Pneumonia, community acquired: guideline in children

History and clinical features

The clinical features of CAP vary with the age of the child and tend not be very specific for diagnosis.

• Absence of rhino rhea or sore throat together with any combination of the following is more suggestive of pneumonia
  • fever
  • tachypnoea
  • increased work of breathing 
  • cough
  • chest pain 
  • Focal chest signs: crepitations or bronchial breathing

• Age is a good predictor of the likely pathogens:
  • Viruses alone are found as a cause in younger children in up to 50%.
  • In older children, when a bacterial cause is found, it is most commonly strep pneumoniae followed by mycoplasma.                

• Bacterial pneumonia should be considered in children when there is persistent or repetitive fever >38.5oC together with chest recession and a raised respiratory rate.

• A persistent, hacking cough can be seen with Mycoplasma

• Abrupt onset of myalgias, arthralgia, headache, and fever suggest influenza or mycoplasm

• Is there any TB contact? Either direct contact with known cases or visitors from or travel to endemic areas. See appendix A.

X-Ray

• Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia who are well enough to be discharged.
• Severe symptoms in children requiring admission would merit a chest x-ray
• Suspicion of complications such as pleural effusion would also be an indication for x-ray.
• A lateral x-ray should not be performed routinely.

Other investigations

• Acute phase reactants are not of clinical utility in distinguishing viral from bacterial infections and should not be tested routinely.
• C reactive protein is not useful in the management of uncomplicated pneumonia and should not be measured routinely.
• Microbiological investigations should not be considered routinely in those with milder disease or those fit for discharge.
• Microbiological diagnosis should be attempted in children with severe pneumonia sufficient to require paediatric intensive care admission, or those with complications of CAP.
• Microbiological methods used should include:
  • Blood culture. Blood culture positivity is uncommon (<10%) of those with pneumococcal pneumonia.
  • Nasopharyngeal secretions and/or nasal swabs for viral detection by PCR and/or immunofluorescence.
  • Acute and convalescent serology for respiratory viruses, Mycoplasma and Chlamydia. 

• Auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia complicated by effusion and should trigger a cxr.
  
  
• Patients whose oxygen saturation is 92 % while breathing air should be treated with oxygen given by nasal cannulae, or face mask to maintain oxygen saturation >92%

What are the indications for transfer to intensive care?

• When the pneumonia is so severe that the child is developing severe respiratory failure requiring assisted ventilation.

• A pneumonia complicated by septicaemia. 

Key features that suggest a child requires transfer include: 

• Failure to maintain oxygen saturation >92% in high flow oxygen 
  
  
• Shock.
  
  
• Rising respiratory and pulse rate with clinical evidence of severe respiratory distress and exhaustion, with or without a raised arterial carbon dioxide tension.
  
  
• Recurrent apnoea or slow irregular breathing. 

Management

• Nasogastric tubes may compromise breathing. If use cannot be avoided, the smallest tube should be passed down the smallest nostril.
• Chest physiotherapy is not beneficial and should not be performed in children with pneumonia

Antibiotic management

• All children with a clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral pneumonia cannot reliably be distinguished from each other.
• Children aged <2 years presenting with mild symptoms of lower respiratory tract infection do not usually have pneumonia and need not be treated with antibiotics but should be reviewed if symptoms persist. A history of conjugate pneumococcal vaccination is reassuring. 
• In pneumonia associated with influenza, co-amoxiclav is recommended (may be staph).
• Antibiotics administered orally are safe and effective for children presenting with even severe CAP and are recommended.

• Recommended Oral antibiotics for CAP see “ Empirical Antibiotic Therapy in Children” guideline

• Recommended IV antibiotics for CAP 
  cefuroxime, if septic add gentamicin (if suspicious of atypical pneumonia add clarithromycin).

• Intravenous antibiotics should be used in the treatment of pneumonia in children when the child is unable to tolerate oral fluids or absorb oral antibiotics (e.g. because of vomiting) or presents with signs of septicaemia or complicated pneumonia. 
  
