Community-acquired pneumonia (CAP) is a major cause of illness and death in children worldwide, especially in developing countries. The presentation of pediatric pneumonia includes cough, fever, tachypnea, grunting, and hypoxemia. Chest x-rays can identify infiltrates but may also show complications like effusions. Treatment involves hospitalization for young infants or severe cases, along with antibiotics chosen based on likely causative organisms and duration of 10 days. Prevention strategies encompass adequate nutrition, immunizations, reducing indoor air pollution, hand washing, exclusive breastfeeding, and influenza vaccination.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Community
Acquired
Pneumonia
The Forgotten Killer
of Children
Sayed Ismail, MD
Professor of pediatrics

3. Learning Objectives
• To describe the presentation of pediatric pneumonia
• To outline the management of pediatric pneumonia
• To summarize the complications of pediatric
pneumonia
• To highlight interventions to prevent and protect
against pediatric pneumonia

4. What is Pneumonia?
• Pneumonia: an acute
infection of the
pulmonary parenchyma

5. Classification Of Pneumonia
1. Community acquired
2. Hospital acquired
3. congenital pneumonia, presents within
the first 24 hours after birth.

6. What is CAP?
Community-acquired
pneumonia (CAP) is
defined as an acute
infection of lung in a
patient who has
acquired the
infection in the
community settings
Thorax 2002;57(suppl 1):i1-24.

7. Global distribution of cause-specific
Mortality among children younger than age 5 yr
Pneumonia is the number one killer of children in these societies . Lancet 371:243–260, 2008;

8. The Lancet Respiratory Medicine DOI: (10.1016/S2213-2600(15)00028-4)
Copyright © 2015 Elsevier Ltd Terms and Conditions
South Asia and sub-Saharan Africa together bear the burden of
more than half of all childhood pneumonia cases worldwide
2012
A child dies every 15 seconds from pneumonia

9. Developing countries bear the
greatest burden
• > 150 million episodes of pneumonia / year
among children < 5 yr.
• 3- million children die from pneumonia
each year worldwide
UNICEF/WHO ,2007

10. The Mortality rate
1.Rudan et al, World Health Organ 2004; 82:895.
In developed countries In developing countries
1000 / year 3 millions /year

11. Risk Groups
• Infants (especially premature). 75% of pneumonia deaths
occur among infants
• Malnutrition
• Suppressed immunity ,HIV infection
• Recurrent RTI during the previous year
• Wheezing episodes

12. How Is Pneumonia Transmitted?
• Inhalation of common bacterial pathogens already present in a
child’s nose or throat .
• Inhalation of contaminated air droplets
• Blood-borne infections.
• During birth, from contact with organisms in the birth canal
National Institutes of Health, November 2005

13. Age
Common Causes(in ORDER OF
FREQUENCY)
Neonates Group B strept, E. coli,
2 months to 5 years
• Viruses RSV, influenza virus
•Strept. Pneumoniae*
•H. influenzae type B
•Chlamydia pneumoniae
•Mycoplasma pneumoniae
•Bordetella pertussis
•Mixed etiology in 40%
5 years to adolescence
•M. Pneumoniae *
•S. Pneumoniae
•C. pneumoniae
Causes of Pneumonia
Michael et al,Am Fam Physician 2004;70:899-908.

14. Pathology of lobar pneumonia (4 phases)
Congestion
• Lasts < 24 hours: Alveoli filled with edema fluid and bacteria.
Red hepatization
• Fluid, RBCs and polymorphonuclear cells in lung
Grey hepatization
• Less hyperaemia. Macrophages, neutrophils + fibrin
Resolution
• Lysis and removal of fibrin via sputum +lymphatics.
• Begins after 8-9 days (without antibiotics).
• Sudden improvement of patient's condition

15. Viral pneumonia
• the alveolar septa are damaged
•The alveoli contain no inflammatory exudate.
•marked inflammatory exudate within
bronchioles
Lobar pneumonia
•Alveoli are completely filled with
inflammatory exudate
• The alveolar septa are relatively
normal
Pathology of pneumonia

16. Ventilation/perfusion (V/Q)
mismatch
and hypoxemia

17. Diagnosis of pneumonia
History
Physical examination
Chest x-rays
Laboratory tests
Cincinnati Children's Hospital Medical Center; 2006 Jul
Clinical Infectious Diseases 2007;44:S27–S72

