Pediatric Community-Acquired Pneumonia Management in the ED

Pediatric Community-Acquired Pneumonia: Diagnosis and Management in the Emergency Department

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Table of Contents
About This Issue

A significant challenge in the management of pediatric community-acquired pneumonia is identifying children who are more likely to have bacterial pneumonia and will benefit from antibiotic therapy while avoiding unnecessary testing and treatment in children who have viral pneumonia. This issue offers guidance for obtaining historical information and interpreting physical examination findings, discusses the utility of various diagnostic studies, and provides recommendations for the treatment of community-acquired pneumonia and associated complications. You will learn:

Common viral and bacterial etiologies of community-acquired pneumonia

Key historical information and physical examination findings that can help differentiate viral and bacterial causes of pneumonia

When diagnostic studies are indicated, and which studies are recommended

Which patients should receive antibiotics, and which should be discharged home with return precautions and appropriate follow-up

Recommendations for outpatient and inpatient empiric antibiotic regimens

Appropriate management of complications, including pleural effusion/empyema

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology
    1. Differentiation of Viral Causes From Bacterial Causes
    2. Viral Etiologies
    3. Bacterial Etiologies
      1. Streptococcus pneumoniae
      2. Staphylococcus aureus and Streptococcus pyogenes
      3. Mycoplasma pneumoniae
      4. Less Common Bacterial Causes
  6. Differential Diagnosis
    1. Bronchiolitis
    2. Recurrent Viral-Induced Wheeze and Asthma
    3. Congenital Heart Disease
    4. Foreign-Body Aspiration
    5. Metabolic Disorders
  7. Prehospital Care
    1. Primary Care Providers
    2. Emergency Medical Services
  8. Emergency Department Evaluation
    1. Initial Stabilization
    2. History
      1. History of Present Illness
      2. Past Medical History
      3. Immunization Status
      4. Family History
    3. Physical Examination
      1. Vital Signs
        • Temperature
        • Respiratory Rate
        • Pulse Oximetry
      2. Other Physical Examination Findings
  9. Diagnostic Studies
    1. Laboratory Studies
      1. Complete Blood Cell Count
      2. Inflammatory Markers
        • Erythrocyte Sedimentation Rate
        • C-Reactive Protein
        • Procalcitonin
        • Combination Testing
      3. Chemistries
      4. Blood Culture
      5. Sputum Culture
      6. Other Microbiological Assays
    2. Imaging
      1. Chest X-Ray
        • Patients With Asthma
      2. Ultrasound
      3. Computed Tomography
  10. Treatment
    1. Oxygen
    2. Antipyretics
    3. Intravenous Fluids
    4. Albuterol and Corticosteroids
    5. Antibiotics
    6. Management of Parapneumonic Effusion and Empyema
  11. Special Populations
    1. Patients With Bronchopulmonary Dysplasia
    2. Patients With Neuromuscular Disease
    3. Patients Who Are Immunodeficient
  12. Cutting Edge
    1. Transcriptomics
    2. Scoring Systems/Risk Models
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Pediatric Patients with Community-Acquired Pneumonia
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for Management of Pediatric Patients With Community-Acquired Pneumonia
  19. Tables and Figures
    1. Table 1. Variables Used to Distinguish Viral From Bacterial Pneumonia
    2. Table 2. Empiric Outpatient Therapy for Children With Community-Acquired Pneumonia1
    3. Table 3. Empiric Antibiotic Therapy for Children Hospitalized With Community-Acquired Pneumonia1
    4. Figure 1. Pleural Effusion on Chest X-Ray
    5. Figure 2. Pneumatocele on Chest X-Ray
    6. Figure 3. Round Pneumonia on Chest X-Ray
    7. Figure 4. Point-of-Care Ultrasound for Identification of Pneumonia
  20. References



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.


Case Presentations

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.


Critical Appraisal of the Literature

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.


Risk Management Pitfalls in the Management of Pediatric Patients with Community-Acquired Pneumonia

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.


