1. Emerg Med Clin N Am
21 (2003) 437–451
Pediatric pneumonia
Richard Lichenstein, MDa,b,*,
Adrienne H. Suggs, MDa, James Campbell, MDc
a
Division of Pediatric Critical Care Medicine, University of Maryland School of Medicine,
22 South Greene Street, Baltimore, MD 21201, USA
b
Pediatric Emergency Medicine, University of Maryland Hospital for Children,
22 Greene Street, Baltimore, MD 21201, USA
c
Division of Pediatric Infectious Disease, University of Maryland School of Medicine,
22 South Greene Street Baltimore, MD 21201, USA
Respiratory infections are encountered commonly in the emergency
department (ED). Visits for respiratory disease account for 10% of pediatric
emergency department (PED) visits and 20% of all pediatric hospital ad-
missions. Pneumonia represents an important cause of many of these visits
[1]. Despite the decline of pneumonia-associated mortality, [2,3] it remains
the most common infectious cause of death in the United States [4]. Because
of overlap with common pediatric upper respiratory tract disease, it also
presents the emergency physician with challenges in diagnosis and
treatment, including the choice of antibiotics in an era of pneumococcal
resistance and pneumococcal vaccine in infants and the challenges of
influenza rapid diagnosis and treatment since approval of the neuraminidase
inhibitors. Bronchiolitis (which is implicated with viral pneumonitis) has
been discussed recently; [5] this review targets the varied clinical character-
istics of other types of pediatric pneumonia.
Definition
Pneumonia has been defined as pulmonary infiltrates on a chest radio-
graph or by clinical signs and symptoms [6,7]. The World Health Organi-
zation (WHO), as part of their Integrated Management of Childhood Illness
program, recommends diagnosis of pneumonia using clinical signs such as
* Corresponding author. University of Maryland, Pediatric Emergency Department, 600
West Lombard Street, Baltimore, MD 21201.
E-mail address: rlichenstein@peds.umaryland.edu (R. Lichenstein).
0733-8627/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S0733-8627(03)00008-7

2. 438 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
tachypnea (respiratory rate greater than 50/min in infants younger than 1
year of age and greater than 40/min in children older than 1 year of age),
retractions, or cyanosis [8,9]. Regardless of the definition, there is significant
overlap between pneumonia and other respiratory conditions such as
bronchiolitis.
Pathophysiology
Bacterial pneumonia occurs after inhalation or aspiration of pathogens.
Less commonly it also can occur after hematogenous spread. An inflam-
matory reaction follows with release of fluid and polymorphonuclear white
blood cells into the alveoli, followed by fibrin and macrophage deposition
over days. Viral pneumonia occurs mainly after inhalation into the lung of
infected droplets from upper airway epithelium. The resulting inflammatory
response causes epithelial cells to slough into airways, thereby causing
bronchial obstruction and hyperinflation. Viral pneumonia also may pre-
dispose infected children to bacterial pneumonia because of damage to
mucosal barriers.
In the neonatal period, pneumonia may occur as a result of infection or
colonization of the nasopharynx or conjunctiva by organisms found in the
mother’s vaginal tract. Lung injury from aspiration or host immunologic
factors also may predispose the child to pneumonia.
Epidemiology
Pneumonia is diagnosed in approximately 4% of children in the United
States per year but the attack rate varies by age. The annual rate of pneu-
monia is 35–40 per 1000 children younger than 1 year of age; 30–35 cases
per 1000 children 2–4 years of age, 15 per 1000 children aged 5–9 years, and
less than 10 per 1000 for children older than 9 years of age [6,7,10,11].
Compared with developing nations most cases of pneumonia in the United
States have lower mortality rates and are treated as outpatients [12]. Some
populations are at higher risk for pneumonia, including children with cystic
fibrosis, aspiration syndromes, immunodeficiencies, or congenital or ac-
quired pulmonary malformations [13–16].
Etiology
Many microbiologic agents cause childhood pneumonia, but given the
difficulty of establishing the definitive cause, the most likely pathogens are
usually inferred from factors such as age, season, and clinical characteristics.
Radiographs, blood tests, and cultures are of limited usefulness to the ED
physician in determining the exact etiology of pneumonia. It is estimated

3. R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451 439
that only one third of cases of pneumonia can be attributed to a specific
etiology using culture, antigen detection, or serology [17].
