Pneumonia is associated with as many as 2 million annual deaths among children globally and 19% of all deaths in children less than 5 years of age (1). It is one of the most common diagnoses made in the acutely ill child, with an annual incidence of 34 to 40 cases per 1,000 children in Europe and North America.
Explore this issue:Supplement: Hospital Medicine and Infectious Diseases
In the past, viral pathogens were estimated to cause as many as 80% of cases. Streptococcus pneumoniae was generally regarded as the most frequent bacterial cause of community-acquired pneumonia (CAP), especially in cases with complicated parapneumonic effusions. Infectious etiologies are age specific, with bacterial etiologies predominating in the very young infant and viral pathogens in the older infant and adult (Table 1). Knowledge of the most likely pathogen, the prevailing susceptibilities of these infecting pathogens, and the severity of the illness will help guide antibiotic and other treatment decision making.
Most children do not require hospital admission, and mildly ill children who likely have a viral illness do not need antibiotics. The following guideline will attempt to help the practitioner identify those who do require hospitalization and provide an approach to management of those with complicated infection.
Recognition of the Patient with CAP
The first obstacle is to identify the patient with pneumonia. In managing the child with CAP, it is important to distinguish those with other underlying pathology, including asthma, RSV, or other confirmed viral etiology. It is important to remember that pathogens in the compromised host, cystic fibrosis patient, or patient with other chronic pulmonary pathology are different from typical CAP pathogens and include a wide differential. Most patients with CAP have an acute illness associated with fever (>38°C), cough, and evidence of lower respiratory tract symptoms/signs. Chest radiograph typically shows pulmonary infiltrate. Whether this is patchy infiltrate or lobar in appearance can assist the practitioner in treatment decision making in that the latter is much more likely to be associated with a bacterial etiology.
Once the diagnosis is considered, further assessment should focus on hydration status, hemodynamic parameters, and oxygenation. A careful assessment should identify other associated foci (i.e., meningitis or bacteremia) on examination and laboratory evaluation.
Identification of the Patient Requiring Hospitalization
Consider hospital admission for the toxic patient, those with altered mental status, significant dehydration, hypoxemia, dyspnea, grunting respirations, or retractions, and any patient with hemodynamic instability. Chest radiograph showing a significant pleural effusion should also be considered an indicator for hospital admission.