Pediatric Pneumonia Treatment & Management

Clinically, it is difficult to distinguish patients with bacterial pneumonia from those with viral illnesses. Therefore, decisions concerning antibiotic prescription for children suspected of having community-acquired pneumonia (CAP) can be challenging. Although pneumonia is commonly caused by viral organisms in children, many children diagnosed with pneumonia are treated empirically with antibiotics. ^[50] Research has shown that the intention to prescribe antibiotics based on clinical findings is the strongest predictor for antibiotic prescription. ^[51]

Treatment decisions for children with pneumonia are dictated on the basis of the likely etiology of the infectious organism and the age and clinical status of the patient. Antibiotic administration must be targeted to the likely organism, bearing in mind the age of the patient, the history of exposure, the possibility of resistance (which may vary, depending on local resistance patterns), and other pertinent history.

After initiating therapy, the most important tasks are resolving the symptoms and clearing the infiltrate. Following successful therapy, symptoms resolve much sooner than the infiltrate. In a study of adults with pneumococcal pneumonia, the infiltrate did not completely resolve in all patients until 8 weeks after therapy. However, resolution occurred sooner in most patients. If therapy fails to elicit a satisfactory response, the entire treatment approach must be reconsidered.

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America created evidence-based guidelines for the management of CAP in infants and children older than 3 months. These guidelines address site-of-care management, diagnosis, antimicrobial therapy, adjunctive surgical therapy, and prevention. While these guidelines do not represent the only approach to diagnosis and therapy, these recommendations may assist in decreasing morbidity and mortality rates in children with CAP. ^[33]

A retrospective study by Handy et al concluded that antibiotic choice for children with CAP varied widely across practices for reasons other than the microbiologic etiology. The study found that 40.7% of the 10,414 children in the study (4239) received amoxicillin. However, 42.5% (4430) received macrolides, and 16.8% (1745) received broad-spectrum antibiotics. ^{[52, 53]}

Another study by Williams et al found that there was an improvement at children’s hospitals in the use of penicillin to treat pneumonia after the publication of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline. Before the guideline was published < 10% of children’s hospitals prescribed penicillin to treat pneumonia versus 27.6% following its publication. ^{[54, 53]}  Children with pneumonia usually benefit from guideline-based antibiotic therapy. ^[55]  Antibiotic stewardship programs are associated with a reduction in the use of broad-spectrum antibiotics. ^[56]

Pulse oximetry should be performed during the prehospital evaluation of children with suspected pneumonia, and supplemental oxygen should be administered, Pulse oximetry can improve outpatient diagnosis of pediatric pneumonia. ^[57] However, many school-aged children do not require hospitalization and respond well to oral antibiotics. Usually, these patients are not toxic appearing or hypoxic enough to require supplemental oxygen. Unless they are vomiting, they do not require intravenous fluids or antibiotics. A parapneumonic effusion that requires drainage usually dictates a hospital admission.

Children younger than 5 years are hospitalized more often. But their clinical status, degree of hydration, degree of hypoxia, and need for intravenous therapy dictate this decision. Hospitalization should be considered for infants who are younger than 2 months or premature because of the risk of apnea in this age group. ^[58]

Children who are toxic appearing may require resuscitation and respiratory support. Treatment of critically ill children (those requiring ventilation) should include timely administration of appropriate antibiotics. Delays of only a few hours in one retrospective study were associated with significantly longer durations of ventilation, intensive care unit (ICU) stay, and total hospitalization. ^[59] Chest radiography should be performed to identify the presence of an effusion/empyema. Drainage of a restrictive or infected effusion or empyema may enhance clearance of the infection and improves lung mechanics. Antibiotic therapy should include vancomycin (especially in areas where penicillin-resistant streptococci have been identified) and the administration of a second- or third-generation cephalosporin.

Red blood cells (RBCs) should be administered to achieve a hemoglobin concentration of 13-16 g/dL in the acutely ill infant to ensure optimal oxygen delivery to the tissues. Delivery of adequate amounts of glucose and maintenance of thermoregulation, electrolyte balance, and other elements of neonatal supportive care are also essential aspects of clinical care.

Attempts at enteral feeding often are withheld in favor of parenteral nutritional support until respiratory and hemodynamic status is sufficiently stable.

Initial priorities in children with pneumonia include the identification and treatment of respiratory distress, hypoxemia, and hypercarbia. Grunting, flaring, severe tachypnea, and retractions should prompt immediate respiratory support. Children who are in severe respiratory distress should undergo tracheal intubation if they are unable to maintain oxygenation or have decreasing levels of consciousness.

