Pneumonia Pada Anak

Chapter 6
Pneumonia in Children
Irena Wojsyk-Banaszak and Anna Brborowicz
Additional information is available at the end of the chapter
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1. Introduction
Pneumonia causes substantial morbidity in children worldwide and is a leading cause of
death in children in the developing world. The incidence of pneumonia is the highest in
children under 5 years of age and in recent years the incidence of complicated and severe
pneumonia seems to be increasing.
Etiological factors vary with age, source of infection (community vs. hospital acquired pneu
monia) and underlying host defects (e.g immunodeficiency). Viruses are the most common
etiological factors in preschool children, although in many cases more than one causative
agents can be identified. There are several emerging pathogens in community acquired
pneumonia in children: virulent strains of Streptococcus pneumoniae that are not present in
currently available vaccines, Panton-Velentine leucocidin producing Staphylococcus aureus,
human Bocaviruses and metapneumoviruses being the most important.
Diagnosis in most of milder cases of community acquired pneumonia is based on clinical
judgement alone, since laboratory tests and radiologic examination do not provide clues
concerning etiology. Children with severe pneumonia, hospital acquired pneumonia and
immunocompromised children require invasive diagnostic approach.
Treatment of mild and moderate cases consists in supportive care and antibiotic treatment.
First-line recommended therapy in previously healthy children regardless of age is amoxicil
lin, as it provides sufficient coverage against the most common invasive bacterial pathogen,
namely Streptococcus pneumoniae. For hospital acquired pneumonia initial empiric treatment
should be based on local antimicrobial susceptibility patterns, and modified adequately as
soon as the results of microbiological tests are available.
Despite the fact, that if properly diagnosed and treated pneumonia resolves with no residual
changes, in some cases due to pathogen virulence and/or host susceptibility its course might
2013 Wojsyk-Banaszak and Brborowicz; licensee InTech. This is an open access article distributed under
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Respiratory Disease and Infection - A New Insight
be complicated with pleural effusion and empyema, pneumoatocele, lung abscess or necrot
izing pneumonia. A recognized complication of severe pneumonia is hyponatremia and
SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion).
Burden of pneumonia can be diminished using preventive measures ranging from the sim
plest infection control methods like hand washing, limiting exposure to infectious cases, lim
iting exposure to tobacco smoke, vaccinations to passive immunization in selected cases.
2. Definition
Pneumonia is defined as an inflammation of lung tissue due to an infectious agent. Com
monly used clinical World Health Organization operational definition is based solely on
clinical symptoms (cough or difficulties in breathing and tachypnoea) [1]. In the developing
world the term Lower Respiratory Tract Infection (LRTI) is widely used instead of pneumo
nia, because of poor access to x-ray and difficulties in radiological confirmation of diagnosis.
Depending on the place of acquisition pneumonia can be divided into:
a.
Community Acqiured Pneumonia (CAP)
b.
Hospital Acquired Pneumonia (HAP).
Recently a third type - Health Care Associated Pneumonia (HCAP) has been distinguished
in adult patients.
The significance of this classification is based on its clinical utility since in most cases patho
gens responsible for CAP and HAP are different, warranting varying approach and empiric
treatment.
3. Community acquired pneumonia

CAP can be defined as pneumonia in previously healthy children caused by an infectious
agent contracted outside the hospital. The common clinical practice is to confirm the diagno
sis by radiological findings of consolidations.
4. Epidemiology
Globally the incidence of pneumonia in children < 5 years in developing countries is 0.28 ep
isodes per child - year (150 mln/year), compared to 0.05 episodes per child - year in devel
oped countries [2]. Pneumonia is responsible for 18% of death (2 mln/year) in young
children worldwide, mostly occurring in impoverished countries with limited access to
healthcare system. In more affluent societies pneumonia is rarely fatal, it leads however to
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substantial morbidity. Incidence of radiologically confirmed pneumonia in previously

healthy children in Europe is 144-147/100,000 children/year and decreases with age, being
the highest in children <5 years (328-338/100,000/year and 421/100,000/year in those aged 0-2
years) [3,4]. The rates of hospitalization due to pneumonia in this age group were
122/100,00/year in children 16 and 287/100,000/year in those 5 [4]. British studies show
the rate of CAP presenting to General Practitioners in children < 5 to be 191/100, 000 person years [5], probably due to the fact that more severely sick children would present directly to
the hospital. In a German study incidence of hospitalized pneumonia was 300/100,000/year
in children 0-16 and 658/100,000/year in those aged 0-5. In 23% of those cases underlying
conditions were present, and it is possible that many children with bronchiolitis were classi
fied as having pneumonia [6].