Tables and Figures

Table 2. Empiric Outpatient Therapy for Children With Community-Acquired Pneumonia



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.

  1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired 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(7):e25-e76. (Clinical guidelines)
  2. Kronman MP, Hersh AL, Feng R, et al. Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics. 2011;127(3):411-418. (Population-based surveillance)
  3. Lee GE, Lorch SA, Sheffler-Collins S, et al. National hospitalization trends for pediatric pneumonia and associated complications. Pediatrics. 2010;126(2):204-213. (Cross-sectional, retrospective, cohort study; 619,102 patients)
  4. 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 Suppl 2:ii1-ii23. (Expert guidelines)
  5. Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835-845. (Prospective study; 2358 patients)
  6. Virkki R, Juven T, Rikalainen H, et al. Differentiation of bacterial and viral pneumonia in children. Thorax. 2002;57(5):438-441. (Prospective study; 236 patients)
  7. O’Grady K-AF, Torzillo PJ, Frawley K, et al. The radiological diagnosis of pneumonia in children. Pneumonia. 2014;5(1):38-51. (Review)
  8. Katz SE, Williams DJ. Pediatric community-acquired pneumonia in the United States: changing epidemiology, diagnostic and therapeutic challenges, and areas for future research. Infect Dis Clin North Am. 2018;32(1):47-63. (Review)
  9. Neuman MI, Hall M, Lipsett SC, et al. Utility of blood culture among children hospitalized with community-acquired pneumonia. Pediatrics. 2017;140(3). (Cross-sectional study; 7509 patients)
  10. Zar HJ, Andronikou S, Nicol MP. Advances in the diagnosis of pneumonia in children. BMJ. 2017;358:j2739. (Literature review)
  11. Korppi M, Don M, Valent F, et al. The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children. Acta Paediatr. 2008;97(7):943-947. (Case-control study; 101 patients)
  12. Toikka P, Irjala K, Juvén T, et al. Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children. Pediatr Infect Dis J. 2000;19(7):598-602. (Case-control study; 126patients)
  13. Ruuskanen O, Lahti E, Jennings LC, et al. Viral pneumonia. Lancet. 2011;377(9773):1264-1275. (Review)
  14. Mani CS. Acute pneumonia and its complications. In: Long SS, Prober CG, Fischer M, eds. Principles and Practice of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Elsevier; 2018:238-242. (Textbook chapter)
  15. Rhedin S, Lindstrand A, Hjelmgren A, et al. Respiratory viruses associated with community-acquired pneumonia in children: matched case-control study. Thorax. 2015;70(9):847-853. (Case-control study; 121 cases, 240 controls)
  16. Lahti E, Peltola V, Virkki R, et al. Influenza pneumonia. Pediatr Infect Dis J. 2006;25(2):160-164. (Prospective study; 936 patients)
  17. Ampofo K, Herbener A, Blaschke AJ, et al. Association of 2009 pandemic influenza A (H1N1) infection and increased hospitalization with parapneumonic empyema in children in Utah. Pediatr Infect Dis J. 2010;29(10):905-909. (Retrospective cohort study; 21 patients)
  18. Black SB, Shinefield HR, Ling S, et al. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis J. 2002;21(9):810-815. (Randomized double-blind trial; 37,868 patients)
  19. Griffin MR, Zhu Y, Moore MR, et al. U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. N Engl J Med. 2013;369(2):155-163. (Population-based surveillance)
  20. Hampton LM, Farley MM, Schaffner W, et al. Prevention of antibiotic-nonsusceptible Streptococcus pneumoniae with conjugate vaccines. J Infect Dis. 2012;205(3):401-411. (Population-based surveillance)
  21. de St Maurice A, Grijalva CG, Fonnesbeck C, et al. Racial and regional differences in rates of invasive pneumococcal disease. Pediatrics. 2015;136(5):e1186-e1194. (Active laboratory and population-based surveillance)
