pneumonia. Pediatr Infect Dis J 2015;34:792.

71. Ostapchuk M, Roberts DM, Haddy R. Communityacquired pneumonia in infants and children. AmFam Physician 2004; 70:899.

72. McCracken GH Jr. Diagnosis and management of pneumonia in children. Pediatr Infect Dis J 2000;19:924.

73. Sandora TJ, Harper MB. Pneumonia in hospitalized children. Pediatr Clin North Am 2005; 52:1059.



74. Hickey RW, Bowman MJ, Smith GA. Utility of blood cultures in pediatric patients found to havepneumonia in the emergency department. Ann Emerg Med 1996; 27:721.

75. Shah SS, Dugan MH, Bell LM, et al. Blood cultures in the emergency department evaluation ofchildhood pneumonia. Pediatr Infect Dis J 2011; 30:475.

76. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rateof pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis2002; 34:434.

77. Myers AL, Hall M, Williams DJ, et al. Prevalence of bacteremia in hospitalized pediatric patients withcommunityacquired pneumonia. Pediatr Infect Dis J 2013; 32:736.

78. Iroh Tam PY, Bernstein E, Ma X, Ferrieri P. Blood Culture in Evaluation of Pediatric CommunityAcquired Pneumonia: A Systematic Review and Metaanalysis. Hosp Pediatr 2015; 5:324.

79. Byington CL, Korgenski K, Daly J, et al. Impact of the pneumococcal conjugate vaccine onpneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006; 25:250.

80. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy withfibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106.

81. Claesson BA, Trollfors B, Brolin I, et al. Etiology of communityacquired pneumonia in children basedon antibody responses to bacterial and viral antigens. Pediatr Infect Dis J 1989; 8:856.

82. Lahti E, Peltola V, Waris M, et al. Induced sputum in the diagnosis of childhood communityacquiredpneumonia. Thorax 2009; 64:252.

83. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/AmericanThoracic Society consensus guidelines on the management of communityacquired pneumonia inadults. Clin Infect Dis 2007; 44 Suppl 2:S27.

84. Murray PR, Washington JA. Microscopic and baceriologic analysis of expectorated sputum. Mayo ClinProc 1975; 50:339.

85. Rein MF, Gwaltney JM Jr, O'Brien WM, et al. Accuracy of Gram's stain in identifying pneumococci insputum. JAMA 1978; 239:2671.

86. Cvitkovic Spik V, Beovic B, Pokorn M, et al. Improvement of pneumococcal pneumonia diagnostics bythe use of rtPCR on plasma and respiratory samples. Scand J Infect Dis 2013; 45:731.

87. De Schutter I, Vergison A, Tuerlinckx D, et al. Pneumococcal aetiology and serotype distribution inpaediatric communityacquired pneumonia. PLoS One 2014; 9:e89013.

88. Selva L, Benmessaoud R, Lanaspa M, et al. Detection of Streptococcus pneumoniae andHaemophilus influenzae type B by realtime PCR from dried blood spot samples among children withpneumonia: a useful approach for developing countries. PLoS One 2013; 8:e76970.

89. Esposito S, Zampiero A, Terranova L, et al. Pneumococcal bacterial load colonization as a marker ofmixed infection in children with alveolar communityacquired pneumonia and respiratory syncytial virusor rhinovirus infection. Pediatr Infect Dis J 2013; 32:1199.

90. Honda J, Yano T, Kusaba M, et al. Clinical use of capillary PCR to diagnose Mycoplasma pneumonia.J Clin Microbiol 2000; 38:1382.

91. Skerrett SJ. Diagnostic testing for communityacquired pneumonia. Clin Chest Med 1999; 20:531.92. VuoriHolopainen E, Salo E, Saxén H, et al. Etiological diagnosis of childhood pneumonia by use of

transthoracic needle aspiration and modern microbiological methods. Clin Infect Dis 2002; 34:583.93. Kornecki A, Shemie SD. Open lung biopsy in children with respiratory failure. Crit Care Med 2001;

29:1247.94. HayesJordan A, Benaim E, Richardson S, et al. Open lung biopsy in pediatric bone marrow transplant

patients. J Pediatr Surg 2002; 37:446.95. De Schutter I, De Wachter E, Crokaert F, et al. Microbiology of bronchoalveolar lavage fluid in children

with acute nonresponding or recurrent communityacquired pneumonia: identification of nontypeableHaemophilus influenzae as a major pathogen. Clin Infect Dis 2011; 52:1437.