18. Clinical Presentation
• Cough and fever
• Nasal flaring
• Shortness of breath
• Tachypnea
• Grunting
• Chest retraction
• Decreased breath sounds
• Bronchial breathing and crepitations
• Hypoxemia
• Abdominal pain is common in lower-lobe pneumonia
World Health Organization, Geneva, 2005.
Boschi-Pinto and Debay M. Accessed online February 27, 2004

19. • Tachypnea is the best single predictor of pneumonia
• If wheeze is present in a preschool child, consider:
– viral or
– Mycoplasmal infection
– or asthma
Thorax, Volume 57 May 2002

20. Chest X-ray
• An infiltrate on CXR supports the diagnosis of
pneumonia; the film may also indicate a complication
such as a pleural effusion or empyema
• The radiographic appearance alone is not diagnostic,
and other clinical features must be considered.
Nelson, 2015

21. Chest Radiography – indications
CXR, PA and lateral, should be obtained in patients with
1. Hypoxemia
2. Respiratory distress
3. in all patients hospitalized for management of CAP
to document the presence of parenchymal
infiltrates and identify complications of pneumonia
1.Clin Infect Dis. (2011) 53 (7): 617-630. doi: 10.1093/cid/cir625
Clin Infect Dis. (2011) 53 (7): 617-630.

22. Right Upper Lobe Pneumonia

23. Right Middle Lobe Pneumonia

24. A 7 year old boy pneumonia affecting the right lower lobe

25. Typical findings are hyperaeration, peribronchial cuffing, (arrows). and increase in parahilar linear
markings. Characteristically, there are no areas of focal lung opacity since the infection involves the
airways and not the airspaces
Viral pneumonia

26. (A) Anteroposterior radiograph from a child with presumptive viral pneumonia. (B) Lateral
radiograph of the same child with presumptive viral pneumonia.

27. Radiographic findings characteristic of pneumococcal pneumonia in a 14 yr old boy with
cough and fever. Posteroanterior (A) and lateral (B) chest radiographs reveal consolidation
in the right lower lobe, strongly suggesting bacterial pneumonia

28. Anteroposterior radiograph from a child with a round pneumonia.

29. Mycoplasma pneumonia pneumonic opacities in both lower lobes,
most pronounced on the right side

30. a) Staphylococcal pneumonia with mottled
multifocal bilateral pulmonary opacities.
b) Staphylococcal pneumonia late stage. The opacities
coalesce and become homogenous in character.
c) Staphylococcal pneumonia late stage with
consolidated pulmonary opacities. Bilateral
pneumothorax has developed.

31. Retrocardiac pneumonia

32. Pulmonary : direct spread of bacterial infection
Pleural effusion or empyema
Pneumothorax
Lung abscess
Bronchopleural fistula
Acute respiratory failure
Metastatic : hematologic spread , rare complications
Meningitis
Central nervous system abscess
Pericarditis , Endocarditis
Osteomyelitis
Septic arthritis
Systemic
Systemic inflammatory response syndrome or sepsis
Hemolytic uremic syndrome
What Are the Complications of Pneumonia?

33. Pneumothorax

34. • Age: 12 years
• Pneumonia with empyema.
• Blood and pleural effusion
cultures: S. Aureus
methicillin sensible.

35. • Age: 17 months
• Extense pneumonia
with empyema
• Pleural Culture:
S. Pneumoniae

36. Chest ultrasonography
is highly sensitive and specific in diagnosing pneumonia in children
by determininglung consolidations and air bronchograms or
effusions.

37. A, Normal lung (A-lines). B, Focal pneumonia,
C, Focal pneumonia, D-E, B-lines, confluent B-lines, subpleural consolidation associated with
viral pneumonia
F, Pleural effusion (anechoic space between lung and chest wall or diaphragm).
Chest ultrasonography

38. • New data show that point-of-care ultrasonography
accurately diagnoses most cases of pneumonia in
children and young adults.
• Ultrasonography may eventually replace x-rays for
diagnosis.
JAMA Pediatr. 2013; 167(2):119-25 (ISSN: 2168-6211)

39. If the chest radiograph is
not conclusive, then further
imaging with chest
ultrasound or computed
tomography (CT) is
recommended.
Severe pneumonia and empyema

40. CT scan of the chest performed with intravenous contrast demonstrates the
left hemithorax opacification is due to a large left pleural effusion causing
complete atelectasis of the left lung and mediastinal shift to the right.