  22. Grijalva CG, Nuorti JP, Zhu Y, et al. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis. 2010;50(6):805-813. (Population-based surveillance)
  23. Erlichman I, Breuer O, Shoseyov D, et al. Complicated community acquired pneumonia in childhood: different types, clinical course, and outcome. Pediatr Pulmonol. 2017;52(2):247-254. (Retrospective cohort study; 144 patients)
  24. Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. 2010;125(1):26-33. (Retrospective study; 2898 patients)
  25. McNeil SA, Qizilbash N, Ye J, et al. A retrospective study of the clinical burden of hospitalized all-cause and pneumococcal pneumonia in Canada. Can Respir J. 2016;2016:3605834. (Retrospective, database analysis)
  26. Pírez MC, Algorta G, Chamorro F, et al. Changes in hospitalizations for pneumonia after universal vaccination with pneumococcal conjugate vaccines 7/13 valent and Haemophilus influenzae type b conjugate vaccine in a pediatric referral hospital in Uruguay. Pediatr Infect Dis J. 2014;33(7):753-759. (Retrospective study)
  27. Centers for Disease Control and Prevention (CDC). Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus — Minnesota and North Dakota, 1997–1999. MMWR Morb Mortal Wkly Rep. 1999;48(32):707-710. (Case series)
  28. Gonzalez BE, Hulten KG, Dishop MK, et al. Pulmonary manifestations in children with invasive community-acquired Staphylococcus aureus infection. Clin Infect Dis. 2005;41(5):583-590. (Retrospective study; 70 subjects)
  29. Carrillo-Marquez MA, Hulten KG, Hammerman W, et al. Staphylococcus aureus pneumonia in children in the era of community-acquired methicillin-resistance at Texas Children’s Hospital. Pediatr Infect Dis J. 2011;30(7):545-550.(Retrospective study; 117 subjects)
  30. Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics. 2008;122(4):805-811. (Retrospective study; 166 subjects)
  31. O’Loughlin RE, Roberson A, Cieslak PR, et al. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis. 2007;45(7):853-862. (Population-basedsurveillance)
  32. Inchley CS, Berg AS, Vahdani Benam A, et al. Mycoplasma pneumoniae: a cross-sectional population-based comparison of disease severity in preschool and school-age children. Pediatr Infect Dis J. 2017;36(10):930-936. (Population-based cross-sectional study; 92 subjects)
  33. Clyde WA Jr. Clinical overview of typical Mycoplasma pneumoniae infections. Clin Infect Dis. 1993;17 Suppl 1:S32-S36. (Review)
  34. Esposito S, Blasi F, Bellini F, et al. Mycoplasma pneumoniae and Chlamydia pneumoniae infections in children with pneumonia. Eur Respir J. 2001;17(2):241-245. (Prospective cohort study; 203 subjects)
  35. Defilippi A, Silvestri M, Tacchella A, et al. Epidemiology and clinical features of Mycoplasma pneumoniae infection in children. Respir Med. 2008;102(12):1762-1768. (Descriptive study; 102 subjects)
  36. Youn YS, Lee KY, Hwang JY, et al. Difference of clinical features in childhood Mycoplasma pneumoniae pneumonia. BMC Pediatr. 2010;10:48. (Retrospective study; 191 subjects)
  37. Spuesens EB, Fraaij PL, Visser EG, et al. Carriage of Mycoplasma pneumoniae in the upper respiratory tract of symptomatic and asymptomatic children: an observational study. PLoS Med. 2013;10(5):e1001444. (Cross-sectional study; 726 subjects)
  38. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. (Clinical practice guideline)
  39. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017;389(10065):211-224. (Review)
  40. Mansbach JM, Piedra PA, Teach SJ, et al. Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis pathogen and length of stay with bronchiolitis. Arch Pediatr Adolesc Med. 2012;166(8):700-706. (Prospective observational study; 2207 subjects)