96. Loens K, Van Heirstraeten L, MalhotraKumar S, et al. Optimal sampling sites and methods fordetection of pathogens possibly causing communityacquired lower respiratory tract infections. J ClinMicrobiol 2009; 47:21.

97. de Blic J, Midulla F, Barbato A, et al. Bronchoalveolar lavage in children. ERS Task Force onbronchoalveolar lavage in children. European Respiratory Society. Eur Respir J 2000; 15:217.



98. Kirkpatrick MB, Bass JB Jr. Quantitative bacterial cultures of bronchoalveolar lavage fluids and

protected brush catheter specimens from normal subjects. Am Rev Respir Dis 1989; 139:546.

99. Naiditch JA, Barsness KA, Rothstein DH. The utility of surgical lung biopsy in immunocompromised

children. J Pediatr 2013; 162:133.

100. Crain EF, Bulas D, Bijur PE, Goldman HS. Is a chest radiograph necessary in the evaluation of every

febrile infant less than 8 weeks of age? Pediatrics 1991; 88:821.

101. Wingerter SL, Bachur RG, Monuteaux MC, Neuman MI. Application of the world health organization

criteria to predict radiographic pneumonia in a USbased pediatric emergency department. Pediatr

Infect Dis J 2012; 31:561.

102. Mani CS, Murray DL. Acute pneumonia and its complications. In: Principles and Practice of Pediatric

Infectious Diseases, 4th, Long SS, Pickering LK, Prober CG. (Eds), Elsevier Saunders, Edinburgh

2012. p.235.

103. Gaston B. Pneumonia. Pediatr Rev 2002; 23:132.

104. Clark CE, Coote JM, Silver DA, Halpin DM. Asthma after childhood pneumonia: six year follow up

study. BMJ 2000; 320:1514.

105. Chen KC, Su YT, Lin WL, et al. Clinical analysis of necrotizing pneumonia in children: threeyear

experience in a single medical center. Acta Paediatr Taiwan 2003; 44:343.

106. Kerem E, Bar Ziv Y, Rudenski B, et al. Bacteremic necrotizing pneumococcal pneumonia in children.

Am J Respir Crit Care Med 1994; 149:242.

107. McCarthy VP, Patamasucon P, Gaines T, Lucas MA. Necrotizing pneumococcal pneumonia in

childhood. Pediatr Pulmonol 1999; 28:217.

108. Ramphul N, Eastham KM, Freeman R, et al. Cavitatory lung disease complicating empyema in

children. Pediatr Pulmonol 2006; 41:750.

109. Bender JM, Ampofo K, Korgenski K, et al. Pneumococcal necrotizing pneumonia in Utah: does

serotype matter? Clin Infect Dis 2008; 46:1346.

110. Sawicki GS, Lu FL, Valim C, et al. Necrotising pneumonia is an increasingly detected complication of

pneumonia in children. Eur Respir J 2008; 31:1285.

111. Cengiz AB, Kanra G, Caĝlar M, et al. Fatal necrotizing pneumonia caused by group A streptococcus. J

Paediatr Child Health 2004; 40:69.

112. Wang RS, Wang SY, Hsieh KS, et al. Necrotizing pneumonitis caused by Mycoplasma pneumoniae in

pediatric patients: report of five cases and review of literature. Pediatr Infect Dis J 2004; 23:564.

113. Hodina M, Hanquinet S, Cotting J, et al. Imaging of cavitary necrosis in complicated childhood

pneumonia. Eur Radiol 2002; 12:391.

114. Schwartz KL, Nourse C. PantonValentine leukocidinassociated Staphylococcus aureus necrotizing

pneumonia in infants: a report of four cases and review of the literature. Eur J Pediatr 2012; 171:711.

115. Lemaître C, Angoulvant F, Gabor F, et al. Necrotizing pneumonia in children: report of 41 cases

between 2006 and 2011 in a French tertiary care center. Pediatr Infect Dis J 2013; 32:1146.

116. Groskin SA, Panicek DM, Ewing DK, et al. Bacterial lung abscess: a review of the radiographic and

clinical features of 50 cases. J Thorac Imaging 1991; 6:62.

117. Emanuel B, Shulman ST. Lung abscess in infants and children. Clin Pediatr (Phila) 1995; 34:2.

118. Donnelly LF, Klosterman LA. The yield of CT of children who have complicated pneumonia and

noncontributory chest radiography. AJR Am J Roentgenol 1998; 170:1627.

