Worldwide, pneumonia is the most common cause of death in children aged < 5 years. Distinguishing viral from bacterial causes of pneumonia is paramount to providing effective treatment but remains a significant challenge. For patients who can be managed with outpatient treatment, the utility of laboratory tests and radiographic studies, as well as the need for empiric antibiotics, remains questionable. This issue reviews viral and bacterial etiologies of community-acquired pneumonia in pediatric patients, offers guidance for obtaining historical information and interpreting physical examination findings, discusses the utility of various diagnostic techniques, and provides recommendations for the treatment of previously healthy and medically fragile children.
A previously healthy 4-year-old girl is brought to the ED for fever and abdominal pain that started 10 hours ago. The girl’s temperature is 39.4°C (103°F). On physical examination, she is ill-appearing, and she states that her belly really hurts. Her abdominal pain appears to be severe, and she is upset, so your abdominal examination is limited. There is no respiratory distress, and her lungs are clear to auscultation. You place an IV and give her morphine for pain. The girl’s peripheral WBC count is 26,000 cells/mcL, with 82% neutrophils. You perform an ultrasound, but the appendix cannot be visualized. You recall that pneumonia can present as abdominal pain and wonder if that could be the case for this patient. Should you order a CT scan of the abdomen or start with a chest x-ray?
A previously healthy 8-year-old girl is referred to the ED for fever ranging from 38.9°C-39.4°C (102°F-103°F) and cough for 8 days. She was started on amoxicillin-clavulanate 2 days prior but has not improved. On physical examination, she is alert, nontoxic, and not in respiratory distress. Chest auscultation reveals decreased breath sounds and questionable rales in the left lower lobe. The high fever and localized chest findings prompt you to obtain a chest x-ray that shows a large left-sided pleural effusion. As you look at the film, you begin to wonder… Should you order a CT scan? What is the utility of ultrasound in this patient? Is a chest tube indicated and, if so, what labs would be useful to run on the pleural fluid? What is the most appropriate antibiotic coverage for this patient?
Your next patient is a 2-year-old boy who was brought in for fever and difficulty breathing. His temperature is 39.4°C (103°F). He appears nontoxic but is in moderate respiratory distress. His pulse oximetry is 92% on ambient air, and his respiratory rate is 56 breaths/min. His past medical history includes a prior hospitalization for pneumonia. His immunizations are up-to-date. Chest auscultation reveals bilateral wheezes and localized rales in the left lower lobe. The resident working with you orders an albuterol nebulization but is concerned that the patient has pneumonia, given the fever and focal rales. You consider starting antibiotics and transferring the patient to the nearest children’s hospital. Is it common for children to have repeat episodes of pneumonia? Are there other questions on review of systems that might be helpful in this patient?
Worldwide, pneumonia is the leading cause of death in children aged < 5 years.1 In the United States, there are an estimated 1.5 million cases2 and 150,000 hospitalizations3 annually for pneumonia. Community-acquired pneumonia (CAP) is defined as “the presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside of the hospital.”4
The challenge for the emergency clinician is identifying the children who are more likely to have bacterial CAP and will benefit from antibiotic therapy while avoiding unnecessary testing and treatment in the majority of children who will have viral etiologies. Children aged < 5 years bear the highest burden of disease; in this population, viral etiologies predominate.1,4,5 Bacterial causes increase in incidence with age.5 Differentiating viral from bacterial pneumonia on the basis of radiological and laboratory findings is difficult. Studies have shown that chest x-ray (CXR) cannot reliably differentiate viral from bacterial pneumonia.6,7 For this reason, expert guidelines recommend against the routine use of both CXR and antibiotics for the majority of young children with the diagnosis of CAP.1,4 In spite of this, it is common for young children to receive CXRs, blood work, and antibiotics for respiratory distress. Additionally, it can be difficult to differentiate CAP from other causes of respiratory distress, such as bronchiolitis and asthma. Finally, certain populations have a higher risk for bacterial pneumonia and complications, and deserve special consideration.