  41. Stempel HE, Martin ET, Kuypers J, et al. Multiple viral respiratory pathogens in children with bronchiolitis. Acta Paediatr. 2009;98(1):123-126. (Prospective study; 180 subjects)
  42. Richard N, Komurian-Pradel F, Javouhey E, et al. The impact of dual viral infection in infants admitted to a pediatric intensive care unit associated with severe bronchiolitis. Pediatr Infect Dis J. 2008;27(3):213-217. (Retrospective study; 188 subjects)
  43. Hall CB, Powell KR, Schnabel KC, et al. Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. J Pediatr. 1988;113(2):266-271. (Prospective study; 565 patients)
  44. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med. 1995;332(3):133-138. (Prospective; 1246 subjects)
  45. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute(US); 2007. (Guidelines)
  46. Shalowitz MU, Sadowski LM, Kumar R, et al. Asthma burden in a citywide, diverse sample of elementary schoolchildren in Chicago. Ambul Pediatr. 2007;7(4):271-277. (Cross-sectional study; 35,583 subjects)
  47. Cloutier MM, Wakefield DB, Hall CB, et al. Childhood asthma in an urban community: prevalence, care system, and treatment. Chest. 2002;122(5):1571-1579. (Retrospective study)
  48. Klingensmith GJ, Tamborlane WV, Wood J, et al. Diabetic ketoacidosis at diabetes onset: still an all too common threat in youth. J Pediatr. 2013;162(2):330-334. (Prospective cohort study; 805 subjects)
  49. Gaston B. Pneumonia. Pediatr Rev. 2002;23(4):132-140. (Literature review)
  50. Shah SN, Bachur RG, Simel DL, et al. Does this child have pneumonia?: The Rational Clinical Examination Systematic Review. JAMA. 2017;318(5):462-471. (Systematic review; 23 prospective cohort studies, 13,833 children)
  51. Murphy CG, van de Pol AC, Harper MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243-249. (Cross-sectional study; 2128 subjects)
  52. Tabain I, Ljubin-Sternak S, Cepin-Bogovic’ J, et al. Adenovirus respiratory infections in hospitalized children: clinical findings in relation to species and serotypes. Pediatr Infect Dis J. 2012;31(7):680-684. (Case-controlstudy; 135 subjects)
  53. Chen SP, Huang YC, Chiu CH, et al. Clinical features of radiologically confirmed pneumonia due to adenovirus in children. J Clin Virol. 2013;56(1):7-12. (Case-control study; 80 subjects)
  54. Dold S, Wjst M, von Mutius E, et al. Genetic risk for asthma, allergic rhinitis, and atopic dermatitis. Arch Dis Child. 1992;67(8):1018-1022. (Cross-sectional survey; 6665 families)
  55. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. 1999;33(2):166-173. (Prospective cohort study; 278 patients)
  56. Mathews B, Shah S, Cleveland RH, et al. Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009;124(1):e29-e36. (Prospective cohort study; 526 subjects)
  57. Wingerter SL, Bachur RG, Monuteaux MC, et al. Application of the world health organization criteria to predict radiographic pneumonia in a US-based pediatric emergency department. Pediatr Infect Dis J. 2012;31(6):561-564. (Prospective study; 2008 subjects)
  58. Pereira JC, Escuder MM. The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia. J Trop Pediatr. 1998;44(1):18-24. (Retrospective study; 153 subjects)
  59. Shuttleworth DB, Charney E. Leukocyte count in childhood pneumonia. Am J Dis Child. 1971;122(5):393-396. (Prospective cohort study; 340 subjects)
  60. Peltola V, Mertsola J, Ruuskanen O. Comparison of total white blood cell count and serum C-reactive protein levels in confirmed bacterial and viral infections. J Pediatr. 2006;149(5):721-724. (Retrospective study; 567 patients)
  61. Triga MG, Syrogiannopoulos GA, Thoma KD, et al. Correlation of leucocyte count and erythrocyte sedimentation rate with the day of illness in presumed bacterial pneumonia of childhood. J Infect. 1998;36(1):63-66. (Retrospective study; 116 patients)