Increased respiratory support requirements, such as increased inhaled oxygen concentration, positive pressure ventilation, or continuous positive airway pressure (CPAP), are commonly required before recovery begins. Bi-level positive airway pressure (BiPAP) may also be used to help support respiratory effort as a stand-alone intervention or as a bridge to intubation. Criteria for institution and weaning of supplemental oxygen and mechanical support are similar to those for other neonatal respiratory diseases. Extra humidification of inspired air (eg, room humidifiers) is also not useful, although supplemental oxygen is frequently humidified for patient comfort.

Adequate gas exchange depends not only on alveolar ventilation, but also on the perfusion and gas transport capacity of the alveolar perfusate (ie, blood). Preservation of pulmonary and systemic perfusion is essential, using volume expanders, inotropes, afterload reduction, blood products, and other interventions (eg, inhaled nitric oxide) as needed. Excellent lung mechanics provide little relief if perfusion is not simultaneously adequate.

The choice of an initial empiric agent is selected according to the susceptibility and resistance patterns of the likely pathogens and experience at the institution.

Antibiotic agents

The vast majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics.

High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for Streptococcus pneumoniae. Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives. However, they should not be used as first-line agents because of lower systemic absorption of the cephalosporins and pneumococcal resistance to macrolides. Treatment guidelines are available from the Cincinnati Children's Hospital Medical Center ^[60] and, more recently, from the Infectious Diseases Society of America (IDSA). ^[33]

Macrolide antibiotics are useful in school-aged children, because they cover the most common bacteriologic and atypical agents such as Mycoplasma, Chlamydophila, and Legionella. However, increasing levels of resistance to macrolides among pneumococcal isolates should be considered (depending on local resistance rates). One study suggests that penicillin and macrolide resistance among S pneumoniae isolates has been increasing. ^[61]  

Hospitalized patients can be safely treated with narrow-spectrum agents such as ampicillin. Indeed, this is the mainstay of current guidelines for pediatric community-acquired pneumonia. ^{[33, 62, 63]}  Children who appear toxic should receive antibiotic therapy that includes vancomycin, along with a second- or third-generation cephalosporin. This may pertain particularly in communities where penicillin-resistant pneumococci and methicillin-resistant Staphylococcus aureus (MRSA) are prevalent.

If gram-negative pneumonia is suspected and beta-lactam antibiotics are administered, some data suggest that continuous exposure to an antimicrobial concentration greater than the mean inhibitory concentration (MIC) for the organism may be more important than the amplitude of the peak concentration. Intramuscular treatment or intravenous therapy with the same total daily dose but a more frequent dosing interval may be advantageous. This may be especially true if the infant's condition fails to respond to conventional dosing. Comparative data to confirm the superiority of this approach are lacking.

Whether this approach offers any advantage with use of agents other than beta-lactams is unclear. A study by Williams et al reported no statistically significant difference in length of hospital stay between children hospitalized with pneumonia and those treated with a beta-lactam alone versus children treated with a beta-lactam plus a macrolide combination therapy. ^[64]

Studies in adults have demonstrated that aminoglycosides reach the bronchial lumen marginally when administered parenterally, although alveolar delivery is satisfactory. ^{[65, 66]} Endotracheal treatment with aerosolized aminoglycosides has been reportedly effective for marginally susceptible organisms in bronchi.

On the other hand, cefotaxime appears to attain adequate bronchial concentrations via the parenteral route. Limited in vitro and in vivo animal data suggest that cefotaxime may retain more activity than aminoglycosides in sequestered foci, such as abscesses. However, such foci are rare in congenital pneumonia, and adequate drainage may be more important than the selection of antimicrobial agents.

Recovery of a specific pathogen from a normally sterile site (eg, blood, urine, cerebrospinal fluid [CSF]) permits narrowing the spectrum of antimicrobial therapies. It may thus reduce the selection of resistant organisms and costs of therapy. Repeated culture of the site after 24-48 hours is usually warranted to ensure sterilization and to assess the efficacy of therapy.

Endotracheal aspirates are not believed to represent a normally sterile site, although they may yield a pathogen that is a true invasive culprit. Repeated culturing of an endotracheal aspirate that identified the presumptive pathogen in a particular case may not be helpful because colonization may persist even if tissue invasion has ceased.

Decreasing respiratory support requirements, clinical improvement, and resolution revealed in radiographs also support the efficacy of therapy. When appropriate, assess plasma antibiotic concentrations to ensure adequacy and reduce the potential for toxicity. Failure to recover an organism does not preclude an infectious etiology. The continuation of empiric therapy may be advisable unless the clinical course or other data strongly suggest that a noninfectious cause is responsible for the presenting signs.

