Pneumonia is a lower respiratory tract infection caused by viruses or bacteria. It may involve a lobe (lobar pneumonia) or be more diffuse (bronchopneumonia).
Pneumonia can be caused by viruses (such as RSV, influenza, parainfluenza and adenovirus), bacteria (most commonly Streptococcus pneumoniae) or atypical bacteria (Mycoplasma pneumoniae and Chlamydia trachomatis).
Viral pneumonia is more common than bacterial pneumonia.
The most common cause of bacterial pneumonia in the < 5 year olds is Streptococcus.
The most common cause of bacterial pneumonia in the > 5 year olds is Mycoplasma.
Differentiation between viral and bacterial pneumonia is best done by clinical acumen.
Neither X-Ray appearance, WCC, neutophil count nor CRP is reliable in trying to distinguish between viral and bacterial pneumonia.
Pneumonia will usually present with fever, cough, tachypnoea and possibly grunting.
It can also present as fever without a source (especially in neonates), and occasionally as abdominal pain or meningism.
Clinically, tachypnoea is a consistently useful sign, but auscultatory signs can be unreliable.
Most children seen in our community with fever and respiratory symptoms will not have pneumonia.
Other clinical features to note:
In the preschool child, if wheeze is present, primary bacterial pneumonia is unlikely.
Presence of bilateral signs with wheeze and/or crackles is more suggestive of a viral pneumonia.
Mycoplasma is the most common cause of community acquired pneumonia in school age children. It generally has a more indolent course and may have quite variable signs. It is often associated with malaise, headache and sore throat.
A CXR may be useful in children with either isolated focal signs or a clear chest
The presence of lobar or segmental consolidation suggests bacterial pneumonia (usually Streptococcus)
Cavitation and significant pleural effusions are rare and suggest a bacterial cause
Should be performed in all children thought to have bacterial pneumonia who are sick enough to require hospital admission
WCC, CRP and ESR are unreliable in distinguishing between bacterial and viral pneumonia
Bacterial serological tests are unhelpful, with the possible exception of paired Mycoplasma titres
Nasopharyngeal aspirate (NPA)
Viruses (if being admitted for isolation purposes)
May be useful to identify Mycoplasma in school age children
Bacterial culture is meaningless and should not be done
Most children with bacterial pneumonia can be treated at home with oral antibiotics and General Practitioner follow up in 24 hours.
Children presenting with mild symptoms of lower respiratory tract infection are likely to be viral and should not be treated with antibiotics.
Community Acquired Pneumonia (CAP)
Neonate < 1 month of age
IV Amoxycillin 50mg/kg/dose AND IV Gentamicin 7.5mg/kg/dose Consider investigating and treating for pertussis
Oral Amoxicillin 25mg/kg (maximum 1g) 8 hourly
IV Benzylpenicillin 30mg/kg (maximum 1.2g) 6 hourly +/- Oral Azithromycin 10mg/kg (maximum 500mg) daily if considering atypical pneumonia
Severe pneumonia Suspected Staphylococcal pneumonia (e.g. pneumatocoeles – any age)
IV Ceftriaxone 50mg/kg (maximum 2g) daily AND IV Vancomycin 15mg/kg (maximum dose of 750mg) 6 hourly AND IV/Oral Azithromycin 10mg/kg (maximum 500mg) daily
For further information (including information on antibitoic choice for aspiration pneumonia and empyema) WA Health Clinicians can access the Children’s Antimicrobial Management Program (ChAMP) – Acute Respiratory Tract Infection Empiric Guideline on the intranet.
Clinical evidence of significant respiratory distress
Hypoxia – reduced oxygen saturation < 93%
Extensive consolidation, large effusion or cavitation on CXR
Not tolerating oral antibiotics
History of chronic respiratory disease, congenital cardiac disease, immunodeficiency, trisomy 21 or ex-preterm (< 32 weeks)
Geographic location and access to travel of parents, or other adverse social circumstance
Referrals and follow-up
If discharged, ensure that child is reviewed within 24 hours, preferrably by the child’s GP.
Baseline observations include heart rate, respiratory rate, oxygen saturations and temperature. Minimum of hourly observations should be recorded whilst in the emergency department. Any significant changes should be reported immediately to the medical team.
Western Australia. Department of Health. Children’s Antimicrobial Management Program (ChAMP). Acute Respiratory Tract Infection. ChAMP Empiric Guidelines. Princess Margaret Hospital: 2013.