When the microbiology of pneumonia has been studied, S pneumoniae has
been found to be the most common cause of bacterial pneumonia, and
respiratory syncytial virus (RSV) the most common viral cause. In children
hospitalized with pneumonia, viral infections become less common with
increasing age, whereas the age-specific incidence of bacterial infections
remains relatively constant [18]. In children younger than 2 years, viral
infections were found in 80% of children with pneumonia; in children older
than 5 years, viral infections were detected only 37% of the time.
In hospitalized and ambulatory children, S pneumoniae is the most
common bacterial pathogen identified in children younger than 4 years of
age. In ambulatory children with pneumonia in Finland [19] and in Texas
[20], 24%–33% of children younger than the age of 4 years with pneumonia
were infected with S pneumoniae.
Mycoplasma pneumoniae and Chlamydia pneumoniae were isolated more
frequently in children 5–9 years of age and 10–16 years of age, overall
[19,20]. Estimates of the percent of pneumonias caused by M pneumoniae
vary from 7%–30% for children 5–9 years of age to 14%–51% in children
10–16 years of age. C pneumoniae is less frequently implicated, ranging from
9%–13% for children 5–9 years of age, to 14%–35% for children 10–16
years of age [19,20]. Studies in other areas of the United States have
confirmed that M pneumoniae and C pneumoniae are more common causes of
pneumonia in children older than 5 years of age [21,22].
Overall S pneumoniae causes most cases of bacterial pneumonia in infants
and children, and viruses become less prevalent with age, whereas myco-
plasma and chlamydia infections become more common with increasing
age, particularly in adolescents. Mixed viral and bacterial infection has
been reported in 16%–34% of children with pneumonia [18,23]. Although
less common, the emergency physician should consider other, more rare
causes of bacterial pneumonia such as Staphylococcus aureus, Moraxella
catarrhalis, Haemophilus influenzae (type b, encapsulated types other than b,
and non-typable), Group A and B streptococci, Mycobacterium tuberculosis,
and Bordetella pertussis, depending on the clinical picture [24].
Specific pediatric considerations
Streptococcus pneumoniae
S pneumoniae is the most common bacterial cause of otitis media, sinusitis,
and bacteremia in the pediatric population and is the most common bacterial
cause of pneumonia in children younger than 5 years of age.
Pneumococci can be part of the normal nasopharyngeal flora of healthy
children. An average of 40%–50% of young children and 20%–30% of
adults are colonized at any point in time [25,26]. Inhalation or aspiration of

4. 440 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
the organisms can lead to pneumonia. Risk factors for colonization include
age younger than 2 years, daycare attendance, winter season, and antibiotic
use [27]. A study of 187 patients with invasive disease also revealed an
association with daycare attendance and antibiotic use [28].
The clinical spectrum of signs and symptoms can be broad, ranging from
mild, nonspecific symptoms of emesis, cough, and abdominal pain to severe
respiratory distress. Tan et al found the most common presenting symptoms
to be fever and nonproductive cough, followed by tachypnea, malaise,
lethargy, and rhinorrhea. The most common examination findings were
decreased breath sounds, crackles, or rales. Although the classic finding of
lobar consolidation often is seen, its absence does not eliminate the pos-
sibility of pneumococcal pneumonia. In this study greater than half the
patients had lobar consolidation and 38% had effusions. Empyema, a known
complication of pneumonia caused by S pneumoniae, was present in 14%
[29].
Resistance to b-lactam antibiotics occurs when one of six penicillin-
binding proteins of the pneumococcus is altered, leading to decreased
affinity of the organism for penicillin and other b-lactam antibiotics. The
National Committee for Clinical Laboratory Standards (NCCLS) considers
susceptible to penicillin those organisms with a minimal inhibitory con-
centration (MIC) of 0.06 mcg/mL, intermediate at 0.1–1 mcg/mL, and
resistant at ! 2 mcg/mL [30]. Many investigators use the term ‘‘penicillin
nonsusceptible’’ to include intermediate and resistant strains.