119. Tan TQ, Seilheimer DK, Kaplan SL. Pediatric lung abscess: clinical management and outcome.

Pediatr Infect Dis J 1995; 14:51.

120. Lorber B. "Bad breath": presenting manifestation of anaerobic pulmonary infection. Am Rev Respir Dis

1975; 112:875.

121. Brook I. Lung abscesses and pleural empyema in children. Adv Pediatr Infect Dis 1993; 8:159.

122. Brook I, Finegold SM. Bacteriology and therapy of lung abscess in children. J Pediatr 1979; 94:10.

123. Hacimustafaoglu M, Celebi S, Sarimehmet H, et al. Necrotizing pneumonia in children. Acta Paediatr

2004; 93:1172.

124. Johnson JF, Shiels WE, White CB, Williams BD. Concealed pulmonary abscess: diagnosis by

computed tomography. Pediatrics 1986; 78:283.



125. Kunyoshi V, Cataneo DC, Cataneo AJ. Complicated pneumonias with empyema and/or pneumatocele

in children. Pediatr Surg Int 2006; 22:186.

126. Amitai I, Mogle P, Godfrey S, Aviad I. Pneumatocele in infants and children. Report of 12 cases. Clin

Pediatr (Phila) 1983; 22:420.

127. Ceruti E, Contreras J, Neira M. Staphylococcal pneumonia in childhood. Longterm followup including

pulmonary function studies. Am J Dis Child 1971; 122:386.

128. Soto M, Demis T, Landau LI. Pulmonary function following staphylococcal pneumonia in children. Aust

Paediatr J 1983; 19:172.

129. Singhi S, Dhawan A. Frequency and significance of electrolyte abnormalities in pneumonia. Indian

Pediatr 1992; 29:735.

130. Dhawan A, Narang A, Singhi S. Hyponatraemia and the inappropriate ADH syndrome in pneumonia.

Ann Trop Paediatr 1992; 12:455.

131. Don M, Valerio G, Korppi M, Canciani M. Hyponatremia in pediatric communityacquired pneumonia.

Pediatr Nephrol 2008; 23:2247.

Topic 5986 Version 31.0



GRAPHICS

Important aspects of the history in a child with pneumonia

Historical feature Possible significance

Age of the child Viral etiologies are most common in infants and preschoolchildren

Atypical bacterial pathogens are more common in schoolagechildren

Recent viral upperrespiratory tract infection

May predispose to bacterial superinfection with Streptococcuspneumoniae or Staphylococcus aureus

Associated symptoms Mycoplasma pneumoniae is often associated withextrapulmonary manifestations (eg, headache, photophobia,rash)

Cough, chest pain,shortness of breath,difficulty breathing

"Classic" features of pneumonia, but nonspecific

Increased work ofbreathing in the absenceof stridor or wheezing

Suggestive of severe pneumonia

Choking episode May indicate foreign body aspiration

Duration of symptoms Chronic cough (>4 weeks) suggests etiology other than acutepneumonia (refer to UpToDate topic on causes of chronic coughin children)

Previous episodes Recurrent episodes may indicate aspiration, congenital oracquired anatomic abnormality, cystic fibrosis,immunodeficiency, asthma, missed foreign body

Immunization status Completion of the primary series of immunizations forHaemophilus influenzae type b, Streptococcus pneumoniae,Bordetella pertussis, and seasonal influenza decreases, but doesnot eliminate, the risk of infection with these organisms

Previous antibiotic therapy Increases the likelihood of antibioticresistant bacteria

Maternal history ofchlamydia duringpregnancy (for infants <4months of age)

May indicate Chlamydia trachomatis infection

Exposure to tuberculosis May indicate Mycobacterium tuberculosis infection

Ill contacts More common with viral etiologies

Travel to or residence incertain areas that suggestendemic pathogens

Measles: Developing world

Coccidioidomycosis: Southwestern US, northern Mexico, Centraland South America

Blastomycosis: Southeastern and central US; states borderingthe Great Lakes

Histoplasmosis: Ohio, Missouri, and Mississippi River valleys inthe United States; Canada; Central America; eastern and



southern Europe; parts of Africa; eastern Asia; and Australia

Hantavirus: West of the Mississippi River; four corners region of

United States (where borders of Colorado, New Mexico, Arizona,

and Utah meet)

