Overview
Definition:
Community-Acquired Pneumonia (CAP) in children is an acute infection of the pulmonary parenchyma acquired outside of a hospital or healthcare setting
It is a leading cause of morbidity and mortality in children worldwide, particularly in resource-limited settings.
Epidemiology:
CAP is common in children globally, with incidence rates varying by age and geographic region
In developed countries, annual incidence is estimated at 20-40 episodes per 1000 children, with higher rates in younger children and during peak seasons
In India, pneumonia remains a significant cause of childhood mortality.
Clinical Significance:
Understanding CAP severity and appropriate antibiotic selection based on age is crucial for optimal patient outcomes
Delayed or incorrect management can lead to severe complications such as respiratory failure, sepsis, empyema, and death
Accurate diagnosis and risk stratification are essential for guiding treatment decisions and reducing unnecessary antibiotic use.
Clinical Presentation
Symptoms:
Fever
Cough (often productive)
Tachypnea
Dyspnea or shortness of breath
Chest pain (may be pleuritic)
Lethargy or irritability
Poor feeding or vomiting
Wheezing or grunting in infants.
Signs:
Tachypnea and increased work of breathing (retractions, nasal flaring, grunting)
Fever
Tachycardia
Auscultatory findings such as crackles (rales), decreased breath sounds, bronchial breath sounds, or wheezing
Dullness to percussion
Signs of consolidation
Cyanosis in severe cases
Signs of dehydration.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by imaging
The presence of fever, cough, tachypnea, and focal or diffuse chest signs on examination, especially in a child who has not been hospitalized recently, strongly suggests CAP
Chest X-ray findings (e.g., lobar consolidation, interstitial infiltrates, lobular pneumonia) confirm the diagnosis
Severity can be assessed using tools like the Pediatric Symptom Score (PSS), PRAM score, or CURB-65/Pneumonia Severity Index (PSI) adapted for children.
Age Specific Considerations
Neonates:
Etiology often includes vertical transmission (GBS, E
coli, Listeria) or hospital-acquired pathogens if NICU exposure
Presentation can be nonspecific (lethargy, poor feeding, apnea, temperature instability)
Rapid deterioration is common
Broad-spectrum IV antibiotics are typically required, covering common neonatal pathogens.
Infants Under 5 Years:
Viral pathogens are most common (RSV, influenza, parainfluenza, adenovirus)
Bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae type b (Hib) if unimmunized, and Staphylococcus aureus
Presentation can be subtle, with tachypnea and feeding difficulties prominent
Chest X-ray may show interstitial or bronchopneumonia patterns
Oral antibiotics are often suitable for outpatient management of mild-moderate cases.
Older Children:
Streptococcus pneumoniae is the most common bacterial pathogen
Atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) become more frequent
Presentation is often more classic with fever, cough, and signs of lobar consolidation
Chest X-ray typically shows lobar pneumonia
Outpatient oral antibiotic therapy is common for uncomplicated cases.
Diagnostic Approach
History Taking:
Onset and duration of symptoms
Fever pattern and height
Nature of cough (dry vs
productive)
Sputum characteristics
Presence of chest pain
Breathing difficulties
Feeding tolerance
Immunization status
Recent antibiotic exposure
History of allergies
Risk factors: prematurity, underlying chronic conditions (asthma, cardiac, immunodeficiency), sick contacts.
Physical Examination:
Assess respiratory rate, work of breathing, oxygen saturation
Listen carefully for breath sounds, crackles, wheezes, and diminished sounds
Palpate for tactile fremitus
Percuss the chest for dullness
Examine for signs of sepsis (hypotension, altered mental status)
Assess hydration status.
Investigations:
Chest X-ray (PA and lateral views): essential for confirming diagnosis, identifying complications (effusions, abscesses), and assessing extent
Gram stain and culture of sputum (difficult in young children, often unreliable)
Blood cultures: indicated for hospitalized children or those with severe illness
Complete Blood Count (CBC) with differential: elevated WBC count suggests bacterial infection, but not always specific
C-reactive protein (CRP): elevated in bacterial infections
Nasopharyngeal swabs for viral PCR: can identify specific respiratory viruses
Pleural fluid aspiration and analysis: if parapneumonic effusion or empyema is suspected.
Differential Diagnosis:
Bronchiolitis
Asthma exacerbation
Acute bronchitis
Viral upper respiratory infection
Foreign body aspiration
Pulmonary edema
Tuberculosis
Pneumonitis of non-infectious origin (e.g., aspiration pneumonitis).
Management By Severity And Age
Mild To Moderate Cap Outpatient:
Children who are alert, able to tolerate oral fluids and medications, have adequate oxygenation (>92% on room air), and have no significant comorbidities can be managed as outpatients
Age-appropriate oral antibiotics are the mainstay of treatment
Duration is typically 5-7 days, or until clinical improvement.