Antibiotic resistance to S pneumoniae, particularly penicillin and
cephalosporin resistance, has been on the increase and of major concern
since the early 1990s. It is an important and concerning factor when
considering invasive disease. A large surveillance of invasive pneumococcal
disease from 1995–1998 [31] revealed an increase in isolates that were
penicillin-resistant (defined as high-level or intermediate by NCCLS
standards) from 21%–25% in that 3-year period alone. That study also
showed an increase in resistance to other agents, including other b-lactam
antibiotics (cefotaxime) from 10%–14%, meropenem from 10%–16%, ery-
thromycin from 11%–15%, trimethoprim/sulfamethoxazole (TMP/SMX)
from 25%–29%, and rifampin from 0.2%–0.6%. Fluoroquinolone re-
sistance also was low, but this class of antibiotics is not recommended for
routine use in children younger than 17 years of age [31]. Vancomycin
tolerance but not resistance has been discovered in S pneumoniae; the clinical
significance is yet to be determined [32]. As with crude rates of colonization
and rates of invasive infection, exposure to antibiotics, young age, and
daycare attendance are associated with a greater likelihood of colonization
or infection with a penicillin-resistant S pneumoniae isolate [28,31]. Serious
complications and treatment failures, however, are rare with pneumonia
compared with other invasive infections and otitis media [33]. In fact, Tan
et al showed that the clinical presentations and outcomes for therapy of
pneumonia did not differ significantly between patients with penicillin-

5. R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451 441
susceptible and penicillin-nonsusceptible isolates who were treated with
traditional antibiotics [29].
Treatment of suspected pneumonia caused by S pneumoniae should take
into account the aforementioned resistance information. Tan et al suggests
that in previously healthy patients with pneumonia attributed to penicillin-
resistant pneumococcal isolates, therapy with standard b-lactam agents is
effective [29]. The American Academy of Pediatrics (AAP) recommends
standard antibiotic therapy for noncritically ill, immunocompetent patients
with possible invasive pneumococcal infections other than meningitis. Ad-
ditional initial antibiotic coverage for potential penicillin-nonsusceptible
strains could be considered for patients who are critically ill, including those
with myopericarditis, severe multilobar pneumonia with hypoxia, or hypo-
tension. Coverage for possible penicillin- and cefotaxime- or ceftriaxone-
nonsusceptible strains could be considered. If vancomycin is administered, it
should be discontinued as soon as antibiotic susceptibilities demonstrate
effective alternative agents [33]. Oral therapy with low- or high-dose
amoxicillin or second-generation cephalosporins such as cefuroxime there-
fore should be effective for initial management of outpatient pneumococcal
pneumonia [17] in children younger than 5 years of age excluding the neo-
natal period. Macrolides, including azithromycin, also are appropriate, but
usually are not necessary given their broad-spectrum coverage [34]. Intra-
venous penicillin, ampicillin, or cefuroxime should be adequate to treat
hospitalized children when pneumococcal pneumonia is suspected. Cefotax-
ime, ceftriaxone, and clindamycin also can be considered when one suspects
a penicillin-resistant organism. When a pneumococcal isolate is resistant to
cefotaxime or ceftriaxone by NCCLS standards, clindamycin or vancomy-
cin is recommended [32].
There are more than 90 different pneumococcal serotypes or subgroups,
but only a small number are highly invasive and account for most disease.
Currently, the newest heptavalent pneumococcal conjugate vaccine (ap-
proved to age 5) is directed against seven serotypes, the major strains that
cause invasive disease. The vaccine’s efficacy varies by infection site, with the
poorest overall protection against otitis media. In the pivotal field trial
leading to licensure, this vaccine provided 94% efficacy against invasive
pneumococcal disease caused by the serotypes found in the vaccine [35].
Atypical pneumonia
The term ‘‘atypical pneumonia’’ has referred for the most part to
pneumonia caused by organisms other than the historically common and
more easily cultured bacteria, including most often Mycoplasma pneumonia,
Coxiella burnetii, Chlamydia pneumoniae, other Chlamydia species (tracho-
matis and psittaci), Legionella pneumophila, Bordetella pertussis, and viral
pathogens [24,36,37]. As mentioned earlier, M pneumoniae and C pneumoniae

6. 442 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
have been reported to be the most frequent causes of community-acquired
pneumonia in children age 5 years or older [19,20,38].