Continue to perform careful continued examinations for evidence of complications that may warrant a change in therapy or dosing regimen, surgical drainage, or other intervention.

Anti-inflammatory therapy

Evidence-supported options for targeted treatment of inflammation independent of antimicrobial therapy are severely limited. ^[67] Considerable speculation suggests that current antimicrobial agents, directed at killing invasive organisms, may transiently worsen inflammatory cascades and associated host injury because dying organisms release proinflammatory structural and metabolic components into the surrounding microenvironment. This is not to imply that eradicating invasive microbes should not be a goal. However, other methods of eradication or methods of directly addressing the pathologic inflammatory cascades await further definition. In pneumonia resulting from noninfectious causes, the quest for targeted, effective, and safe anti-inflammatory therapy may be of even greater importance.

A few small studies in adults suggest that the use of glucocorticoids might be beneficial in the treatment of serious (hospitalized) community-acquired pneumonia. However, the study design and sample size limit the ability to properly interpret these data. ^[68] Until definitive studies are performed, corticosteroids should not be routinely used for uncomplicated pneumonia.

Antiviral agents

Most infants with respiratory syncytial virus (RSV) pneumonia do not respond to antimicrobials. Serious infections with this organism often occur concurrently in infants with underlying lung disease.

Influenza A viruses, including 2 subtypes (H1N1) and (H3N2), and influenza B viruses currently circulate worldwide. However, the prevalence of each can vary among communities and within a single community over the course of the influenza season. In the United States, 4 prescription antiviral medications (oseltamivir, zanamivir, amantadine, rimantadine) have been approved for the treatment and chemoprophylaxis of influenza.

Influenza A pneumonia that is particularly severe or when it occurs in a high-risk patient may be treated with zanamivir or oseltamivir. The neuraminidase inhibitors have activity against influenza A and B viruses, whereas the adamantanes only have activity against influenza A viruses.

Check for resistance patterns exhibited by other antiviral agents indicated for the treatment or chemoprophylaxis of influenza. Since January 2006, the neuraminidase inhibitors (oseltamivir, zanamivir) have been the only recommended influenza antiviral drugs because of widespread resistance to the adamantanes (amantadine, rimantadine) among influenza A (H3N2) virus strains.

From 2007 to 2008, a significant increase in the prevalence of oseltamivir resistance was reported among influenza A (H1N1) viruses worldwide. During the 2007-2008 influenza season, 10.9% of H1N1 viruses tested in the United States were resistant to oseltamivir.

These reports prompted the US Centers for Disease Control and Prevention (CDC) to issue revised interim recommendations for antiviral treatment and prophylaxis of influenza. Zanamivir is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected.

A second-line alternative is the combination of oseltamivir plus rimantadine rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician on the subject of antiviral agent choice. Complete recommendations are available from the CDC.

Herpes simplex virus pneumonia is treated with parenteral acyclovir. Cytomegalovirus (CMV) pneumonitis should be treated with intravenous ganciclovir or foscarnet.

Antifungal agents

Invasive fungal infections, such as those caused by Aspergillus or Zygomycetes species, are treated with amphotericin B or voriconazole.

Bronchodilators

Bronchodilators should not be routinely used. Bacterial lower respiratory tract infections rarely trigger asthma attacks, and the wheezing that is sometimes heard in patients with pneumonia is usually caused by airway inflammation, mucus plugging, or both and does not respond to a bronchodilator. However, infants or children with reactive airway disease or asthma may react to a viral infection with bronchospasm, which responds to bronchodilators.

A thin layer of fluid (approximately 10 mL) is usually found between the visceral and parietal pleura and helps prevent friction. This pleural fluid is produced at 100 mL/h. Ninety percent of the fluid is reabsorbed on the visceral surface, and 10% is reabsorbed by the lymphatics. Pleural fluid accumulates when the balance between production and reabsorption is disrupted. A transudate accumulates in the pleural cavity when changes in the hydrostatic or oncotic pressures are not accompanied by changes in the membranes. Increased membrane permeability and hydrostatic pressure often result from inflammation and result in a subsequent loss of protein from the capillaries and an accumulation of exudates in the pleural cavity.

When a child with pneumonia develops a pleural effusion, thoracentesis should be performed for diagnostic and therapeutic purposes. The pleural fluid should be obtained to assess pH and glucose levels. Gram staining and culture, CBC count with differential, and protein assessment should be performed. Amylase and lactase dehydrogenase (LDH) levels can also be measured. But these measurements are less useful in a parapneumonic effusion than in effusions of other etiologies. The results are helpful in determining whether the effusion is a transudate or an exudate and help to determine the best course of management for the effusion.