  62. Myers AL, Hall M, Williams DJ, et al. Prevalence of bacteremia in hospitalized pediatric patients with community-acquired pneumonia. Pediatr Infect Dis J. 2013;32(7):736-740. (Prospective study; 658 patients)
  63. Gauchan E, Adhikari S. C-reactive protein versus neutrophil/lymphocyte ratio in differentiating bacterial and non-bacterial pneumonia in children. J Nepal Health Res Counc. 2016;14(34):154-158. (Retrospective study; 285 patients)
  64. Higdon MM, Le T, O’Brien KL, et al. Association of C-reactive protein with bacterial and respiratory syncytial virus-associated pneumonia among children aged <5 years in the PERCH Study. Clin Infect Dis. 2017;64(suppl_3):S378-S386. (Prospective study; 119 children)
  65. Flood RG, Badik J, Aronoff SC. The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children. Pediatr Infect Dis J. 2008;27(2):95-99. (Meta-analysis;1230 children)
  66. van Rossum AM, Wulkan RW, Oudesluys-Murphy AM. Procalcitonin as an early marker of infection in neonates and children. Lancet Infect Dis. 2004;4(10):620-630. (Literature review)
  67. Moulin F, Raymond J, Lorrot M, et al. Procalcitonin in children admitted to hospital with community-acquired pneumonia. Arch Dis Child. 2001;84(4):332-336. (Case-control study; 72 children)
  68. Schützle H, Forster J, Superti-Furga A, et al. Is serum procalcitonin a reliable diagnostic marker in children with acute respiratory tract infections? A retrospective analysis. Eur J Pediatr. 2009;168(9):1117-1124. (Case-control study; 327 children)
  69. Korppi M, Remes S, Heiskanen-Kosma T. Serum procalcitonin concentrations in bacterial pneumonia in children: a negative result in primary healthcare settings. Pediatr Pulmonol. 2003;35(1):56-61. (Prospective study; 190 children)
  70. Principi N, Esposito S. Biomarkers in pediatric community-acquired pneumonia. Int J Mol Sci. 2017;18(2). (Review)
  71. Berg AS, Inchley CS, Fjaerli HO, et al. Clinical features and inflammatory markers in pediatric pneumonia: a prospective study. Eur J Pediatr. 2017;176(5):629-638. (Prospective study; 394 patients)
  72. Hickey RW, Bowman MJ, Smith GA. Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Ann Emerg Med. 1996;27(6):721-725. (Retrospective review; 939 patients)
  73. Claesson BA, Trollfors B, Brolin I, et al. Etiology of community-acquired pneumonia in children based on antibody responses to bacterial and viral antigens. Pediatr Infect Dis J. 1989;8(12):856-862. (Retrospective observational study; 336 patients)
  74. Shah SS, Dugan MH, Bell LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia. Pediatr Infect Dis J. 2011;30(6):475-479. (Case-control study; 877 patients)
  75. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg. 2009;44(1):106-111. (Randomized controlled trial;36 patients)
  76. Byington CL, Korgenski K, Daly J, et al. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J. 2006;25(3):250-254. (Retrospective study; 776 patients)
  77. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002;34(4):434-440. (Retrospective cohort study; 153 patients)
  78. Andrews AL, Simpson AN, Heine D, et al. A cost-effectiveness analysis of obtaining blood cultures in children hospitalized for community-acquired pneumonia. J Pediatr. 2015;167(6):1280-1286. (Retrospective cost analysis)
  79. Doan Q, Enarson P, Kissoon N, et al. Rapid viral diagnosis for acute febrile respiratory illness in children in the emergency department. Cochrane Database Syst Rev. 2014(9):CD006452. (Cochrane review; 4 trials, 1588 children)
  80. Honda J, Yano T, Kusaba M, et al. Clinical use of capillary PCR to diagnose mycoplasma pneumonia. J Clin Microbiol. 2000;38(4):1382-1384. (Prospective study; 197 patients)