Pneumonia caused by C pneumoniae and M pneumoniae has been reported
as being mild and rarely resulting in hospitalization. Falguera studied 247
patients with community-acquired pneumonia in whom a causative agent
was found in 66%. The most common pathogens were S pneumonia,
M pneumoniae, and C pneumoniae, in that order. When patients were
stratified into groups according to clinical severity, however, M pneumoniae
and other ‘‘atypical pathogens’’ (C pneumoniae, C burnetii, and C psittaci)
were the most frequent agents identified in the group with the mildest
symptoms, whereas S pneumoniae was isolated more frequently in the groups
with more severe symptoms. The exception is that Legionella species, often
classified as atypical, usually causes more acute and severe symptoms [36].
Chest radiograph findings are less likely lobar for atypical pneumonias than
those caused by S pneumoniae. Radiographic abnormalities in M pneumoniae
vary, but bilateral, diffuse infiltrates are common [39]. Treatment for atypical
pneumonia covering M pneumoniae and C pneumoniae includes macrolides in
any age group and tetracyclines in children older than 8 years of age.
Fluoroquinolones (including levofloxacin and ofloxacin, not ciprofloxacin)
also are appropriate in children older than 16 years of age [3,40].
Chlamydia trachomatis
Chlamydia trachomatis can be transmitted from the genital tract of
infected mothers to their newborn infants. Following vaginal delivery, 50%
of infants acquire the organism. The nasopharynx and the conjunctivae are
the most commonly infected sites, but not all colonized newborns progress
to overt infection. Pneumonia occurs in 5%–20% of infected infants.
Chlamydia pneumonia typically presents 2–19 weeks after birth, making
C trachomatis the most common cause of infection in the 4–11-week age
group. A staccato cough, tachypnea, and crackles are often but not always
present. As a general rule, fever is not present. Children with chlamydia
pneumonia often present with bilateral diffuse infiltrates on radiograph and
peripheral blood eosinophilia. One must confirm the diagnosis by culture of
the nasopharynx or by the detection of bacterial antigens or DNA, but
treatment should be initiated based on clinical suspicion. A 14-day course of
oral erythromycin is recommended, but known to have an efficacy of only
80%. Oral sulfonamides are appropriate in children older than 2 months of
age [41].
Pertussis
Although not exactly a cause of pneumonia, Bordetella pertussis is an
important respiratory pathogen that may lead to pneumonia. B pertussis
remains endemic in the United States and continues to cause epidemics

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despite widespread vaccination of the population in childhood. Most cases
occur in individuals who have not been adequately vaccinated, however [42],
and infection in vaccinated individuals is usually mild [43]. Paroxysmal
cough and posttussive vomiting are the most common presenting symptoms.
Fever is rare. In one study, the median age was 4.1 years; the overall com-
plication rate was 5.8% with pneumonia being the most common compli-
cation [42]. The complication rate was higher (23.8%) in infants younger
than 6 months of age. Of all infants younger than 6 months of age, the most
common complication was apnea (15.9%) [42]. The Red Book reports
a fatality rate of 1.3% in children younger than 1 month and 0.3% in
children 2–11 months of age [41]. Because of the risk for apnea in very
young infants, the emergency physician must have a high level of suspicion
when infants present with paroxysmal cough. The lack of fever and the
presence of a high proportion and absolute number of lymphocytes on the
peripheral blood smear are clues to the diagnosis of pertussis in the child
who presents with cough. In addition, the typical staccato cough in which
multiple forceful coughs proceed in rapid progression followed by a deep
inspiration (and possible whooping sound and posttussive emesis) also may
lead the clinician to suspect pertussis. These paroxysms may be followed by
periods of calm, during which the child appears well. The prompt initiation
of treatment and possible admission of young infants (given the risk for
apnea) should occur based on clinical suspicion, whereas confirmatory
nasopharyngeal cultures are sent (this guides prophylaxis of household
contacts). Treatment during the early, often unrecognized catarrhal stage is
required to ameliorate disease, but treatment initiated after paroxysms have
been established is still recommended to limit disease spread. The treatment
of choice is erythromycin, although other macrolides are likely to be
effective. TMP/SMX is also considered an alternative in children older than
2 months of age [43]. The hospital infection control team and the local
public health authorities should be notified of all cases of suspected and
confirmed pertussis and recommendations for the care of exposed people
should be followed carefully.
