Community Acquired

Pneumonia

Epidemiology
Leading cause of death globally among children
younger than age 5 yrs.
Higher incidence in developing countries.
In the Philippines, a study of children below 5 years old
with pneumonia confirmed the burden of invasive
pneumococcal disease which ranged from 25-35 per
100,000 population. (2009-2010)
WHO: 50% of deaths due to pneumonia in children 5
years old and below are due to S. pneumoniae
infections. H. influenza infections account for 20% of
deaths (serotypes 6, 18, 14 most prevalent).

Etiology
Most cases caused by microorganisms
Noninfectious causes: aspiration, hypersensitivity
reaction, drug- or radiation induced pneumonitis.
Streptococcus pneumoniae: most common bacterial
pathogen in children 3wk-4yr of age.
Mycoplasma pneumoniae & Chlamydophila
pneumonaie: most frequent bacterial pathogens in age
5yr and older.
Other bacterial causes: Group A Strep (S. pyogenes) and
S. aureus (complicates an infection caused by influenza
viruses)

Etiology
S. pneumoniae, H. influenza and S. aureus: major causes of
hospitalization and death from bacterial pneumoniae
M. tuberculosis, Salmonella, E. coli and P. jiroveci: causes of
pneumonia in HIV infected children.
Viral pathogens: prominent cause of LRT infections in infants
and children older than 1 month but younger than 5 yrs.
RSV and rhinoviruses are the most commonly identified
pathogens especially in children younger than 2yrs.
Other common viruses: influenza virus, parainfluenza,
adenovirus, enterovirus, and human metapneumovirus.

AGE GROUP
Neonates (<3wk)

3wk-3mo

4mo-4yr

FREQUENT PATHOGENS (IN ORDER OF

FREQUENCY)
Group B streptococcus,Escherichia
coli,other Gram-negative
bacilli,Streptococcus pneumoniae,
Haemophilus influenzae(type b,*
nontypeable)
Respiratory syncytial virus, other
respiratory viruses (rhinoviruses,
parainfluenza viruses, influenza viruses,
adenovirus),S. pneumoniae, H.
influenzae(type b,*nontypeable); if
patient is afebrile, considerChlamydia
trachomatis
Respiratory syncytial virus, other
respiratory viruses (rhinoviruses,
parainfluenza viruses, influenza viruses,
adenovirus),S. pneumoniae, H.
influenzae(type b,*
nontypeable),Mycoplasma
pneumoniae,group A streptococcus

Pathogenesis
Normal physiologic barriers include the mucociliary
clearance, secreatory immunoglobulin in sectretions
and clearing of airway by coughing.
Immunologic defense mechanisms of the lung include
macrophages that are present in alveoli and
bronchioles, secretory IgA.
Trauma, anesthesia, and aspiration increases the risk of
pulmonary infection.

Pathogenesis: Viral Pneumonia

Spread of infection along the airways, accompanied by direct
injury of respi epithelium.
This results in airway obstruction from swelling, abnormal
secretions, and cellular debris.
Small caliber of airways in young infants makes such patients
susceptible to severe infection.
Atelectasis, interstitial edema, and ventilation-perfusion
mismatch causing significant hypoxemia often accompanies
airway obstruction.
Viral infection can predispose to secondary bacterial infection
by disturbing normal host defense mechanisms, altering
secretions, and modifying the bacterial flora.

Pathogenesis: Bacterial Pneumonia

Most often occurs when respiratory tract organisms
colonize the trachea and gain access to the lungs.
The pathologic process varies according to invading
organism.
M. pneumoniae: attaches to respi epithelium, inhibits
ciliary action, and leads to cellular destruction and an
inflammatory response in the submucosa. Sloughed
cellular debris, inflammatory cells, and mucus cause
airway obstruction, with spread of infection occurring
along the bronchial tree.

Pathogenesis: Bacterial Pneumonia

S. pneumoniae: produces local edema that aids in
proliferation of organisms and their spread into adjacent
portions of the lung, resulting in focal lobar
involvement.
Group A Strep: results in a more diffuse infection with
interstitial pneumonia. Pathology includes necrosis of
tracheobronchial mucosa; formation of large amounts of
exudate, edema, and local hemorrhage, with extension
into the interalveolar septa. There is also involvement of
lymphatic vessels and pleura.

Pathogenesis: Bacterial Pneumonia

S. aureus: manifests in confluent bronchopneumonia.
Often unilateral and characterized by presence of
extensive area of hemorrhagic necrosis and irregular
areas of cavitation of the lung parenchyma. This results
in pneumatoceles, empyema, or even
bronchopulmonary fistulas.

Recurrent Pneumonia
Defined as 2 or more episodes in a single year or
3 or more episodes ever, with radiographic clearing
between occurences.

Clinical Manifestations
Preceded by several days of symptoms of an URTI,
usually rhinitis and cough.
Fever
Tachypnea: most consistent manifestation of
pneumonia
Increased work of breathing with intercostal, subcostal
and suprasternal retractions, use of accessory muscles,
nasal flaring.
Cyanosis and lethargy in severe infection.
Crackles and wheezing upon auscultation.

Clinical manifestations in older

children
Typically begins with high fever, cough, and chest pain.
Drowsiness with intermittent periods of restlessness
Rapid respirations
Anxiety and occasionally delirium.
Some children may lay on one side with knees drawn up
to the chest: minimize pleuritic pain.