  81. Subramony A, Zachariah P, Krones A, et al. Impact of multiplex polymerase chain reaction testing for respiratory pathogens on healthcare resource utilization for pediatric inpatients. J Pediatr. 2016;173:196-201. (Retrospective analysis; 4779 patients)
  82. Shi T, McLean K, Campbell H, et al. Aetiological role of common respiratory viruses in acute lower respiratory infections in children under five years: a systematic review and meta-analysis. J Glob Health. 2015;5(1):010408. (Meta-analysis; 23 studies, 18,592 children)
  83. McCracken GH. Diagnosis and management of pneumonia in children. Pediatr Infect Dis J. 2000;19(9):924-928. (Literature review)
  84. Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Physician. 2004;70(5):899-908. (Literature review)
  85. Skerrett SJ. Diagnostic testing for community-acquired pneumonia. Clin Chest Med. 1999;20(3):531-548. (Literature review)
  86. Tapiainen T, Aittoniemi J, Immonen J, et al. Finnish guidelines for the treatment of community-acquired pneumonia and pertussis in children. Acta Paediatr. 2016;105(1):39-43. (Clinical guidelines)
  87. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993;22(7):1198-1210. (Practice guideline)
  88. Alario AJ, McCarthy PL, Markowitz R, et al. Usefulness of chest radiographs in children with acute lower respiratory tract disease. J Pediatr. 1987;111(2):187-193. (Prospective study; 102 patients)
  89. Korppi M, Kiekara O, Heiskanen-Kosma T, et al. Comparison of radiological findings and microbial aetiology of childhood pneumonia. Acta Paediatr. 1993;82(4):360-363. (Retrospective study; 61 patients)
  90. Bettenay FA, de Campo JF, McCrossin DB. Differentiating bacterial from viral pneumonias in children. Pediatr Radiol. 1988;18(6):453-454. (Retrospective study; 58 patients)
  91. Courtoy I, Lande AE, Turner RB. Accuracy of radiographic differentiation of bacterial from nonbacterial pneumonia. Clin Pediatr (Phila). 1989;28(6):261-264. (Case control; 36 patients)
  92. Clements H, Stephenson T, Gabriel V, et al. Rationalised prescribing for community acquired pneumonia: a closed loop audit. Arch Dis Child. 2000;83(4):320-324. (Retrospective observational study and prospective study; 42 and 89 patients, respectively)
  93. McCarthy PL, Spiesel SZ, Stashwick CA, et al. Radiographic findings and etiologic diagnosis in ambulatory childhood pneumonias. Clin Pediatr (Phila). 1981;20(11):686-691. (Case control study; 128 patients)
  94. Tan TQ, Mason EO, Barson WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics. 1998;102(6):1369-1375.(Prospective study; 254 patients)
  95. Finnegan OC, Fowles SJ, White RJ. Radiographic appearances of mycoplasma pneumonia. Thorax. 1981;36(6):469-472. (Case-control study; 63 patients)
  96. Griscom NT. Pneumonia in children and some of its variants. Radiology. 1988;167(2):297-302. (Literature review)
  97. McLennan MK. Radiology rounds. Round pneumonia. Can Fam Physician. 1998;44:751, 757-759. (Case study and literature review)
  98. Kim YW, Donnelly LF. Round pneumonia: imaging findings in a large series of children. Pediatr Radiol. 2007;37(12):1235-1240. (Retrospective review; 109 patients)
  99. 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(3):307-310. (Retrospective study; 226 patients)
  100. Dawson KP, Long A, Kennedy J, et al. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. 1990;26(4):209-211. (Retrospective study; 153 patients)
  101. Simpson W, Hacking PM, Court SD, et al. 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(3):155-160. (Case-control study; 352 patients)
  102. Davies HD, Wang EE, Manson D, et al. Reliability of the chest radiograph in the diagnosis of lower respiratory infections in young children. Pediatr Infect Dis J. 1996;15(7):600-604. (Retrospective study; 40 patients)