Neonatal pneumonia
Neonatal pneumonia and neonatal sepsis are very different entities from
community-acquired pneumonia in other children. These neonates typically
present with tachypnea, grunting, and retractions. Nonspecific symptoms
such as irritability and poor feeding also may be seen. They may have fever
or may present with hypothermia. The most common etiologic bacterial
agent is group B streptococci, but Listeria monocytogenes and other bacteria
that cause pneumonia in older infants also can be seen. Gram-negative
enteric bacteria also can cause pneumonia in neonates usually older than
1 week of age, from nosocomial infection [24].

8. 444 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
Diagnosis
Clinical presentation
Pneumonia can have different clinical presentations depending on the
etiology and the patient’s age. In most cases of bacterial community-ac-
quired pneumonia, children have sudden onset of fever, tachypnea, and
cough. This constellation may be preceded by symptoms of a minor upper
respiratory tract infection.
Because neonates may be discharged from the newborn nursery within 24
hours of delivery, the emergency physician may need to identify the neonate
with neonatal pneumonia or neonatal sepsis. These neonates typically present
with tachypnea (respiratory rate greater than 60/min), grunting, and re-
tractions. Nonspecific symptoms such as irritability and poor feeding also
may be seen. Hypothermia rather than fever may be seen in this population.
Infants older than 1 month of age with pneumonia may have similar
symptoms but cough is a more prominent symptom. Unlike newborns,
infants with bacterial pneumonia are more often febrile. Infants with
pneumonia caused by viruses or atypical organisms may be afebrile and have
wheezing respirations. Chlamydia trachomatis is the most common cause of
pneumonia seen in infants 4–11 weeks of age. It is caused by maternal genital
infection and causes a subacute interstitial pneumonia [24]. These infants
also may have conjunctivitis on physical examination [44].
Toddlers and preschool children with pneumonia usually present with
cough. Vomiting, chest pain, and abdominal pain also may be seen.
Sometimes fever and tachypnea may be seen with few other respiratory
symptoms [45]. Older children and adolescents may present with symptoms
similar to younger children and also may have generalized symptoms such
as headache and abdominal pain. In a series of patients with bacteremic
pneumococcal pneumonia, 28% had no respiratory symptoms, 6% pre-
sented with only gastrointestinal symptoms in addition to fever, and 4% had
only fever. Tachypnea was recorded in 19% and crackles in 14% of patients
[45]. Older children and adolescents also may complain of chest pain, which
is often pleuritic in nature and localized [46,47].
Children without the more classic presentation of tachypnea and rales
who appear only mildly ill and lack specific respiratory symptoms also may
have pneumonia [23]. In addition, crackles may not be heard in pneumonia
if the child is uncooperative or crying or if the child is dehydrated. Wheezing
can be heard in the pediatric patient with viral or mycoplasma pneumonia.
In 1997 a Canadian task force reviewed literature and published evidence-
based guidelines for diagnosing pediatric pneumonia. They concluded that
the absence of each of four signs (ie, respiratory distress, tachypnea, crackles,
and decreased breath sounds) accurately excludes pneumonia (level 2
evidence) [48]. When an attempt was made to validate these guidelines in
pediatric patients in an urban emergency department, the guidelines were

9. R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451 445
only 45% sensitive (95% confidence interval (CI) = 35–58 [8]) and 66%
specific (95% CI = 18–34) for diagnosing pneumonia. Positive and negative
predictive values were 25% (95% CI = 18–34) and 82% (95% CI = 77–
87), respectively [49]. Reliable diagnosis of pneumonia is still difficult and
requires careful attention to a patient’s individual clinical characteristics.