Since introduction of conjugate pneumococcal vaccine (PCV7) to national immunization
programs in the USA and Europe the incidence of pneumococcal pneumonia has decreased
(by 65% in the USA) and rates of CAP hospitalizations have decreased for children <1 but
seem to be increasing for children > 5 [7-9]. At the same time the incidence of severe pneu
monia requiring hospital management as well as complicated pneumonia seems to be in
creasing. Between 1997 and 2006, the rate of local complications of CAP increased by 77.8%
(5.4 and 9.6 cases per 100 000 population, respectively). Empyema accounted for >97% of all
local complications [8,9].
5. Etiology
Organisms causing pneumonia are varied and include bacteria, viruses, fungi and protozo
ans. Most cases of pneumonia are preceded by acute viral bronchitis. Viruses facilitate infec
tions with pathogenic microorganisms colonizing nasopharynx. These pathogens include
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Previous colonisa
tion with Streptococcus mitis and anaerobic cocci Peptostreptococcus anaerobius may have pro
tective effect against pathogenic strains.
Etiological factor of pneumonia can be identified in no more than 65-86% patients combin
ing multiple diagnostic tools including culture, serology and PCR [7,11]. In everyday clinical
practice these methods are rarely used and treatment remains empiric based on national and
international guidelines.
Viruses are responsible for 30-67% cases of CAP, and are the most common in children <2.
The most frequently identified are respiratory syncytial virus (RSV) isolated in 13-29% and
rhinovirus (3-45%) either in combination with bacteria or alone. Other viruses responsible
for pneumonia comprise adenovirus (1-13%), influenza (4-22%) and parainfluenza virus
(3-10%), rhinovirus (3-45%), human metapneumovirus (5-12%), human bocaviruses (5-15%).
The less common are enterovirus, varicella-, herpes- and cytomegalovirus [7,11-13]. In older
children bacterial infections are more frequent: Streptococcus pneumoniae being the leader
(30-44% of CAP) followed by Mycoplasma pneumoniae (22-36%) and Chlamydophila pneumoniae
(5-27%) [7,11,13-16]. Streptococcus pneumoniae remains the leading cause of severe pneumo
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nia requiring hospitalization even in countries with reduced rates of invasive pneumococcal
disease [17]. Since introduction of PCV7 the most common pneumococcal isolates are 1 (pre
dominantly responsible for empyema), 19A, 3, 6A and 7F (all included in 13-valent vaccine)
[18]. Contrary to previous reports Mycoplasma pneumoniae seems to be equally frequent in
school and preschool children [11,13]. Less common bacterial causes of CAP in children in
clude Haemophilus influenzae type B (5-9%), Staphylococcus aureus, Moraxella catarrhalis
(1.5-4%), Bordatella pertussis, Streptococcus pyogenes (1-7%), Chlamydia trachomatis and a new
pathogen identified in the 1990ies Simkania negevensis [7,12]. Unlike in adults Legionella
pneumophila is a rare cause of CAP in children [19].
In malariaendemic regions of tropical Africa a challenging etiological factor of pneumonia
is multidrugresistant non typhoidal Salmonella, and in regions where tuberculosis is en
demic it is increasingly being recognized as a cause of acute pneumonia [20].
8-40% of cases represent a mixed viral - bacterial or bacterial - bacterial infection
[3,4,7,12,16,19]. Primary viral infection predisposes to bacterial pneumonia: influenza epi
demics in developed countries coincide with epidemics of Streptococcus pneumoniae and
Staphylococcus aureus pneumonias and measles or RSV infections contribute to increased
pneumonia mortality in developing countries [2].
6. Risk factors for cap

There are several known risk factors for CAP to consider in addition to immunization
status, epidemiological data and exposure to other children, especially preschoolers. Un
derlying comorbidities like diabetes mellitus, asplenia or splenic dysfunction, chronic car
diac disease, nephrotic syndrome, severe liver disease are risk factors for invasive
pneumococcal disease including pneumonia. Other risk factors for CAP include: asthma,
history of wheezing episodes, otitis media treated by tympanocentesis in the first 2 years
of life (risk factor for children <5), tobacco smoke exposure, malnutrition, immunological
deficits (primary or secondary), mucocilliary dysfunction (cystic fibrosis, cilliary dyskine
sia), congenital malformation of airways, impaired swallowing, microaspiration, gastroe
sophageal reflux, neuromuscular disorders, treatment with gastric acid inhibitors (risk
factor in adults, in children its role was confirmed in one study). Environmental factors
like indoor air pollution caused by cooking and heating with biomass fuels (like wood
or dung), living in crowded conditions and parental smoking also increase a child's sus
ceptibility to pneumonia [1,7]. Tobacco smoke exposure has been found to increase risk
of hospitalization for pneumonia in children < 5 [21]. Conditions predisposing to severe
pneumonia include age <5 and prematurity (24-28 GA) [11]. Viral infections, especially
influenza and prior antibiotic exposure additionally predispose to pneumococcal and
staphylococcal pneumonia. Antibiotics alter bacterial microflora in the airways destroy
ing commensal bacteria like alfa-hemolytic Streptococci while viruses release neuramini
dase and other enzymes promoting adherence and expression of pneumococcal receptors
on host cells like platelet activating factor receptor or CD14 [17,22].