Animal exposure May indicate histoplasmosis, psittacosis, Q fever

Day care center

attendance

Exposure to viruses and antibioticresistant bacteria

Fluid and nutrition intake Difficulty or inability to feed suggests severe illness

Graphic 52510 Version 6.0



Important aspects of the physical examination in a child withsuspected pneumonia

Examinationfeature

Possible significance

Generalappearance (stateof awareness,cyanosis)*

Most children with radiographically confirmed pneumonia appear ill

Vital signs

Temperature Fever may be the only sign of pneumonia in highly febrile youngchildren; however, it is variably present and nonspecific

Respiratory rate Tachypnea correlates with radiographically confirmed pneumonia andhypoxemia

Absence of tachypnea helps to exclude pneumonia

Degree ofrespiratorydistress

Respiratory distress is more specific than fever or cough for lowerrespiratory infection

Tachypnea

Hypoxemia Predictive of pneumonia

Increased work of breathing:

Retractions More common in children with pneumonia than without; absence does not

exclude pneumonia

Nasal flaring More common in children with pneumonia than without; absence does not

exclude pneumonia

Grunting Sign of severe disease and impending respiratory failure

Accessory

muscle use

Sign of severe disease

Head bobbing Sign of severe disease

Lung examination

Cough Nonspecific finding of pneumonia

Auscultation Findings suggestive of pneumonia include: crackles (rales,crepitations), decreased breath sounds, bronchial breath sounds,egophany, bronchophony, and whispered pectoriloquy

Wheezing more common in viral and atypical pneumonias

Tactile fremitus Suggestive of parenchymal consolidation

Dullness topercussion

Suggestive of parenchymal consolidation or pleural effusion

Mental status Altered mental status may be a sign of hypoxia

* For young infants: Ability to attend to the environment, feed, vocalize, and be consoled.¶ World Health Organization definitions of tachypnea according to age are as follows: <2 months:>60 breaths/min; 2 to 12 months: >50 breaths/min; 1 to 5 years: >40 breaths/min; ≥5 years:

¶



>20 breaths/min.




Severity of community acquired pneumonia in infants and children

Clinical features of mild pneumoniaClinical features of severe

pneumonia

Temperature <38.5°C (101.3°F) Temperature ≥38.5°C (101.3°F)

Mild or absent respiratory distress:

Increased RR, but less than the agespecific RR

that defines moderate to severe respiratory

distress

Mild or absent retractions

No grunting

No nasal flaring

No apnea

Mild shortness of breath

Moderate to severe respiratory distress:

RR >70 breaths/minute for infants;

RR >50 breaths/minute for older

children

Moderate/severe suprasternal,

intercostal, or subcostal retractions

(<12 months)

Severe difficulty breathing (≥12

months)

Grunting

Nasal flaring

Apnea

Significant shortness of breath

Normal color Cyanosis

Normal mental status Altered mental status

Normoxemia (oxygen saturation ≥92 percent in

room air)

Hypoxemia (sustained oxygen saturation

<90 percent in room air at sea level)

Normal feeding (infants); no vomiting Not feeding (infants) or signs of

dehydration (older children)

Normal heart rate Tachycardia

Capillary refill <2 seconds Capillary refill ≥2 seconds

RR: respiratory rate.

Data from:

1. Bradley JS, Byington CL, Shah SS, et al. The management of communityacquired

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:e25.

2. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of

community acquired pneumonia in children: update 2011. Thorax 2011; 66:ii1.




Clinical and radiographic clues to the etiology of pneumonia inchildren*

Etiology Clinical featuresRadiographicfeatures

Bacteria

(most commonly

Streptococcuspneumoniae)

Children of all ages

Abrupt onset

Illappearance

Chills

Moderate to severe respiratory distress

Focal auscultatory findings

Localized chest pain

WBC count >15,000/microL (if obtained)

Elevated acute phase reactants (if

obtained)

Alveolar infiltrates

Segmental

consolidation

Lobar

consolidation

"Round"

pneumonia

Complications:

Pleural

effusion/empyema

Lung abscess

Necrotizing

pneumonia

Pneumatocele

Atypical bacterial

(Mycoplasmapneumoniae,Chlamydophilapneumoniae)

Children of all ages (most common in

children >5 years)

Abrupt onset with constitutional findings

(malaise, myalgia, headache, rash,

conjunctivitis, photophobia, sore throat,

headache)