Radiologic and laboratory testing
Although chest radiographs cannot be used to reliably discriminate
between bacterial and viral pneumonia [49–51], there are patterns that can
be helpful. Most radiologists support that an alveolar or lobar infiltrate with
air bronchograms is an insensitive but fairly specific indication of bacterial
pneumonia [52,53]. Unilobar infiltrates or round infiltrates may be seen with
pneumococcal pneumonia [45,54]. Pneumatoceles may be present with
severe necrotizing pneumonia, such as that caused by S aureus [54]. Viral
pneumonias usually are characterized by diffuse interstitial infiltrates,
hyperinflation, or atelectasis. Peribronchial thickening or hilar adenopathy
also may be seen [54,55]. Chest radiographs are often normal in pertussis but
perihilar infiltrates of the right middle lobe or lingular region also can be seen
[54]. Chlamydia pneumonia is characterized by diffuse interstitial markings
and hyperinflation [54,56]. Radiographs of patients suffering from a pneu-
monia caused by M pneumoniae may be normal or have characteristics
of viral or bacterial pneumonia as described previously. Pleural effusions
also can be seen with M pneumoniae [54,57], but are more common with
S pneumoniae and S aureus. Pediatric tuberculosis also can have a varied
radiographic appearance. This variation is attributable in part to the time
during disease progression that the radiograph is taken. The most common
findings are mediastinal or hilar adenopathy. Lobar consolidation and
pleural effusions also can be seen. In later stages, the classic findings of
calcification, focal fibrosis, and cavitary lesions in the upper lobes may
be seen, even in children. Miliary tuberculosis is characterized by a diffuse
mottling on chest radiographs [58].
In aspiration syndromes, infiltrates may be seen in the right upper lobes
of infants and in the posterior or bases of the lung in older children [54].
Specific testing such as barium swallow, pH probe, and flexible endoscopic
evaluation of swallowing and sensory testing (FEEST) may be needed for
patients admitted with possible aspiration syndromes [59].
Other tests are also problematic in distinguishing bacterial from non-
bacterial pneumonia. Considering that clinical and epidemiologic factors are
most important in reaching a diagnosis, radiographs and selected blood tests
can solidify the diagnosis in certain instances [60]. C reactive protein may be
elevated in bacterial pneumonia [61,62], and likewise elevated absolute
neutrophil count and elevated white blood cell count are frequently seen
with bacterial pneumonia, especially pneumococcal pneumonia [45,63].

10. 446 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
Blood cultures are rarely positive in pneumonia but may be helpful in the
management of children with suspected pneumococcal pneumonia who do
not respond to initial treatment. Hickey et al reviewed charts of 939 patients
who had a radiologic diagnosis of pneumonia over a 1-year period at
a children’s hospital. A total of 409 patients (44%) had blood cultures sent.
Of those, 11 (2.7%) were positive for a pathogen; 10 grew S pneumoniae [64].
Serologic blood tests are of limited clinical value to the emergency physician
who needs information quickly for decision making. One exception is the
cold agglutinin test that can be performed at the bedside for children over
the age of 3 years with suspected mycoplasma pneumonia. Although there
are false positives with viral disease, the test is positive in 70%–90% of cases
of mycoplasma [65]. Sputum cultures should be obtained for suspected
bacterial pneumonia in preadolescents and adolescents but adequate
specimens are difficult to obtain in younger children. Many tests performed
on nasopharyngeal samples, such as enzyme-linked immunosorbent assays
or direct fluorescent antibody assays, are sensitive and specific for detecting
viral etiologies of lower respiratory disease such as RSV and influenza.
Finally, a positive purified protein derivative (PPD) should be placed and
followup for reading arranged if tuberculosis is suspected.
Pulse oximetry is a useful test for the evaluation of respiratory disorders
and has been demonstrated to be associated with clinical signs of pneumonia
(tachypnea, crepitations) in undeveloped countries [66,67] and in areas of
high altitude [68]. In developed countries measurements of oxygen satu-
ration should be useful to the emergency physician to support the diagnosis
of pneumonia and influence management decisions such as admission or
outpatient treatment.
Treatment
In the ED, the decision to treat a patient for pneumonia is usually based
on epidemiologic, seasonal, clinical, and radiographic findings, with some
laboratory data as an adjunct. The exact etiology, however, is almost always
unknown at the time of initial treatment. Empiric antibiotic treatment
should be based not only on clinical factors, immediate laboratory data,
and radiographic findings, but also on age and epidemiologic factors. For
instance, if certain viruses are detected (usually by rapid antigen detection
techniques) during a season peak for that virus in a mildly ill child, then
withholding antibiotic therapy may be appropriate despite the presence of
a streaky infiltrate on a chest radiograph. It is important to recognize,
however, that there may be infection with bacterial and viral copathogens.
