1. By
Dr.Mousa El-shamly
Consultant pulmonology king saud
hospital

2.  Pneumonia: an acute infection of the
pulmonary parenchyma
The term “Lower Respiratory Tract Infection”
(LRTI) may include pneumonia,
bronchiolitis and/or bronchitis
Bronchopneumonia, a patchy consolidation involving one
or more lobes, usually involves the dependent lung
zones,
Miliary pneumonia is a term applied to multiple, discrete
lesions resulting from the spread of the pathogen to the
lungs via the bloodstream

3. In interstitial pneumonia, patchy or diffuse
inflammation involving the interstitium is characterized by
infiltration of lymphocytes and macrophages
The alveoli do not contain a significant exudate,
but protein-rich hyaline membranes similar to
those found in adult respiratory distress syndrome
(ARDS) may line the alveolar spaces
congenital pneumonia, presents within the first 24
hours after birth.
Pneumonia may originate in the lung or may be a focal
complication of a contiguous or systemic inflammatory
process

4. Although in developed countries the
diagnosis is usually made on the basis of
radiographic findings, the World Health
Organization (WHO) has defined
pneumonia solely on the basis of clinical
findings .

5.  Pneumonia kills more children under
the age of five than any other illness in
every region of the world.
 It is estimated that of the 9 million child
deaths in 2007, 20% (1.8 million) were
due to pneumonia
 Approximately 98% of children who die
of pneumonia are in developing
countries.

6. United States statistics
Pneumonia can occur at any age, although it is more
common in younger children. Pneumonia accounts for 13%
of all infectious illnesses in infants younger than 2 years. In a
large community-based study conducted by Denny and
Clyde, the annual incidence rate of pneumonia was 4 cases
per 100 children in the preschool-aged group, 2 cases per
100 children aged 5-9 years, and 1 case per 100 children
aged 9-15 years.[16]

7.  Most cases of pneumonia are caused by the
aspiration of infective particles into the lower
respiratory tract.
 Organisms that colonize a child’s upper
airway can cause pneumonia.
 Pneumonia can be caused by person to
person transmission via airborne droplets.

8. Etiology
While virtually any microorganism can lead to
pneumonia, specific bacterial, viral, fungal, and
mycobacterial infections are most common in
previously healthy children.
pathogen was identified in 79% of children,
Pyogenic bacteria accounted for 60% of cases, of
which 73% were due to Streptococcus
pneumoniae, while the atypical bacteria Mycoplasma
pneumoniae andChlamydophila pneumoniae were
detected in 14% and 9%, respectively. Viruses were
documented in 45% of children.

9. Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

10. Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

12. It is not possible to distinguish between bacterial
and viral pneumonia on clinical grounds alone!
Suggestive of bacteria:
 Rapid onset (tachypnea, cough, retractions)
 Likely to appear very sick
 Higher temperatures (>39º C)
Suggestive of virus:
 Low-grade fever, irritable but not toxic (usually!)
 Associated complaints: sore throat, myalgias, GI
complaints
 Longer prodrome (2-3 days or longer)
 Concomitant URI symptoms at times

13. Newborns with pneumonia rarely cough;
they more commonly present with poor
feeding and irritability, as well as
tachypnea, retractions, grunting, and
hypoxemia. Grunting in a newborn is due
to vocal cord approximation as they try to
provide increased positive end-expiratory
pressure (PEEP) and keep their lower
airways open

14. After the first month of life, cough is the
most common presenting symptom of
pneumonia. Infants may have a history of
antecedent upper respiratory symptoms.
Grunting may be less common in older
infants; however, tachypnea, retractions,
and hypoxemia are common and may be
accompanied by a persistent cough, fever,
irritability, and decreased feeding.