  103. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet. 1998;351(9100):404-408. (Randomized controlled trial; 522 children)
  104. Cao AM, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev. 2013(12):CD009119. (Cochrane review; 2 randomized controlled trials, 2024 patients)
  105. Florin TA, Carron H, Huang G, et al. Pneumonia in children presenting to the emergency department with an asthma exacerbation. JAMA Pediatr. 2016;170(8):803-805. (Retrospective cohort study; 14,007 patients, 4708 patients with CXR)
  106. Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol. 2013;48(3):280-287. (Descriptive study; 102 patients)
  107. Yilmaz HL, Özkaya AK, Sarı Gökay S, et al. Point-of-care lung ultrasound in children with community acquired pneumonia. Am J Emerg Med. 2017;35(7):964-969. (Observational prospective study; 160 patients)
  108. Ho MC, Ker CR, Hsu JH, et al. Usefulness of lung ultrasound in the diagnosis of community-acquired pneumonia in children. Pediatr Neonatol. 2015;56(1):40-45. (Retrospective study; 163 patients)
  109. Copetti R, Cattarossi L. Ultrasound diagnosis of pneumonia in children. Radiol Med. 2008;113(2):190-198. (Prospective study; 79 patients)
  110. Boursiani C, Tsolia M, Koumanidou C, et al. Lung ultrasound as first-line examination for the diagnosis of community-acquired pneumonia in children. Pediatr Emerg Care. 2017;33(1):62-66. (Prospective study; 69 patients)
  111. Guerra M, Crichiutti G, Pecile P, et al. Ultrasound detection of pneumonia in febrile children with respiratory distress: a prospective study. Eur J Pediatr. 2016;175(2):163-170. (Prospective study; 207 patients)
  112. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr. 2013;167(2):119-125. (Prospective study; 200 patients)
  113. Urbankowska E, Krenke K, Drobczyński Ł, et al. Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children. Respir Med. 2015;109(9):1207-1212. (Prospective study; 106 patients)
  114. Claes AS, Clapuyt P, Menten R, et al. Performance of chest ultrasound in pediatric pneumonia. Eur J Radiol. 2017;88:82-87. (Prospective study; 143 patients)
  115. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015;135(4):714-722. (Meta-analysis)
  116. Reali F, Sferrazza Papa GF, Carlucci P, et al. Can lung ultrasound replace chest radiography for the diagnosis of pneumonia in hospitalized children? Respiration. 2014;88(2):112-115. (Prospective study; 107 patients)
  117. Liu J, Liu F, Liu Y, et al. Lung ultrasonography for the diagnosis of severe neonatal pneumonia. Chest. 2014;146(2):383-388. (Prospective study; 40 patients)
  118. Iuri D, De Candia A, Bazzocchi M. Evaluation of the lung in children with suspected pneumonia: usefulness of ultrasonography. Radiol Med. 2009;114(2):321-330. (Prospective study; 32 patients)
  119. Dankoff S, Li P, Shapiro AJ, et al. Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED. Am J Emerg Med. 2017;35(4):615-622. (Prospective study; 60 patients)
  120. Ambroggio L, Sucharew H, Rattan MS, et al. Lung ultrasonography: a viable alternative to chest radiography in children with suspected pneumonia? J Pediatr. 2016;176:93-98. (Prospective study; 132 patients)
  121. Jones BP, Tay ET, Elikashvili I, et al. Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest. 2016;150(1):131-138. (Randomized controlled trial; 191 patients)
  122. Esposito S, Papa SS, Borzani I, et al. Performance of lung ultrasonography in children with community-acquired pneumonia. Ital J Pediatr. 2014;40:37. (Prospective study; 48 patients)
  123. Kuhn JP, Brody AS. High-resolution CT of pediatric lung disease. Radiol Clin North Am. 2002;40(1):89-110. (Review)
  124. Haviv M, Haver E, Lichtstein D, et al. Atrial natriuretic peptide in children with pneumonia. Pediatr Pulmonol. 2005;40(4):306-309. (Prospective study; 28 patients)