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7. Clinical manifestations
Typical clinical symptoms of pneumonia consist of:
cough (30% of children presenting to outpatient clinic with cough, after excluding those
with wheeze, have radiographic signs of pneumonia, and cough was reported in 76% of
children with CAP) [13,23]. It should be noted that sputum production in preschool chil
dren is rare, because they tend to swallow it.
fever (present in 88-96% of children with radiologically confirmed pneumonia) [13]
toxic appearance
signs of respiratory distress: tachypnoe (table 1), history of breathlessness or difficulty in
breathing chest retractions, nasal flaring, grunting, use of accessory muscles of respira
tion. Tachypnoe is a very sensitive marker of pneumonia. 50-80% of children with WHO
defined tachypnoe had radiological signs of pneumonia, and the absence of tachypnoe is
the best single finding for ruling out the disease [13,23]. In children <5 tachypnoe had sen
sitivity of 74% and specificity of 67% for radiologically confirmed pneumonia, but its clin
ical value was lower in the first 3 days of illness. In infants < 12 months respiratory rate of
70 breaths/min had a sensitivity of 63% and specificity of 89% for hypoxemia [7].
Age
Respiratory rate/minute
0-2 months
"/>60
2-12 months
"/>50
1-4 years
"/>40
5 years
"/>30
Table 1. Tachypnoe defined according to WHO criteria [1]
chest pain,
abdominal pain (referred pain from the diaphragmatic pleura might be the first sign of
pneumonia in little children) and/or vomiting
headache
Based on clinical symptoms pneumonia can be divided into severe pneumonia that warrants
hospitalization and mild, moderate or non-severe. Signs of severe pneumonia differ with
age and according to BTS comprise of: temperature 38,5 0C, respiratory rate > 70 breaths/
minute in infants and > 50 breaths/minute in older children, moderate to severe recessions in
infants and severe difficulty in breathing in older children, nasal flaring, cyanosis, intermit
tent apnoea, grunting, not feeding in infants and signs of dehydration in older children, ta
chycardia, capillary refill time 2s [7]. Agitation may be the sign of hypoxemia. Table 2
presents a simplified approach recommended by WHO to be implemented in developing
world to help field healthcare workers assess the need for hospital referral.
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Physical examination:
crackles (present in 33-90% of children with pneumonia), diminished breath sounds over
affected site, bronchial breath sounds specific for lobar consolidation, absent breath
sounds and dullness to percussion suggestive of effusion. A pleural rub may be heard if
pneumonia is accompanied by pleuritis. Crackles and bronchial breath sounds have sensi
tivity of 75% and specificity of 57% in pneumonia diagnosis [7].
presence of wheeze, especially in the absence of fever, makes the diagnosis of typical bac
terial pneumonia unlikely [24]. It is however a common sign in viral and Mycoplasma
pneumonia (up to 30%) infection [7].
combining several clinical symptoms into diagnostic algorithm improves sensitivity and
specificity of diagnosis. WHO criteria for defining pneumonia (cough or difficulties in
breathing and tachypnoea) investigated in a Brasilian study of 390 children have sensitivi
ty of 94% for children <2, and 62% for children 2 and specificities of 20% and 16% respec
tively. Adding fever improved specificity to 44% and 50% [25]. In an Australian study of
febrile children < 5 presenting to tertiary emergency department, clinical indicators of
pneumonia confirmed radiologically and microbiologically comprised an unwell appear
ance, fever 39 0 C, breathing difficulties, chronic disease, prolonged capillary refill time,
tachypnoe, crackles on auscultation and lack of antipneumococcal vaccination [26].
It is important to note that no clinical or radiological sign either alone or in combination, is
sensitive and specific enough to differentiate between viral, atypical or typical bacterial eti
ology of pneumonia.
Pneumonia/non severe pneumonia
Cough
Problems with breathing
Tachypnoe *
No signs of severe pneumonia present
Severe pneumonia
Signs of pneumonia & 1

- lower chest wall indrawing
- nasal flaming
- expiratory grunting
- no signs of very severe pneumonia
Very severe pneumonia
Signs of severe pneumonia & 1

- inability to feed
- cyanosis
- severe respiratory distress
- impaired consciousness or convulsions
*Look table 1
Table 2. Severity of pneumonia WHO classification [2,27]
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8. Additional tests
1.
Pulsoximetry should be performed in all children with pneumonia since its results facil
itate assessment of severity and therefore the need for hospital referral. Pulsoximetry
should be definitely performed in all children admitted to hospital [7].
2.
Laboratory studies
3.