This issue of Pediatric Emergency Medicine Practice provides guidance on obtaining appropriate historical information, interpreting physical examination findings, and using laboratory testing and imaging judiciously in order to accurately differentiate between the various causes of pneumonia in children. Recommendations for antibiotic choice and indications for admission are also provided.
A literature search was performed used the following terms: neonatal pneumonia, pneumonia NOT bronchiolitis, and pediatric pneumonia AND community acquired, bacterial, diagnosis, physical exam, viral, atypical, fungal, diagnostic imaging, x-ray, ultrasound, inflammatory markers, CRP, procalcitonin, CBC, PCR, viral testing, computerized tomography scan, antibiotics, mycoplasma, atelectasis, medically complex, medically fragile, and aspiration. Available studies included observational studies, cross-sectional studies, randomized controlled trials, meta-analyses, Cochrane Database of Systematic Reviews analyses, and review articles. Multiple guidelines exist, most notably the Finnish, British Thoracic Society (BTS), World Health Organization (WHO), and Infectious Diseases Society of America (IDSA) guidelines. Of the thousands of articles that resulted, a total of 143 articles were selected, representing the most pertinent and current literature available.
There are several limitations associated with the available literature. Varying definitions of pneumonia exist in the literature and guidelines, making consensus difficult and limiting comparative analyses. In addition, despite a large body of literature, more prospective studies are needed, particularly of emerging diagnostic studies (such as ultrasound). Most notably, no definitive, agreed-upon gold standard for diagnosis exists; some studies use radiographs only, while some use laboratory findings plus radiographs, and some are based on the overall clinical picture. Limitations also exist in the available tests for pneumonia. Viral detection does not necessarily mean causation, and similarly, upper respiratory cultures and associated laboratory markers do not distinguish active infection from colonization. Furthermore, agreed-upon gold standards of diagnosis (such as blood cultures) are rarely positive except in complicated pneumonias, while sputum cultures, considered to be accurate in diagnosis, are difficult to obtain in young children. These deficits in knowledge in the literature of the specific viral, bacterial, and atypical causes of CAP limit the ability to provide narrow and definitive treatment.
2. “The 4-year-old boy had asthma, fever, wheezing, and rales on exam. His chest CXR was read by the radiologist as left lower lobe infiltrate versus atelectasis. I sent him home on amoxi-cillin, and he came back 2 days later with persistent cough, wheeze, and rales. His fever had resolved. Repeat CXR showed resolution of the infiltrate.”
Wheezing is typically a viral process and neither the presence of rales nor findings on CXR reliably differentiate viral from bacterial pneumonia. Furthermore, radiographic lobar pneumonia does not typically resolve in 2 days, suggesting, in this case, that the initial CXR finding was atelectasis rather than infiltrate. In a young child with asthma, fever, wheezing, and suspected CAP, consider a viral process first. Treat the asthma exacerbation with bronchodilators and corticosteroids. If there is concern for bacterial CAP, consider CXR or treat empirically with amoxicillin, but do not forget to give the patient corticosteroids.
3. “I gave my patient ceftriaxone for lobar pneumonia.”
Rates of resistant pneumococcus have declined since the introduction of PCV. Current recommendations for uncomplicated lobar pneumonia are to give amoxicillin or ampicillin. Indications for ceftriaxone include incomplete vaccination status and areas in which resistance is common.
6. “The 8-year-old girl with fever for 8 days and cough had lobar consolidation with significant pleural effusion, so I obtained a chest CT.”
Given the inherent risk of ionizing radiation associated with CT, lung ultrasound should be the initial modality used to assess findings concerning for empyema demonstrated on CXR in pediatric patients in the emergency setting. If the patient is not in significant distress, a CT scan in the ED can often be avoided.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Jonathan Cooper-Sood, MD; Rebecca Wallihan, MD; James Naprawa, MD
Michael Gottlieb, MD; Dante Pappano, MD, MPH
April 2, 2019
May 1, 2022
4 AMA PRA Category 1 Credits, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME and 4 Infectious Disease CME credits, subject to your state and institutional approval.
Date of Original Release: April 1, 2019. Date of most recent review: March 15, 2019. Termination date: April 1, 2022.
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