Gradually worsening nonproductive cough

Wheezing

Extrapulmonary manifestations or

complications (eg, StevensJohnson

syndrome, hemolytic anemia, hepatitis,

etc)

Interstitial infiltrates

Viral Usually children <5 years

Gradual onset

Preceding upper airway symptoms

Nontoxic appearing

Diffuse, bilateral auscultatory findings

Wheezing

May have associated rash (eg, measles,

varicella)

Interstitial infiltrates

Afebrile pneumonia

of infancy (most

commonly Chlamydiatrachomatis)

Usually in infants 2 weeks to 4 months

Insidious onset

Rhinorrhea

Staccato cough pattern

Hyperinflation with

interstitial process



Peripheral eosinophilia (if CBC obtained)

Fungal Appropriate geographic or environmentalexposure

Mediastinal or hilaradenopathy

Mycobacteriumtuberculosis

Children of any ageChronic cough

Constitutional symptomsExposure history

Mediastinal or hilaradenopathy

WBC: white blood cell; CBC: complete blood count.* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypicalbacterial, and viral etiologies; up to onehalf of communityacquired pneumonias in children may bemixed bacterial/viral infections. Chest radiography generally is not helpful in determining thepotential causative agent of pneumonia. Nonetheless, these features may facilitate decisionsregarding empiric therapy.

Data from: 1. Bartlett JG, Mundy LM. Communityacquired pneumonia. N Engl J Med 1995; 333:1618.

2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6th ed,

Feigin RD, Cherry JD, DemmlerHarrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009.

p.289.

3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis

1986; 5:71.

4. McIntosh K. Communityacquired pneumonia in children. N Engl J Med 2002; 346:429.




Boy with measles

Source: Centers for Disease Control and Prevention.




Measles exanthem

Blanching erythematous macules with some confluent areas on thetrunk in a patient with measles.

Copyright Dr. Michael Bennish; reproduced with his permission.




Primary varicella lesions

Vesicular lesions on an erythematous base are characteristic ofchickenpox. The lesions occur in crops and are present in a variety ofstages from maculopapular to vesicular or even pustular. Centralnecrosis and early crusting is also visible.

Courtesy of Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text,Sanders CV, Nesbitt LT Jr (Eds), Williams & Wilkins, Baltimore 1995.

http://www.lww.comGraphic 55533 Version 5.0



Herpes simplex virus infection of the hand

Closeup view of vesicles on an erythematous base.

Courtesy of Beth G Goldstein, MD and Adam O Goldstein, MD.




Herpes simplex labialis

Grouped vesicles are evident on the lower vermilion border.

Reproduced with permission from: Bickley LS, Szilagyi P. Bates' Guide to Physical

Examination and History Taking, Eighth Edition. Philadelphia: Lippincott Williams &

Wilkins, 2003. Copyright © 2003 Lippincott Williams & Wilkins.




Rightsided pneumonia with pleural effusion

Courtesy of Dwight A Powell, MD.




Computed tomography: Leftsided pneumonia withpleural effusion





Computed tomography: Leftsided Streptococcuspneumoniae necrotizing pneumonia

Courtesy William J Barson, MD.




Plain radiograph: Mycoplasma pneumoniae pneumonia

Diffuse bilateral interstitial infiltrates with M. pneumoniae infection.





Suggested criteria for full Haemophilus influenza type b andStreptococcus pneumoniae immunization status when consideringempiric antibiotics for community acquired pneumonia in children

Current age* Criteria for full immunization

Haemophilus influenzae type b

12 to 15 months ≥2 doses of Hib conjugate vaccine, with at

least one dose at ≥12 months of age

15 months to 5 years ≥2 doses of Hib conjugate vaccine, with at

least one dose at ≥12 months of age, or

≥1 dose of Hib conjugate vaccine at ≥15

months of age

≥5 years, not high risk Hib immunization not necessary

Streptococcus pneumoniae

12 to 24 months ≥3 doses of PCV at <16 months, with ≥1

dose at ≥12 months, or

2 doses of PCV, both at ≥12 months

24 months through 5 years ≥3 doses of PCV at <16 months, with ≥1

dose at ≥12 months, or

2 doses of PCV, both at ≥12 months, or

≥1 dose of PCV at ≥24 months

>5 years, not high risk PCV immunization not necessary

Hib: Haemophilus influenzae type b; PCV: pneumococcal conjugate vaccine.