Determination of etiology microbiological investigations
Determining the specific pathogen in children with CAP is difficult. Little children do not
expectorate sputum, nasopharyngeal swabs are not reliable since bacteria present in the up
per airways are not necessarily the same as those causing pneumonia. Invasive diagnostic
tools, though efficacious are hardly acceptable in otherwise healthy children most of whom
improve with empiric treatment. British Thoracic Society (BTS) standards, Pediatric Infec
tious Diseases Society guidelines as well as American Academy of Pediatrics Policy state
ments do not recommend microbiological investigation of the child with pneumonia treated
as an outpatient. For patients admitted to the hospital, especially those admitted to ICU and
those with complications of CAP, microbiological diagnosis should be attempted.
blood cultures are positive in <10% of patients with pneumonia and < 2% of patients treat
ed in the outpatient setting. They should nevertheless be performed since if positive, they
provide information on CAP etiology and antibiotic resistance [7,19]. In children with
complicated pneumonia prevalence of bacteremia vary from 7.8% to 26.5% in pneumonia
with parapneumonic effusion [19].
nasopharyngeal aspirates or nasal lavage samples may be helpful in identifying respirato
ry viruses including respiratory syncytial virus, parainfluenza virus, influenza virus and
adenovirus by immunofluorescence method. The results of these tests are particularly
useful for cohorting infected children during outbreaks and for epidemic purposes [7].
sputum is difficult to obtain in small children. A reliable sputum sample, as opposed to
saliva, contains <10 epithelial cells per low-powered field [35]. Sputum induced by inhala
tion with 5% hypertonic saline has much higher bacterial yield and seems to be a valuable
tool in microbiological diagnosis in children with CAP [36].
children who require mechanical ventilation should have tracheal aspirates taken for
Gram stain and culture at the time of endotracheal tube placement [19].
aspirated pleural fluid should be sent for microscopy, culture and antigen detection. Cul
tures are positive in 9% - 18% of cases (sensitivity 23%, specificity 100%) [7, 37]. Pneumo
coccal antigen detection in pleural fluid has sensitivity of 90% and specificity of 95% [38].
Pleural fluid should be checked for Mycobacteria.
pneumococcal antigens detection in urine is not specific, as it is often positive in young
children with nasopharyngeal colonization
Serological testing: fourfold rise in antibody titers in complement fixation test is a golden
diagnostics standard, unfortunately not useful for treatment guidance. In many laborato
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ries enzyme linked immunosorbent assays (ELISA) has replaced complement fixation
tests as less time consuming. Positive anti Mycoplasma IgM antibody titer 9-11 days from
the onset of illness is also suggestive of recent infection. Cross reactions with adenovirus
and Legionella pneumophila have been described [23]. Cold agglutinins measurement value
is limited in school children the positive predictive value for Mycoplasma of a rapid cold
agglutinin test was 70% [7]. In Chlamydophila pneumoniae infection IgM rise is observed af
ter 3 weeks and IgG rise after 6-8 weeks.
Legionella pneumophila urinary antigen detection remains golden standard for the diagno
sis of legionellosis. The test remains positive for weeks after acute infection. Urinary anti
gen is positive only in case of infection with serogroup 1. Antigens are excreted in urine at
the beginning of the second week of illness. Quick diagnostic tests are commercially avail
able with sensitivity of 80% and specificity of 99-100%. Infection with serogroup 1 can be
excluded when the results of 3 consecutive urine samples are negative.
real time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) can be used for in
vestigating the etiology of pneumonia. The advantage of this method is the availability of
results on the same day. It does not however provide information on bacterial sensitivity
nor is readily available outside research settings. Pneumolysin based PCR has been in
creasingly used to detect Streptococcus pneumoniae in blood and pleural fluid with sensitiv
ity of 100% and specificity of 95% [7]. Measuring bacterial load with RT-PCR may help
predict the outcome of CAP as adult patients with bacterial load > 1000 copies/mL were at
higher risk for sepsis, respiratory insufficiency and death [39].
4.
Chest radiography
Figure 1. Alveolar consolidations in the left lower lobe and in the right lower lobe. Mycoplasma pneumoniae pneumonia
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Figure 2. Round focus of consolidation in the left upper lobe. Pneumonia.