41. Laboratory tests
• White blood cell count and differential
• Acute phase reactants
• Sputum gram stain and culture, nonspecific
• Pleural culture
• PPD with a history of exposure to tuberculosis.
• Blood cultures positive in 10%
• Rapid viral antigen detection in nasopharyngeal aspirates for RSV,
parainfluenza ,influenza, and adenovirus
• Serology for chlamydia pneumoniae and IgM serologic studies for
Mycoplasma infection
• Reliable DNA or RNA tests for the rapid detection of many respiratory
pathogens, such as mycoplasma, pertussis, and viruses,including RSV,
parainfluenza, influenza, and adenoviruses, are availableand
accurate. C
Clinical Infectious Diseases 2007;44:S27–S72

42. What Additional Diagnostic Tests Should Be Used in a Child
With Severe or Life-Threatening CAP?
1. obtain tracheal aspirates for Gram stain and culture
2. testing for viral pathogens, including influenza virus, at the time of
initial endotracheal tube placement in children requiring
mechanical ventilation.
3. Bronchoscopic brush sampling, bronchoalveolar lavage (BAL)
4. Percutaneous lung aspiration, or open lung biopsy should be
reserved for the immunocompetent child with severe CAP if initial
diagnostic tests are not positive.
Clin Infect Dis. (2011) 53 (7): 617-630.

43. Treatment

44. Indications For Hospitalization
1. Infants younger than 6 months of age
2. Poor compliance
3. Hypoxemia less than 94 % in room air
4. Dehydration, or inability to feed in an infant
5. Moderate to severe respiratory distress: respiratory rate >70 breaths/min in
infants <12 months or >50 breaths/min in older children, difficulty breathing, apnea,
grunting
6. Toxic appearance suggest severe pneumonia
7. Underlying conditions eg, cardiopulmonary disease, metabolic disorder,
immunocompromised host)
8. Presence of complications (eg, effusion/empyema)
9. Failure of outpatient therapy (worsening or no response in 24 to 72
hours)
William et al, ©2009 UpToDate,

45. ANTI-INFECTIVE TREATMENT
Recommendations :
Outpatients:
1. Amoxicillin or amoxicillin clavulanate are the first-line therapy
for children < 5 yr.
2. Macrolide for school-age children
3. Influenza antiviral therapy to children with moderate to severe
CAP consistent with influenza virus infection (Oseltamivir ,Zanamivir)
Clin Infect Dis. (2011) 53 (7): 617-630.

46. For inpatient
• 3nd generation cephalosporin + a macrolide
• Children who are toxic appearing should receive
vancomycin

47. Organism Preferred
antimicrobial(s)
Alternative
antimicrobial(s)
Streptococcus
pneumoniae
Penicillin resistant
High‐dose amoxicillin Ceftriaxone,Levofloxacin
Vancomycin
,clindamycin,linezolid
Haemophilus
influenzae
Β‐lactamase
producing
Amoxicillin‐clavulanate
2nd or 3rd
cephalosporin
cefdinir, cefixime
Mycoplasma
pneumoniae
azithromycin levofloxacin .
clarithromycin
Staphylococcus
aureus
Methicillin susceptible
Cefazolin , oxacillin,
clindamycin
Vancomycin or linezolid if
Methicillin resistant
Recommended antimicrobial therapy for specific pathogens

48. What Is the Appropriate Duration of
Antimicrobial Therapy for CAP?
• Treatment courses of 10 days have been best studied,
although shorter courses may be just as effective, particularly
for more mild disease managed on an outpatient basis.
• Infections caused by certain pathogens, notably CA-MRSA,
may require longer treatment than those caused by S.
pneumoniae. (strong recommendation)
Clin Infect Dis. (2011) 53 (7): 617-630.