* Children younger than 12 months are incompletely immunized against Hib and S. pneumoniae.

¶ Immunizations must be completed at least two weeks before pneumonia diagnosis.

Δ Children at high risk for invasive Hib disease include chemotherapy recipients and those with

anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV)

infection, immunoglobulin deficiency, or early component complement deficiency. Please refer to the

UpToDate topic on prevention of Haemophilus influenzae infection for a discussion of full Hib

immunization in children at high risk for invasive Hib disease.

◊ Children at high risk for invasive S. pneumoniae disease include those with chronic heart disease

(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including

asthma if treated with highdose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid

leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional

asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with

treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms,

leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; or congenital

immunodeficiency. Please refer to the UpToDate topics on pneumococcal conjugate vaccine and

pneumococcal polysaccharide vaccines for a discussion of full S. pneumoniae immunization in

children at high risk for invasive S. pneumoniae disease.


¶

Δ

◊



Sputum from a patient with pneumococcalpneumonia

Gram stain of sputum (x1000) shows abundant inflammatory cells andgrampositive diplococci; Streptococcus pneumoniae was identified fromthis specimen by culture and by the optochin disk test.

Courtesy of Harriet Provine.




Noninfectious condititions that can mimic pneumonia in children

Anatomical considerations

Prominent thymus

Breast shadows

Bronchogenic cyst

Vascular ring

Pulmonary sequestration

Congenital lobar emphysema

Atelectasis (due to a foreign body or mucusplug)

Aspiration of gastric contents

Gastroesophageal reflux

Tracheoesophageal fistula

Cleft palate

Neuromuscular disorders

Chronic pulmonary disorders

Asthma

Bronchiectasis

Bronchopulmonary dysplasia

Cystic fibrosis

Pulmonary fibrosis

Alpha1antitrypsin deficiency

Pulmonary hemosiderosis

Alveolar proteinosis

Desquamative interstitial pneumonitis

Sarcoidosis

Histiocytosis X

Drugs and chemical exposures

Nitrofurantoin

Bleomycin

Cytotoxic drugs

Opiates

Radiation therapy

Smoke inhalation

Lipoid pneumonia

Vasculitic disorders

Systemic lupus erythematosus

Granulomatosis with polyangiitis(Wegener's)

Juvenile idiopathic arthritis

Others

Hypersensitivity pneumonitis

Neoplasm

Pulmonary edema due to heart failure

Pulmonary infarction

Acute respiratory distress syndrome

Graftversushost disease

Poor inspiratory film

Near drowning event

Underpenetrated film

Data from:

1. Klein JO. Bacterial pneumonias. In: Textbook of Pediatric Infectious Diseases, 5th ed, Feigin

RD, Cherry JD, Demmler GJ, Kaplan SL (Eds), WB Saunders, Philadelphia 2004. p.299.

2. McIntosh K. Communityacquired pneumonia in children. N Engl J Med 2002; 346:429.

3. Gaston B. Pneumonia. Pediatr Rev 2002; 23:132.

4. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Disease, 5th ed,

Feigin RD, Cherry JD, Demmler GJ, Kaplan SL (Eds), WB Saunders, Philadelphia 2004. p.286.




Complications of pneumococcal pneumonia

Radiographic images of the complications of pneumococcal pneumonia.(Left panel) Lung abscess with an airfluid level in the right lung. Abscesscavity material is nearly always culture positive, and patients commonlydefervesce within 48 hours of interventional drainage.(Right panel) Radiograph of necrotizing pneumonia in the left lung.




Disclosures: William J Barson, MD Grant/Research/Clinical Trial Support: Pfizer [US Pediatric Multicenter PneumococcalSurveillance Group (Pneumococcal conjugate vaccine (13valent))]. Sheldon L Kaplan, MD Grant/Research/Clinical Trial Support:Pfizer [vaccine (PCV13)]; Forest Lab [antibiotic (Ceftaroline)]; Optimer [antibiotic (fidaxomicin)]. Consultant/Advisory Boards: Pfizer

[vaccine (PCV13)]. George B Mallory, MD Nothing to disclose. Mary M Torchia, MD Nothing to disclose.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting

through a multilevel review process, and through requirements for references to be provided to support the content. Appropriately

referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

Disclosures

community-acquired pneumonia in children- clinical features and diagnosis

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