9. Management
Most children with CAP can be safely managed on outpatient basis. Indications for hospital
referral comprise:
clinical signs of severe pneumonia (listed above),
signs of sepsis or septic shock
young age < 6 months of life
hypoxemia oxygen saturation < 92% (according to BTS) or <90% (according to AAP and
PIDS), PaO2 <60 mmHg and PaCO2 >50 mmHg, central cyanosis
underlying conditions eg. congenital heart defect, cystic fibrosis, bronchopulmonary dys
plasia, immune deficiencies
diffuse radiological changes: multilobar pneumonia, pleural effusion
outpatient treatment failure
CAP caused by pathogen with increased virulence eg. MRSA(PIDS)
parents inability to manage the illness at home
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Children who are not improving despite treatment and present with impeding respirato
ry failure or shock should be admitted to Intensive Care Unit. Criteria for ICU admis
sion comprise:
need for invasive mechanical ventilation or non-invasive positive pressure ventilation,
fluid refractory shock
hypoxemia requiring FiO2 greater than inspired concentration or flow feasible in general
care area; pulsoximetry measurements 92% with inspired oxygen of 0.5 (according to
BTS) or 0.6 (according to PIDS)
altered mental status due to hypercarbia, hypoxemia or as a result of pneumonia
recurrent apnea, grunting or slow irregular breathing
rising respiratory rate and heart rate with clinical evidence of severe respiratory distress
and exhaustion with or without hypercarbia [7,19]
10. General management

All children treated for pneumonia should be reassessed in 48 hours if there is no clinical
improvement or deterioration and persistence of fever. It is important that parents of chil
dren treated at home have clear written instructions on fever management, preventing de
hydration, recognizing signs of deterioration as well as further access to healthcare
professionals [7].
Hospitalized hypoxemic children should be given oxygen to maintain oxygen saturation >
92%. Dehydrated children should be provided adequate amount of oral fluids and if unable
to drink should receive intravenous fluids. Their electrolytes and creatinine serum levels
should be measured on daily basis. Up to date there have been no studies proving beneficial
effects of chest physiotherapy in children with pneumonia and therefore chest physiothera
py should not be performed.
A child should improve as evaluated by clinical symptoms and laboratory inflammatory
markers in 48-72 hours after initiation of adequate treatment. Failure to improve war
rants further investigation for possible complications, resistant microorganisms or alter
native diagnosis.
11. Antibiotic treatment

There is no consensus between experts whether all children with CAP should receive antibi
otics. According to BTS guidelines issued in 2011 all children diagnosed with pneumonia
should be treated with antibiotics. This is in contrast to previous guidelines stating that if
viral etiology is suspected antibiotics might be withheld provided that the child is reas
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sessed in 24-48 hours. The reason for this change, despite the obvious concerns of increasing
antibiotic resistance among bacteria as well as possible adverse reactions in children unnec
essarily treated with antibiotics, is the fact that based on clinical, laboratory and radiological
markers, either alone or in combination, a reliable distinction between viral and bacterial in
fection is impossible. Children <2 especially with a history of conjugate pneumococcal vacci
nation and with mild symptoms of lower respiratory tract infection are unlikely to have
pneumonia. In these children antibiotics might be withheld provided reassessment of the
child is made if the symptoms persist or deterioration occurs [7]. PIDS guidelines, on the
contrary, state that preschool children with CAP do not routinely require antibiotic therapy
since pneumonia in this age group is predominantly of viral origin [19].
Antibiotic of choice for CAP treated in community is amoxicillin 90 mg/kg/day applied
in two doses for 5-10 days. Results from two randomized trials on short course (3 days)
oral antibiotics performed on infants in developing countries are difficult to interpret
since many of these children had bronchiolitis with wheeze or upper respiratory tract in
fection and did not need antibiotics at all [43,44]. Amoxicillin is effective against the ma
jority pathogens responsible for CAP in children. It is well tolerated and affordable.
Alternatives are co-amoxiclav, cefaclor and macrolides. For Streptococcus pneumoniae re
sistant to penicillin with MICs up to 4.0 g/mL preferred treatment consists in ceftriax
one, and for MICs >4.0 g/mL in vancomycin, linezolid or clindamycin though resistance
to clindamycin seems to be increasing amounting to 15-40% in certain geographic re
gions [19]. It should be noted that interpretation of in vitro susceptibility tests to penicil
lin depends on the route of administration. Intravenously administered penicillin can
achieve tissue concentrations effective against organisms with minimal inhibitory concen
tration (MICs) 2.0 g/mL, possibly effective for strains with MICS of 4 g/mL and not
likely to be effective for strains with MICS 8 g/mL. For orally administered penicillin
corresponding values are <0.06 g/mL, 0.12 1.0 g/mL, and 2.0 g/mL for resistant
strains [19]. Clinical laboratory standards vary depending on the region. Those given
above, were issued jointly by Infectious Diseases Society of America (IDSA) and Ameri
can Thoracic Society (ATS). BTS recommends cut off values for intravenously adminis
tered penicillin of <0.1 mg/L; 0.1-1.0 mg/L and > 1.0-4.0 mg/L and European Respiratory
Society (ERS) recommends MIC breakpoints <0.5 mg/L; 0.5 2.0 mg/L and >2.0 mg/L re
spectively [17,19]. PIDS recommends levofloxacin for children from 6 months of age as
preferred choice for oral therapy [19]. Macrolide antibiotics may be added if Mycoplasma
pneumoniae or Chlamydophila pneumonia are suspected when the child is not improving af
ter 24 - 48 hours or in very severe cases. They are not recommended as first choice anti
biotics because up to 40% of currently isolated in USA strains of S. pneumoniae are
resistant to macrolides [19].