49. How Should the Clinician Follow the Child With CAP
for the Expected Response to Therapy?
• Children on adequate therapy should demonstrate clinical and
laboratory signs of improvement within 48–72 hours.
• For children whose condition deteriorates after admission and
initiation of antimicrobial therapy or who show no improvement
within 48–72 hours, further investigation should be performed.

50. Causes of failure of treatment
1. Alternative diagnosis e.g. asthma
2. Resistant organisms to either penicillins or macrolides
3. Complications such as empyema
4. Viral etiology
5. Preexisting diseases such as immunodeficiencies,

51. MANAGEMENT OF THE CHILD NOT RESPONDING
TO TREATMENT after 48-72hr
• Clinical and laboratory assessment of the current severity of illness
• Imaging evaluation to assess the extent and progression of the
pneumonic or parapneumonic process.
• Further investigation
– A BAL specimen for Gram stain and culture for the mechanically
ventilated child.
– A percutaneous lung aspirate should be obtained for Gram stain
and culture in the persistently and seriously ill child for whom
previous investigations have not yielded a microbiologic
diagnosis.

52. What Laboratory Testing Should Be Performed on
Pleural Fluid?
• Gram stain and bacterial culture of pleural fluid should be
performed whenever a pleural fluid specimen is obtained.
• Antigen testing or nucleic acid amplification through polymerase
chain reaction (PCR) increase the detection of pathogens in
pleural fluid and may be useful for management.
• Analysis of the pleural fluid white blood cell (WBC) count, with
cell differential analysis, is recommended primarily to help
differentiate bacterial from mycobacterial etiologies and from
malignancy.

53. What Are the Drainage Options for Parapneumonic
Effusions?
• Small, < ¼ thorax opacity can be treated with antibiotic therapy
alone.
• Moderate < ½ thorax opacity associated with respiratory distress,
large parapneumonic effusions, or documented purulent effusions
should be drained.
• Both chest tube drainage with the addition of fibrinolytic agents
and VATS have been demonstrated to be effective methods of
treatment.
• However, in patients with moderate-to-large effusions that are free
flowing (no loculations), placement of a chest tube without
fibrinolytic agents is a reasonable first option.
Bradley J S et al. Clin Infect Dis. 2011;53:617-630
VATS, video-assisted thoracoscopic surgery.

54. What Antibiotic Therapy and Duration Is Indicated for
the Treatment of Parapneumonic Effusion/Empyema?
• When the blood or pleural fluid bacterial culture identifies a
pathogenic isolate, antibiotic susceptibility should be used to
determine the antibiotic regimen.
• In the case of culture-negative parapneumonic effusions, antibiotic
selection should be based on the treatment recommendations for
patients hospitalized with CAP
• The duration of antibiotic treatment depends on the adequacy of
drainage and on the clinical response demonstrated for each
patient. In most children, antibiotic treatment for 2–4 weeks is
adequate.

55. How Is Pneumonia Prevented?
• Adequate nutrition (including breastfeeding )
• Immunization
• Reducing indoor air pollution.
• Hand washing
Luby, S.P., et al., The Lancet, vol. 366, 2005,

56. • Promote exclusive
breast feeding for 6
months
• Impact :
• 20 % reduction in
pneumonia incidence.
• 13% reduction in all
child deaths.
Breast feeding

57. Vaccinations
• Influenza vaccine is recommended for children aged 6
months and older.
• The pneumococcal conjugate vaccine (PCV13) is
recommended for all children younger than 59 months
old.
• The 23-valent polysaccharide vaccine (PPV23) is
recommended for children 24 months or older who are at
high risk of pneumococcal disease.

59. Key points
• Pneumonia kills more children under the age of five than any other
illness
• Tachypnoea is the best single predictor of pneumonia in children of
all ages.
• Common first-line antibiotics include amoxicillin and amoxclav
• Viruses , Streptococcus pneumoniae , mycoplasma and chlamydial
pneumonia are most common causes of pneumonia

61. Questions
1. What is the is the best single predictor sign of pneumonia
1. Cough and fever
2. Shortness of breath
3. Tachypnea
4. Grunting
5. Chest retraction
2. All are Indications For Hospitalization in pneumonia except
1. Infants younger than 6 months of age
2. Hypoxemia less than 94 % in room air
3. Dehydration, or inability to feed in an infant
4. Moderate to severe respiratory distress
5. Fever