  

Advice for a child with CAP who does not require hospital admission comprises advising parents and carers about:

• Management of fever
  • use of antipyretics
  • Avoidance of tepid sponging
• Preventing dehydration
  • identifying signs of deterioration
  • identifying signs of other serious illness
• How to access further healthcare.

(Over-the-counter remedies:  No over-the-counter cough medicines have been found to be effective in pneumonia)

Children with CAP in the community who attended the department should be reassessed if they are not responding to treatment, e.g. persistence of fever 48hours after initiation of treatment, increased work of breathing or if the child is becoming distressed or agitated. 

Pleural Effusions/Empyema

May develop in 1% of patients with CAP and incidence of empyema is increasing.  A clinician should consider empyema when a child presents with a persistent fever beyond 7 days  or a persisting fever despite adequate antibiotic treatment for 48hrs. A chest xray will show fluid in the pleural space +/- ultrasound and respiratory team referral to decide on if and mode of pleural drainage employed.

Lung Abscess

Rare but important complication may be suggested by CXR. Certain groups of patients such as those with congenital cysts, sequestrations, bronchiectasis, neurological disorders and Immunodeficiency are thought to be more prone. Referral to respiratory team and CT chest will be necessary.

Septicaemia and metastatic infection

Children may have pneumonia but also show signs of sepsis (these children usually need PICU)

Metastatic infection can rarely occur as a result of the septicaemia associated with pneumonia.e.g. osteomyelitis or septic arthritis should be considered, particularly with S aureus infections.

Haemolytic uraemic syndrome

S pneumoniae is a rare cause of haemolytic uraemic syndrome. Will be suggested by pallor, severe anaemia and anuria.

Complications associated with Mycoplasma pneumonia

Various complications in association with M pneumoniae have been reported.

Rashes are common, the Stevens Johnson syndrome occurs rarely, and haemolytic anaemia, polyarthritis, pancreatitis, hepatitis, pericarditis, myocarditis and neurological complications including encephalitis, aseptic meningitis, transverse myelitis and acute psychosis have all been reported.

Follow-up radiography is not required in those who were previously healthy and who are recovering well, but should be considered in those with a round pneumonia, collapse on CXR if it was done or persisting symptoms/signs are present.

• Pulmonary Tuberculosis is considered separately from community acquired pneumonia. It is a rare presentation to the department. 

• A  study in 2005  comparing children who had pulmonary TB with those who had persistant (>2/52) respiratory symptoms presenting to a healthcare facility showed :
  • Persistent, non-remitting cough was reported in 15/16 (93.8%) children with tuberculosis and in 2/135 (1.5%) children without tuberculosis, indicating a specificity of 98.5% (135/137).
  • Persistent fatigue of recent onset was also sensitive (13/16, 81.3%) and specific (134/135, 99.3%).
  • Persistent fever and/or chest pain were exclusively reported in children with tuberculosis, but were present in only 4/16 (25.0%) children without tuberculosis

Around 50% of children with TB have been reported to have no symptoms

• Suspicion should also be raised in a patient with  weight loss , cough and  fever who does not respond to antibiotic therapy for acute respiratory disease

• Contact with known cases or visitors from or travel to endemic areas in children with respiratory symptoms and or signs would be an indication for a CXR.

• Remember to ask about and check for marks of BCG vaccination

Any patient with X-ray changes suggestive of TB should be referred to the TB clinic the next week for further investigation.

Contact Sandra Stewart via Email sandra.stewart@ggc.scot.nhs.uk and also copy the Email to Dr James Paton who runs the clinic please James.Paton@glasgow.ac.uk .

Let them know the patients details, date of attendance and reason for referral. They will usually organise the exact time and date of attendance and notify the family. If necessarily they can involve one of the TB nurses. The appointment will usually be at the next clinic (i.e. within one week).