Severe Cap Hospitalization:
Indications for hospitalization include respiratory distress, hypoxemia (SpO2 <92% on room air), inability to tolerate oral intake, lethargy or altered mental status, signs of sepsis, severe dehydration, underlying chronic illness, or presence of complications like parapneumonic effusion/empyema
These patients require intravenous antibiotics, oxygen therapy, and supportive care
Decision to admit based on clinical judgment and severity scoring.
Antibiotic Selection Neonates:
Empirical coverage for GBS, E
coli, Listeria, and other Gram-negative bacteria
Common choices: Ampicillin plus Gentamicin or Cefotaxime
Consider coverage for atypical pathogens if suspected
Duration typically 7-10 days for uncomplicated bacterial pneumonia, longer for sepsis or empyema.
Antibiotic Selection Infants Under 5 Years:
Viral pneumonia: supportive care, no antibiotics unless secondary bacterial infection suspected
Bacterial pneumonia: Empiric coverage for Streptococcus pneumoniae and Haemophilus influenzae
Amoxicillin (high dose) or Amoxicillin-clavulanate orally for mild-moderate CAP
For hospitalized or severe cases: IV Ceftriaxone or Cefotaxime
Consider Azithromycin for suspected atypical pathogens if persistent symptoms.
Antibiotic Selection Older Children:
Bacterial pneumonia: Amoxicillin (high dose) is first-line for suspected S
pneumoniae
If Mycoplasma or Chlamydia suspected (often in school-aged children and adolescents), Macrolides (Azithromycin) or Doxycycline (for children >8 years)
For severe CAP requiring hospitalization: IV Ceftriaxone or Cefotaxime, potentially adding a Macrolide if atypical pathogens are suspected.
Antibiotic Dosing Examples
Amoxicillin High Dose:
80-90 mg/kg/day divided into two doses, max 2000 mg/day.
Amoxicillin Clavulanate:
90 mg/kg/day of amoxicillin component, divided into two doses.
Ceftriaxone:
100 mg/kg/day intravenously once daily (max 2 g/day) for moderate-severe CAP.
Azithromycin:
10 mg/kg on day 1, then 5 mg/kg/day for days 2-5 (total 5 days course) for suspected atypical pathogens.
Doxycycline Children Over 8 Years:
4 mg/kg/day divided into two doses (max 200 mg/day) for atypical pathogens.
Complications
Early Complications:
Parapneumonic effusion
Empyema (pus in pleural space)
Lung abscess
Bacteremia and sepsis
Respiratory failure requiring mechanical ventilation
Necrotizing pneumonia.
Late Complications:
Bronchiectasis
Persistent lung infiltrates
Pleural thickening.
Prevention Strategies:
Vaccination (Pneumococcal conjugate vaccine - PCV, Haemophilus influenzae type b - Hib, Influenza vaccine)
Early recognition and prompt treatment of CAP
Good hygiene practices
Avoidance of indoor air pollution.
Prognosis
Factors Affecting Prognosis:
Age (neonates and very young infants have worse prognosis)
Causative pathogen
Severity of illness at presentation
Presence of comorbidities
Timeliness and appropriateness of treatment
Development of complications.
Outcomes:
With prompt and appropriate treatment, most children with CAP recover fully
Mortality rates for CAP have significantly decreased due to antibiotics and supportive care, but remain high in low-resource settings
Severe CAP and its complications carry a significant risk of morbidity and mortality.
Follow Up:
Children with uncomplicated CAP usually do not require specific follow-up beyond ensuring clinical resolution
Children hospitalized for severe CAP, those with complications (e.g., empyema), or those with underlying chronic conditions may benefit from follow-up chest X-rays and clinical assessment to ensure complete recovery and detect sequelae.
Key Points
Exam Focus:
Differentiating bacterial vs
viral pneumonia
Understanding age-based etiologies and antibiotic choices
Recognizing signs of severe pneumonia and indications for hospitalization
Management of parapneumonic effusion and empyema
Role of imaging in diagnosis and management.
Clinical Pearls:
Always consider atypical pathogens in school-aged children and adolescents
High-dose amoxicillin is a cornerstone for outpatient bacterial CAP in children >3 months
IV Ceftriaxone is a common and effective choice for hospitalized patients
Fever alone does not indicate bacterial etiology
focus on respiratory distress and clinical signs
Consider viral pneumonia management if clinically suggested and bacterial infection is less likely.
Common Mistakes:
Underestimating severity in young infants
Inadequate antibiotic dosing or duration
Prescribing antibiotics for viral pneumonia
Failing to consider atypical pathogens in older children
Not pursuing investigations for complications like effusion or empyema
Reliance solely on fever or cough without assessing respiratory status.