15. Infants with bacterial pneumonia are often
febrile, but those with viral pneumonia or
pneumonia caused by atypical organisms may
have a low-grade fever or may be afebrile.
The child's care takers may complain that the
child is wheezing or has noisy breathing.
Toddlers and preschoolers most often present
with fever, cough (productive or
nonproductive), tachypnea, and congestion.
They may have some vomiting, particularly
posttussive emesis. A history of antecedent
upper respiratory tract illness is common

16. Older children and adolescents may also
present with fever, cough (productive or
nonproductive), congestion, chest pain,
dehydration, and lethargy. In addition to the
symptoms reported in younger children,
adolescents may have other constitutional
symptoms, such as headache, pleuritic chest
pain, and vague abdominal pain. Vomiting,
diarrhea, pharyngitis, and otalgia/otitis are
other common symptoms.

17. Travel history is important because it may
reveal an exposure risk to a pathogen more
common to a specific geographic area (eg,
dimorphic fungi). Any exposure to TB should
always be determined. In addition, exposure to
birds (psittacosis), bird droppings
(histoplasmosis), bats (histoplasmosis), or other
animals (zoonoses, including Q fever,
tularemia, and plague) should be determined.

18. Age Respiratory Indication of
Rate severe
(breaths/min) infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5 years > 40 >50
Greater than 5 years > 20

19. Lower chest wall indrawing: with inspiration,
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

20. Nasal flaring: with inspiration, the side of the
nostrils flares outwards
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

21. Consider if
 Diagnosis is otherwise inconclusive
 To exclude other causes of shortness of breath
(e.g.. foreign body, heart failure)
 To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema,
pleural effusion)
 To exclude pneumonia in an infant less than
three months with fever

25. Bacteria - WBC count & leukocytosis ,blood cultures (3%-11% in
pneumonia),
CRP, ESR; “sputum “ (Gram stain and culture), urine
pneumococcal
antigen (good sensitivity, poor specificity)
Viral - viral isolation, antigen detection, molecular diagnostics, serology
limited.
Mycoplasma – serology (IgM has poor specificity ~60%), paired serology,
PCR (limited sensitivity in children; poor sputum sample)
Chlamydophila – Serology (poor sensitivity , limited specificity in
children),
Legionella – Urinary antigen (sensitivity ~80%, specificity ~100%)
Radiology – to follow.

26.  All pt’s should have CXR
 Blood culture
 CBC
 ESR/CRP
 Urinary antigen for Pneumococcal infection is
not recommended
 Sputum samples
 Rapid tests for Influenza and viruses should be
used
 Mycoplasma pneumoniae should be tested for if
suspicious
 No reliable test for Chlamydophila pneumoniae

29.  RSV is the most common cause of LRTIs in
children less than 1.
 Infants and young children typically present
with pneumonia or bronchiolitis.
 Older children may have upper respiratory
tract infection symptoms.
 RSV is associated with apnea in infants.
 Wheezing is common.

30. Most common in late winter or early spring
during the peak of viral infection
 Abrupt onset of fever
 Restlessness
 Respiratory distress following URI

31. Test Specimen Sensitivity(%) Specificity(%) Comments
Culture Throat or NP swab, > 90 50-90 Not routinely available;
sputum, bronchial slow-growing organism
washing
tissue
PCR Throat or NP swab, 95 95-99 Not commercially available
sputum, potencially useful for rapid
broncial washings, diagnosis test
tissue
Serology cold agglutinins 50 < 50 Nonspecific;takes several
wks to develop
Serum 75-80 80-90 Paired acute-convalescent
Complement sera preferred;takes 4-9wks
fixation for seroconversion
Elisa Diagnostic criteria
Definite: 4-fold increase in
titer

32. Common symptoms of tuberculosis include:
 Chronic cough that has been present for more
than 3 weeks and is not improving
 Fever greater than 38°C for at least two
weeks, not attributable to other common
causes
 Weight loss or failure to thrive

33.  Physical exam findings of children with
pulmonary tuberculosis are similar to those
of a lower respiratory tract infection.
 In children less than age five tuberculosis can
progress rapidly from latent infection to
active disease and serve as a sentinel case in
the community.
 Consider the diagnosis of tuberculosis,
especially in those children who fail to
respond appropriately to routine treatment
for pneumonia.

35. Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosis
RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or supervision
Older Children Oxygen Saturation <= 92%, cyanosis
RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or supervision
From: British Thoracic Society (BTS) of Standards of Care Committee.
BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.