Physical Findings
Diminished breath sounds, scattered crackles, and
rhonchi over the affected lung feilds.
Dullness noted on percussion with increasing
consolidation.
Lag in respiratory excursion often on the affected side
Abdominal distention prominent due to gastric dilations
from swallowed air or ileus.
Abdominal pain common in lower-lobe pneumonia
Liver may seem enlarged due to downward
displacement of the diaphragm secondary to
hyperinflation of the lungs.

Findings in Infants
Prodrome of URTI and diminished appetite,, leading to
abrupt onset of fever, restlessness, apprehension, and
respi distress.
Appear ill with respiratory distress manifested as
grunting; nasal flaring; retractions of the
supraclavicular, intercostal, and subcostal area;
tachypnea; tachycardia; air hunger and often cyanosis.
Associated GI disturbances characterized by vomiting,
anorexia, diarrhea and abdominal distention secondary
to paralytic ileus.

Diagnosis
Chest Rdiograph (PA and lateral views) shows
infiltrates.
Indicates complications: pleural effusion or empyema
Viral pneumonia: hyperinflation with bilateral interstitial
infiltrates and peribronchial cuffing
Pneumococcal pneumonia: confluent lobar consolidation
Radiographic appearance alone is not diagnostic, other clinical
features must be considered.

A: radiographic finding characteristic of RSV pneumonia in a 6

mo old infant with rapid respirations and fever. AP view shows
hyperexpansion of the lungs with bilateral fine air space
disease and streaks of density, indicating presence of both
pneumonia and atelectasis. ET tube is in place.

B: AP view shows increased bilateral pneumonia a day later.

Diagnosis
Handheld ultrasonography is highly sensitive and
specific in diagnosis pneumonia in children by
determining lung consolidations and air bronchograms
or effusions.
WBC count:
may be normal in viral pneumonia, if elevated it is not higher
than 20,000/mm3 with lymphocyte predominance
Bacterial pneumonia associated with elevated WBC in the
range of 15,000-40,000/mm3 and a predominance of
granulocytes.

Definitive Diagnosis: viral

pneumonia
Isolation of avirus or detection of the viral genome or
antigen in the respi tract secretions.
DNA or RNA tests for the rapid detection of respi
pathogens are available and accurate.
Serologic techniques may also be used but generally
crequire testing of acute and convalescent serum
samples for a rise in antibodies to a specific viral agent
PCR is an emerging technology that may help
differentiate viral from bacterial causes of pneumonia.

Definitive diagnosis: Bacterial

Infection
Isolation of an organism from the blood, pleural fluid, or
lung.
Culture of sputum ids of little value in young children.
Percutaneous lung aspiration is invasive and not
routinely performed.
blood cultures recommended for those who fail to
improve or have clinical deterioration
Acute infection caused by M. pneumoniae can be
diagnosed on the basis of (+) PCR test result or
seroconversion in an IgG assay.
Serologic evidence, such as the antistreptolysin O titer,

Factors suggesting need for hospitalization of children

with pneumonia
Age <6mo
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
Immunocompromised state
Toxic appearance
Moderate to severe respiratory distress
Requirement for supplemental oxygen
Complicated pneumonia*
Dehydration
Vomiting or inability to tolerate oral fluids or medications
No response to appropriate oral antibiotic therapy
Social factors (e.g., inability of caregivers to administer medications at home or
follow-up appropriately)

Different
ial
Diagnosi
s

Treatment
Penicillin G is the parenteral drug of choice for infections
caused by penicillin-susceptible strains of S.
pneumoniae. Dosage ranging from 50,00-300,000
units/kg/day for minor infections and sever infections
such as meningitis.
Macrolides and cephalosporins are alternative treatment
for penicillin-allergic patients.
Critical time for treatment is during the first few hours
after the initial patient evaluation before cultures are
available.
S. pneumoniae is resistant to cotrimoxazole, penicillin,
chloramphenicol and erythromycin.

Prognosis
patients with uncomplicated community-acquired bacterial
pneumonia show response to therapy, with improvement in
clinical symptoms (fever, cough, tachypnea, chest pain), within
48-96 hr of initiation of antibiotics.
patient does not improve with appropriate antibiotic therapy:
emphysema
Bacterial resistance
Viral or Foreign body aspiration
Bronchial obstruction
Preexisting condition such as immunodeficiency, ciliary dyskinesia, cystic fibrosis,
pulmonary sequestration, or cystic adenomatoid malformation

A repeated chest radiography is the 1st step in determining the

reason for delay in response to treatment.

Compliactions
Complications of pneumonia are usually the result of
direct spread of bacterial infection within the thoracic
cavity (pleural effusion, empyema, pericarditis) or
bacteremia and hematologic spread.
Meningitis, suppurative arthritis, and osteomyelitis are
rare complications of hematologic spread of
pneumococcal or H. influenzae type b infection.
S. aureus, S. pneumoniae, and S. pyogenes are the
most common causes of parapneumonic effusions and
of empyema.

Prevention
vaccination has reduced the incidence of pneumonia
hospitalizations.
7-valent pneumococcal conjugate vaccine (PCV7) and
currently the 13-valent pneumococcal conjugate
vaccine (PCV13) is licensed.
influenza vaccine recommendations to include all
children >6 mo of age.

IMCI Booklet