As is the case with indications for antibiotics in CAP there is no consensus as to how they
should be administered. According to BTS guidelines if the child is feeding well and not
vomiting, antibiotics should be given orally. Children with moderate pneumonia admitted
because of respiratory distress can be treated with oral antibiotics and discharged when fe
ver and respiratory distress subside [7,45]. Intravenous route of antibiotic administration is
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reserved for children with severe, complicated pneumonia or sepsis for whom intravenous
amoxicillin, co-amoxiclav, cefuroxime, cefotaxime or ceftriaxone are recommended. Accord
ing to PIDS guidelines however all children treated in hospital should receive antibiotics in
travenously to provide reliable blood and tissue concentrations [19]. In hospitalized children
suspected of S. aureus infection vancomycin or clindamycin should be added to beta-lactam
therapy. For children with penicillin allergy recommended drugs are cephalosporins and in
case of type-I allergic reactions macrolides, vancomycin or clindamycin are suggested. In
children who do not tolerate vancomycin or clindamycin, linezolid may be administered
[19]. Antibiotic should be changed according to results of culture and sensitivity if these
tests are positive. As soon as the childs condition improves, a switch to oral antibiotics
should be considered [7].
12. Complications
12.1. Empyema and parapneumonic effusion
Parapneumonic effusion is defined as pleural fluid collection in association with underlying
pneumonia and empyema is defined as the accumulation of purulent fluid in the pleural
cavity [46]. Incidence of parapneumonic effusion is increasing (by 70-100% between 1990s
and the beginning of the present century), affecting 0.6% of all children with CAP, 2 - 10% of
pneumonia hospitalizations and 1/3 of pneumococcal pneumonia hospitalizations [47-50].
Predominant etiological factors are S. pneumonia (serotype 1,3,14,19A) responsible for
10-66% of empyema cases, S. aureus including MRSA (4-30%) and S. pyogenes. The less com
mon include Haemophilus influenzae, Mycobacterium spp, Pseudomonas aeruginosa, anaerobes,
Mycoplasma pneumonia and fungi [28,46,47,51,52]. Fluid collection is usually unilateral. Em
pyema classically exhibits three stages:
Exudative pleural space contains free flowing fluid with a low white cell count, so
called parapneumonic effusion that results from increased vascular permeability and mi
gration of neutrophils, lymphocytes and eosinophils in the course of inflammatory proc
ess.
Fibrinopurulent occurs 5-10 days from the onset of the disease and consists in the deposi
tion of fibrin in the pleural space that leads to septation and formation of loculations. The
number of white cells increases (empyema) in response to bacterial invasion across the
damaged epithelium and if left untreated it progresses into
Organizing - includes infiltration of fibroblasts and evolution of thick elastic membrane in
the pleural cavity (the peel). These membranes may impair lung function and prevent
lung re-expansion. Empyema at this stage may heal spontaneously or a chronic empyema
may develop [46].
Some authors distinguish pleuritis sicca stage that precedes exudative stage, not necessa
rily leading to it [53].
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Empyema should be suspected in every child with pneumonia with a history of prolonged
fever, tachypnoe, pain on abdominal palpation, pleuritic chest pain, splinting of the affected
side and persistence of high serum C-reactive protein levels [50]. On physical examination
asymmetry of breath sounds, unilateral decreased chest wall expansion, dullness to percus
sion might be appreciated [27]. In some children with pneumonia empyema may develop
during intravenous antibiotic treatment [50]. One of the identified risk factors for bacterial
empyema is precedent varicella [49].
Chest radiographs show homogenous opacity over the entire lung (large effusion) (Figure
3). In smaller effusions an ascending rim of fluid along the lateral chest wall (meniscus sign)
occurs. Costophrenical angle obliteration is the first sign of pleural effusion. Based on radio
graph it is not possible to distinguish effusion from empyema [47]. A method of choice for
radiologic evaluation of patients with parapneumonic effusion and empyema is ultrasonog
raphy. It helps estimate the amount of fluid, its echogenicity, detects loculations and fibrin
strands and is used to guide invasive procedures [28]. Chest CT should not be routinely per
formed, it may be useful however for diagnosis of underlying pathology eg. tumor in the
mediastinum or lung abscess [46,53].
Figure 3. Opacification of left hemithorax with mediastinal shift to the opposite side. Alveolar consolidations in the
central field of the right lobe. Lobar pneumonia with pleural effusion caused by Streptococcus pneumoniae
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Figure 4. Multiple abscesses in the right upper lobe. Diffuse alveolar consolidations with thickening of intraalveolar
spaces in the middle and lower right lobes. Fluid in the right pleural space. Staphylococcus aureus pneumonia with
lung abscesses and pleural effusion.
Pleural fluid, if obtained during thoracocentesis or video-assisted thoracoscopic surgery

(VATS), should be sent for culture, Gram stain, cytology and molecular techniques if availa
ble. Bacteriological investigations should always be undertaken even though they are posi
tive in of cases since they may provide useful information guiding antibiotic therapy.