36. Admission

37.  Consideration must be given to the provision
of adequate hydration, oxygenation, nutrition,
antipyretics and pain control.
 Monitoring should include:
 Respiratory rate
 Work of breathing
 Temperature
 Heart rate
 Oxygen saturation (if available)
 Findings on auscultation.

38.  Assist ventilation (e.g., bag-mask ventilation)
as needed
 Provide oxygen
 Continuously monitor oxygen saturation
 Consider use of CPAP or BIPAP
 Prepare for endotracheal intubation as
needed
 Administer medications as needed

39.  Respiratory failure is the most common indication for
intubation in children with pneumonia
 Clinical evidence of respiratory failure:
 Poor or absent respiratory effort
 Poor colour
 Obtunded mental status
 Oxygen saturation and end-tidal carbon dioxide can be
used to support the decision to intubate, but intubation
should not be delayed if there is clinical evidence of
respiratory failure

41.  Pleural effusion – fluid in the pleural space
as the result of inflammation.
 Empyema – bacterial infection in the pleural
space.
 Parapneumonic effusions develop in
approximately 40% of patients admitted to
hospital with bacterial pneumonia.
 If an effusion is present and the patient is
persistently febrile, the pleural space should
be drained.

42.  Necrotizing Pneumonia – necrosis or
liquefaction of lung parenchyma.
 Lung Abscess – A collection of inflammatory
cells leading to tissue destruction resulting in one
or more cavities in the lungs. A rare
complication.
 Treatment of both Necrotizing Pneumonia and
Lung Abscess involves long term parenteral
antibiotics for 2-4 weeks, or 2 weeks after the
patient is afebrile, and has clinically improved.

43.  Pneumatocele – thin walled, air filled cysts of
the lung, often occurs with empyema.
 Pneumatoceles often resolve spontaneously,
but may lead to pneumothorax.

44.  Hyponatremia:
 Serum sodium <135 mmol/L.
 Studies in India (1992) revealed that in children
hospitalized with pneumonia, 27% had
hyponatremia and 4% had hypernatremia.
 SIADH was the most common cause of
hyponatremia.
 Hyponatremia is associated with increased hospital
stay, complications and increased mortality,
however most cases were found to be mild.

46. Outpatient Treatment of Pneumonia Child < 5 years old
 Presumed bacterial pneumonia
 Amoxicillin, oral (90 mg/kg/day in 2 doses)
Alternative: oral amoxicillin clavulanate (amoxicillin
component, 90 mg/kg/day in 2 doses)
 Presumed atypical pneumonia
 Azithromycin oral (10 mg/kg on day 1, followed by 5
mg/kg/day once daily on days 2–5);
 Alternatives: oral clarithromycin (15 mg/kg/day in 2
doses for 7-14 days) or oral erythromycin (40
mg/kg/day in 4 doses)
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

47.  Presumed bacterial pneumonia
 Oral amoxicillin (90 mg/kg/day in 2 doses to a
maximum of 4 g/day); for children with
presumed bacterial CAP who do not have
clinical, laboratory, or radiographic evidence that
distinguishes bacterial CAP from atypical CAP, a
macrolide can be added to a b-lactam antibiotic
for empiric therapy;
 alternative: oral amoxicillin clavulanate
(amoxicillin component, 90 mg/kg/day in 2
doses to a maximum dose of 4000 mg/day, eg,
one 2000-mg tablet Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
IDSA
twice daily)

48.  Presumed atypical pneumonia
 Oral azithromycin (10 mg/kg on day
1, followed by 5 mg/kg/day once daily
on days 2–5 to a maximum of 500 mg
on day 1, followed by 250 mg on days
2–5); alternatives: oral clarithromycin
(15 mg/kg/day in 2 doses to a
maximum of 1 g/day); erythromycin,
doxycycline for children >7 years old
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

49.  Presumed bacterial pneumonia
 Ampicillin or penicillin G;
 alternatives: ceftriaxone or
cefotaxime;
 addition of vancomycin or
clindamycin for suspected CA-
MRSA
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