Based on the literature review, Table 1 summarizes the most appropriate
first- and second-line therapies for hospitalized and ambulatory pediatric
patients with presumed community-acquired pneumonia and neonatal
pneumonia.

11. Table 1
Treatment of pediatric pneumonia according to age and etiology
Age 0–4 weeks 4–8 weeks 8–12 weeks 12 weeks–4 years 5 years–adolescence
Etiology Group B strep C trachomatis C trachomatis Viruses (RSV, parainfluenza, M pneumoniae
(in order of Gram (À) enteric Viruses (RSV, Viruses (RSV, parainfluenza) influenza, adenovirus, C pneumoniae
prevalence) bacteria parainfluenza) S pneumoniae rhinovirus) S pneumoniae
L monocytogenes S pneumoniae B pertussis S pneumoniae Viruses (RSV, parainfluenza,
B pertussis H influenza (non-type b) influenza, adenovirus,
Group B strep M catarrhalis rhinovirus)
Gram (À) enteric Group A strep M tuberculosis
L monocytogenes M pneumoniae
M tuberculosis
Treatment For pertussis or For pertussis or Amoxicillin or Macrolides or
Outpatient chlamydia: chlamydia: amoxicillin/clavulanate tetracyclines ([ 8 yrs)
(in order of Erythromycin or Erythromycin or or cefuroxime Fluoroquinolones ([ 16 yrs)
initial choice) other macrolides other macrolides Macrolides
Sulfonomides
For S pneumoniae:
see next column
Treatment Neonatal Neonatal For S pneumoniae: Penicillin or Macrolides
Inpatient pneumonia pneumonia see next column ampicillin or Cefuroxime
or sepsis: or sepsis: cefuroxime plus macrolides
Ceftriaxone or Ceftriaxone or Cefotaxime or ceftriaxone Macrolides plus cefotaxime or
R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
cefotaxime plus cefotaxime plus Clindamycin ceftriaxone or clindamycin
ampicillin ampicillin Vancomycin until Vancomycin
alternative susceptible
agents identified
447

12. 448 R. Lichenstein et al / Emerg Med Clin N Am 21 (2003) 437–451
Treatment also should include oxygen titrated to an oxygen saturation
greater than 95% and albuterol by way of nebulization if wheezing is heard.
Intubation and positive pressure ventilation are required for respiratory
failure and apnea that is seen with RSV pneumonia or pertussis. Intra-
venous fluids should be given to patients with tachypnea and increased work
of breathing or signs of moderate to severe dehydration.
Although many cases of pneumonia can be treated on an ambulatory
basis, admission should be considered for patients with pneumonia who
are not responding to outpatient therapy. Empyema may be the cause of
prolonged or secondary fever despite appropriate therapy in a child with
pneumonia and is an important complication of S aureus, S pneumoniae,
H influenzae, group A Streptococcus, Legionella, M tuberculosis, and other
pathogens [69]. All infants younger than 1 month of age should be admitted
and infants under the age of 6 months or children whose caretaker may be
poorly compliant with therapy also should be seriously considered for
admission. Patients should be admitted to the hospital if there are significant
clinical signs, such as respiratory distress, dehydration, or hypoxia, but an
observation unit in the ED can be used if clinical improvement is expected to
occur rapidly [70]. Children with other chronic diseases such as congenital
heart disease, chronic lung disease, immunodeficiency, or neurologic im-
pairment who present with new onset respiratory disease also should be
candidates for admission. Finally, patients with other complications (eg,
pneumatoceles) or potential complications (paroxysmal phase of pertussis
with apnea) should be admitted for further therapy and observation.
Summary
Respiratory disease is common in pediatrics and diagnosing pneumonia
may be clinically challenging. Changes in pneumococcal resistance and
immunization practices continue to change the incidence and etiologies of
pneumonia. Careful attention to epidemiologic, seasonal, and specific
pediatric clinical factors and using adjunct radiographs and laboratory tests
should guide the emergency physician in his or her management strategy,
including selection of antibiotics and inpatient or outpatient disposition.
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