Stain for acid-fast bacilli, culture and PCR should also be performed [46]. In most cases of
bacterial empyema polymorphonuclear leukocytes are the predominant cells. In case of ma
lignancy the fluid may be blood stained with lymphocytic predominance, although malig
nant cells may not be present. In tuberculosis there is also predominance of lymphocytes in
pleural fluid although in 10% of cases effusion might be neutrophilic [46]. Light criteria, use
ful for treatment guidance in adult patients, have not been properly validated in children
and their routine use is not recommended [46,53].
All children with empyema or pleural effusion should be treated as inpatients [46]. There is
no consensus however as to what is optimal treatment of empyema: antibiotics alone for
small to moderate effusions, chest tube insertion with or without fibrinolytics or VATS for
moderate to severe cases. Differences in management result to some extent from personal
experience and availability of different treatment modalities, including experienced inter
ventional radiologists and pediatric thoracic surgeons. Generally, two most important fac
tors determining the need for chest tube insertion are the size of effusion and the childs
degree of respiratory compromise [19]. There is agreement that due to an invasive nature of
the procedure and the need for general anesthesia in younger children, a drain should be
inserted instead of repeated needle thoracocenteses [46]. According to PIDS, pleural effu
sions can be divided depending on their size into:
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Small: < 10 mm on lateral decubitus radiograph or opacifies < hemithorax

Moderate: >10 mm rim of fluid and opacifies < hemithorax
Large: opacifies > hemithorax
Conservative treatment with antibiotics is recommended for small effusions. Antibiotic se
lection is based on blood or pleural fluid culture results, and if these are not available, on
treatment guidelines. Many patients improve with conservative treatment alone. In an
American study over 50% of all patients with moderate to severe effusions recovered with
antibiotic treatment alone [54]. Management of moderate effusions depends on childs de
gree of respiratory compromise: if clinical condition is good, treatment with antibiotics is ap
propriate and if the child presents signs of respiratory distress, treatment is the same as for
large effusions: fluid should be removed either by tube thoracocentesis (for not loculated
fluid) or chest tube with fibrinolytics or VATS (both for loculated fluid) [19]. Once the chest
tube is inserted, no more than 10 ml/kg of fluid in little children and 1.5 liters of fluid in old
er children and adolescents should be removed in order to avoid re-expansion pulmonary
edema. When this volume is reached, the drain should be clamped for an hour [46]. There is
no clear evidence on advantage in clinical outcome of children treated with fibrinolytic
agents versus VATS [55,56]. The recommended doses for fibrinolytic agents are [19,57,58]:
Urokinase (not available in USA) 10,000 U every 12 hours for 3 days in children < 1 year
and 40,000 U every 12 hours for 3 days in children > 1 year
Streptokinase 12,000 - 25,000 IU/kg/dose daily for 3-5 days
Tissue plasminogen activator 0.1 mg/kg; maximum of 3 mg three times a day for 3 to 4
days or 4 mg every 24 hours
With streptokinase and urokinase there is risk of hypersensitivity reactions.
Children who fail to improve despite antibiotics, drainage and fibrinolytics, should undergo
VATS in order to debride fibrinous adhesions and remove dense loculated fluid. It seems
prudent to ask for surgical opinion if the patient is not improving after 7 days of treatment.
Another indication for surgery is bronchopleural fistula with pyopneumothorax [46]. As an
alternative to VATS, especially in organized empyema in a child with non-resolving signs of
systemic infection with fever, formal thoracotomy with decortications should be considered
[19]. According to BTS guidelines indications for surgery referral are clinical signs and
symptoms and not aberrant radiologic picture in an asymptomatic child [46]. Risk factors for
the failure of tube thoracostomy include duration of symptoms > 7 days before the proce
dure, complex multiloculated empyema, pneumatocele, pulmonary necrosis and an under
lying medical condition [59,60]. A chest tube can be removed if fluid output is < 1 ml/kg/day
calculated over the last 12 hours or 50-60 ml/day and there is no air leak [19].
A more aggressive approach is to perform VATS in the first 48 hours of treatment. That
gives a chance for bacteriological diagnosis and shorter hospital stay, though not all studies
confirm the latter observation [54].
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The optimal duration of antibiotic treatment for parapneumonic effusion and empyema de
pends on clinical response. Recommended route of administration is intravenous until the
chest tube is removed, and then can be switched to oral route for 1 to 4 weeks or longer if
the child has not fully recovered. However, there are no randomized clinical trials to sup
port this approach [19,46]. Long-term outcome in children is favorable. Radiological evi
dence of pleural disease completely resolves within 3 months in up to 80% of children and
by 18 months in all children. Lung function tests results as well as exercise tolerance in most
patients are normal 12 months after discharge [46,52,53]. Conditions predisposing to severe
pneumonia with pleural effusion and empyema include immunodeficiencies and cystic fib
rosis and they should be excluded during follow-up period [46].