50.  Presumed atypical pneumonia
 Azithromycin (in addition to ß-lactam,
if diagnosis of atypical pneumonia is in
doubt);
 alternatives: clarithromycin or
erythromycin; doxycycline for children
>7 years old; levofloxacin for children
who have reached growth maturity, or
who cannot tolerate macrolides
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

51.  Presumed bacterial pneumonia:
 Ceftriaxone or cefotaxime;
addition of vancomycin or
clindamycin for suspected CA-
MRSA;
 alternative: levofloxacin; addition
of vancomycin or clindamycin for
suspected CA-MRSA
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

52.  Presumed atypical pneumonia
 Azithromycin (in addition to ß-lactam,
if diagnosis in doubt);
 alternatives: clarithromycin or
erythromycin; doxycycline for children
>7 years old; levofloxacin for children
who have reached growth maturity or
who cannot tolerate macrolides
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

53.  Preferred: ceftriaxone (100 mg/kg/day every 12–24 hours);
 Alternatives: ampicillin (300–400 mg/kg/day every 6 hours),
levofloxacin (16–20 mg/kg/day every 12 hours for children 6
months to 5 years old and 8–10 mg/kg/day once daily for
children 5–16 years old; maximum daily dose, 750 mg), or
linezolid (30 mg/kg/day every 8 hours for children <12 years
old and 20 mg/kg/day every 12 hours for children ≥12 years
old);
 may also be effective: clindamycin (40 mg/kg/day every 6–8
hours) or vancomycin (40–60 mg/kg/day every 6–8 hours)
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

54.  Preferred: intravenous azithromycin (10
mg/kg on days 1 and 2 of therapy;
transition to oral therapy if possible);
 Alternatives: intravenous erythromycin
(20 mg/kg/day every 6 hours) or
 (16-20 mg/kg/day every 12 hours;
maximum daily dose, 750 mg)
IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25

55. Suspect MRSA in:
“Patients with severe pneumonia,
particularly during influenza season,
in patients with cavitary infiltrates,
and in those with a history of MRSA infection”
Treatment:
Vancomycin or linezolid should be used in such patients
Med Lett Drugs Ther 2007; 49(1266):62-64

56. Moderately severe (non-ICU) pneumonia:
Erythromycin, or azithromycin, or doxycycline
PLUS
Ceftriaxone or cefotaxime
Complicated pneumonia/abscess/effusion or severely ill patients
requiring ICU admission:
Ceftriaxone or cefotaxime
PLUS
Vancomycin (trough levels 15-20 ug/mL) or ? clindamycin
PLUS
Azithromycin

57.  Few evidence-based data to guide duration of therapy
 Parenteral: Generally preferable to switch to oral antimicrobial therapy
in patients who have received IV medications if (a) afebrile for 24-48
hours and (b) able to keep food down.
 Uncomplicated cases: 7-10 days combined IV/PO for routine pathogens
in uncomplicated infection.
 Consider continuing PO therapy until one week beyond resolution of
fever
 Complicated cases: Necrotizing pneumonia or abscess – likely 4 weeks
and patient improving.

58.  It is estimated that hand washing, when
combined with improved water and
sanitation could lead to a 3% reduction in all
child deaths.
 Promote exclusive breast feeding for 6
months. Impact 15-23% reduction in
pneumonia incidence. 13% reduction in all
child deaths. Shown to be cost effective.

59.  Adequate nutrition throughout the first five
years of life, including adequate
micronutrient intake. Impact 6% reduction
in all child deaths for adequate
complementary feeding (age 6-23 months).
 Reduce incidence of low birth weight.

60.  Tachypnea and respiratory distress are
considered the most important signs in the
diagnosis of pneumonia.
 Only 1 in 5 caregivers know that fast
breathing and respiratory distress are a
reason to seek care immediately.

61.  Reducing indoor air pollution, by changing
to cleaner gas or liquid fuels or high-quality,
well maintained biomass stoves, may reduce
the incidence of pneumonia by 22 to 46% in
appropriate settings. This intervention may
be cost-effective in low-income settings.

62. Cp5