Drainage of parapneumonic effusions with or without intrapleural instillation of a fibrinolytic agent (eg, tissue plasminogen activator [TPA]) may be indicated. Chest tube placement for drainage of an effusion or empyema may be performed. A video-assisted thoracic surgery (VATS) procedure may be performed for decortication of organized empyema or loculated effusions.

For more information, see Infections of the Lung, Pleura, and Mediastinum.

Aside from avoiding infectious contacts, which is difficult for many families who require the use of daycare facilities, vaccination should be the primary mode of prevention. Since the introduction of the conjugated Haemophilus influenzae type b (Hib) vaccine, the rates of Hib pneumonia have significantly declined. However, the diagnosis should still be considered in unvaccinated persons, including those younger than 2 months, who have not received their first dose of vaccine.

Conjugated and unconjugated polysaccharide vaccines for S pneumoniae have been developed for infants and children, respectively. A 13-valent conjugated vaccine (Prevnar 13) was approved in 2010 and replaces PCV7 for all doses. PCV13 includes serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. In 2021, a 15-valent conjugate vaccine (PCV15; Vaxneuvance) is indicated for active immunization for prevention of invasive disease caused by S pneumoniae in individuals aged 6 weeks and older. Use for primary vaccination and catch-up immunization in children aged 6 weeks and older is interchangeable with PCV13. It contains all serotypes in the PVC13 vaccine plus 22F and 33F. ^[18]  

 Pneumococcal vaccine polyvalent (Pneumovax) covers 23 different strains. The 23-valent polysaccharide vaccine (PPVSV) is recommended for children aged 24 months and older who are at high risk for contracting a pneumococcal disease.

An influenza vaccine is recommended for children aged 6 months and older. The vaccine exists in 2 forms: inactivated vaccine (various products), administered as an intramuscular injection, and a cold-adapted attenuated vaccine (FluMist), administered as a nasal spray, which is licensed only for persons aged 2-49 years.

Although the influenza vaccine is especially recommended for children at high risk, such as those with bronchopulmonary dysplasia (BPD), cystic fibrosis, or asthma, the use of FluMist is cautioned in persons with known asthma because of reports of transient increases in wheezing episodes in the weeks following its administration. However, in years when vaccine strains have been mismatched with the circulating influenza strains, FluMist has provided good protection (approximately 70%), even when the inactivated vaccine was entirely ineffective.

Clinical trials are ongoing to lower the age of administration of Fluzone, one of the inactivated intramuscular vaccines, to 2 months (currently approved for children 6 months and older) to help protect this high-risk, but unvaccinated, population. The safety and efficacy of this approach remain unknown.

Pneumocystis carinii pneumonia (PCP) prophylaxis with trimethoprim-sulfamethoxazole 3 times a week is widely used in immunocompromised children and has all but eradicated this organism in patients receiving prophylactic treatments.

The use of pneumococcal and Hib vaccines and penicillin prophylaxis in patients with sickle cell disease have helped reduce the incidence of bacterial infections in these children.

RSV prophylaxis consists of monthly intramuscular injections of palivizumab at a dose of 15 mg/kg (maximum volume, 1 mL per injection; multiple injections may be required per dose). This strategy is currently recommended for high-risk infants only (ie, premature infants and newborns with congenital heart disease). Monthly injections during the RSV season approximately halve the rate of serious RSV disease that leads to hospitalization. This expensive therapy is generally restricted to infants at high risk, such as children younger than 2 years with chronic lung disease of prematurity, premature infants younger than 6 months (or with other risk factors), and children with significant congenital heart disease.

Malnutrition is a known risk factor for infections, but zinc deficiency in particular has been shown to increase the risk of childhood pneumonia. In areas of the world where zinc deficiency is common, supplementation may significantly reduce the incidence of childhood pneumonia. ^[69]

Consultations

Consultation is not needed in the care of most children with pneumonia. However, children who have underlying diseases may benefit from consultation with the specialist involved in their long-term care. For example, most children with cystic fibrosis are monitored by a pulmonologist.

Consultation with a pediatric infectious disease specialist may be appropriate in the treatment of a child with persistent or recurrent pneumonia, and children with pleural effusions or empyema should be referred to a tertiary medical center, where thoracentesis can be performed. This procedure may be performed in an emergency department setting and may require subspecialty consultation.

Although some pneumonias are destructive (eg, adenovirus) and can cause permanent changes, most childhood pneumonias have complete radiologic clearing. If a significant abnormality persists, consideration of an anatomic abnormality is appropriate.

Careful longitudinal surveillance for long-term problems with growth, development, otitis, reactive airway disease, and other complications should be performed.