  125. Ambroggio L, Test M, Metlay JP, et al. Adjunct systemic corticosteroid therapy in children with community-acquired pneumonia in the outpatient setting. J Pediatric Infect Dis Soc. 2015;4(1):21-27. (Retrospective cohort study; 2244 patients)
  126. Padman R, King KA, Iqbal S, et al. Parapneumonic effusion and empyema in children: retrospective review of the duPont experience. Clin Pediatr (Phila). 2007;46(6):518-522. (Retrospective; 101 patients)
  127. Aziz A, Healey JM, Qureshi F, et al. Comparative analysis of chest tube thoracostomy and video-assisted thoracoscopic surgery in empyema and parapneumonic effusion associated with pneumonia in children. Surg Infect (Larchmt). 2008;9(3):317-323. (Comparative analysis; 49 patients)
  128. Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg. 2012;47(11):2101-2110. (Review and clinical guidelines)
  129. Ekingen G, Guvenc BH, Sozubir S, et al. Fibrinolytic treatment of complicated pediatric thoracic empyemas with intrapleural streptokinase. Eur J Cardiothorac Surg. 2004;26(3):503-507. (Prospective study; 32 patients)
  130. Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax. 2002;57(4):343-347. (Randomized trial; 60 patients)
  131. Breysem L, Smet MH, Van Lierde S, et al. Bronchopulmonary dysplasia: correlation of radiographic and clinical findings. Pediatr Radiol. 1997;27(8):642-646. (Prospective cohort study; 22 patients)
  132. Gien J, Kinsella JP. Pathogenesis and treatment of bronchopulmonary dysplasia. Curr Opin Pediatr. 2011;23(3):305-313. (Review)
  133. Reilly S, Skuse D, Poblete X. Prevalence of feeding problems and oral motor dysfunction in children with cerebral palsy: a community survey. J Pediatr. 1996;129(6):877-882. (Survey; 49 patients)
  134. Birnkrant DJ, Bushby K, Bann CM, et al. Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Lancet Neurol. 2018;17(5):445-455. (Review)
  135. Ramilo O, Allman W, Chung W, et al. Gene expression patterns in blood leukocytes discriminate patients with acute infections. Blood. 2007;109(5):2066-2077. (Prospective study; 131 patients)
  136. Suarez NM, Bunsow E, Falsey AR, et al. Superiority of transcriptional profiling over procalcitonin for distinguishing bacterial from viral lower respiratory tract infections in hospitalized adults. J Infect Dis. 2015;212(2):213-222. (Prospective study; 118 patients)
  137. Zaas AK, Chen M, Varkey J, et al. Gene expression signatures diagnose influenza and other symptomatic respiratory viral infections in humans. Cell Host Microbe. 2009;6(3):207-217. (Prospective study; 57 patients)
  138. Wallihan RG, Suarez NM, Cohen DM, et al. Molecular distance to health transcriptional score and disease severity in children hospitalized with community-acquired pneumonia. Front Cell Infect Microbiol. 2018;8:382. (Prospective observational study; 152 patients)
  139. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-250. (Retrospective study; 14,199 patients)
  140. Neill AM, Martin IR, Weir R, et al. Community acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax. 1996;51(10):1010-1016. (Prospective study; 255 patients)
  141. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382. (Retrospective study; 1068 patients)
  142. Capelastegui A, Espana PP, Quintana JM, et al. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006;27(1):151-157. (Retrospective study; 1776 patients)
  143. Williams DJ, Zhu Y, Grijalva CG, et al. Predicting severe pneumonia outcomes in children. Pediatrics. 2016;138(4). (Prospective study; 2319 patients)
Publication Information

Jonathan Cooper-Sood, MD; Rebecca Wallihan, MD; James Naprawa, MD

Peer Reviewed By

Michael Gottlieb, MD; Dante Pappano, MD, MPH

Publication Date

April 1, 2019

Pub Med ID: 30908905

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