12.2. Lung abscess
Lung abscess is a thick-walled cavity containing necrotic tissue 2 cm or greater in diame
ter caused by an infection [28]. It may be either primary occurring in healthy children
without lung abnormalities or secondary occurring in children with underlying condi
tion predisposing to lung disease. The most important mechanism of lung abscess forma
tion is aspiration, especially in children with neuromuscular disorders. Other risk factors
include immunodeficiencies, underlying lung disease like congenital malformations, cyst
ic fibrosis, swallowing problems, eg. achalasia, poor dental hygiene. Abscesses may also
ensue by hematogenous spread from septicemia or right-sided bacterial endocarditis, ex
tension from foci in abdominal cavity or retropharyngeal space or from airway obstruc
tion by foreign body [61,62].
The main causative organisms are usually streptococci, anaerobic bacteria, S. aureus and
Klebsiella pneumonia, however there are rare reports of other causative organisms including
Mycoplasma pneumoniae [63]. Mixed infections are common. The most frequent sites for lung
abscess formation in recumbent position are: the right upper lobe, the left lower lobe and the
apical segments of both lower lobes. When the patient aspirates in supine position the poste
rior segments of the upper lobes are usually involved.
Clinical symptoms include cough, purulent sputum production, fever, dyspnea, chest pain,
tachypnoe, weight loss, hemoptysis, malaise/lethargy. Physical signs do not differ from un
complicated pneumonia, decreased breath sounds and dull note on percussion may be ap
preciated. Symptoms may persist for several weeks [61].
Diagnosis is usually made by chest radiograph showing an inflammatory infiltrate of the
pulmonary parenchyma with a cavity containing an air-fluid level. Initially it may appear as
a solid lesion surrounded by an alveolar infiltrate. Bulging fissure representing increased
volume of the affected lobe may be present. CT is usually performed to exclude other com
plications like empyema, pneumatocoele, underlying congenital abnormality like sequestra
tion, bronchogenic cyst or adenomatoid malformation. Features distinguishing abscess from
other entities include well-marginated walls, density greater than water, contrast enhance
ment in adjacent tissues (Figure 4, Figure 5) [61].
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Figure 5. Infiltrate with air-fluid level in the upper field of the right lobe. Lung abscess.
The mainstay of treatment is conservative antibiotic therapy with spectrum covering S.

pneumoniae, S. aureus and Gram-negative bacilli and anaerobes in case of secondary abscess.
For immunocompromised patients antibiotics should cover fungal pathogens. Antibiotic of
choice is penicillin with clindamycin or metronidazole. Other experts recommend third-gen
eration cephalosporin and flucloxacillin, ticarcillin, ampicillin/clavulanic acid and piperacil
lin/tazobactam. One should consider the possibility of MRSA infection, especially if the
abscess complicates pneumonia or results from hematogenous spread from other organs
[61,62]. A 2-3 week course of intravenous therapy followed by oral treatment for 4 to 8
weeks is usually recommended [28]. In experienced interventional radiology centers CTguided aspiration of the lung abscess and placement of pigtail catheter is performed for di
agnostic and therapeutic reasons. Surgical intervention is indicated for abscesses failing to
improve despite medical treatment.
The overall outcome is favorable, mortality being much lower than in adults: <5% and most
ly occurring in children with secondary lung abscesses or underlying medical problems. The
complications include empyema or pyopneumothorax if abscess ruptures into pleural cavi
ty, bronchopleural fistula if connection between the abscess cavity and pleural space persists
and localized bronchiectasis.
12.3. Necrotising pneumonia
Necrotizing pneumonia (NP), defined as multiple cavitary lesions in consolidated areas, is a
rare, though increasingly detected complication in children. It is characterized by liquefac
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tion and cavitation of pulmonary tissue [63]. The most frequently associated pathogen is
Streptococcus pneumoniae, especially serotypes 3 and 14. Other pathogens involved include
group A Streptococci, Staphylococcus aureus and Mycoplasma pneumoniae [64-68]. The majority
of patients have no prior medical history. Necrotizing pneumonia should be suspected in
patients with complicated pneumonia who do not improve despite optimal medical treat
ment. Diagnosis can be established by computed tomography. Radiographic criteria for ne
crotizing pneumonia include the loss of normal pulmonary parenchymal architecture and
the presence of areas of liquefaction replaced within 1-2 days by multiple small cavities [64].
Necrotizing pneumonia often coexists with pleural effusion.
Treatment consists in prolonged course of intravenous antibiotics active against CAP patho
gens including resistant strains of S. pneumoniae. Interventional procedures are contraindi
cated in children with NP, as they may increase the risk of complications such as
bronchopleural fistula formation [35]. Generally, despite prolonged hospital course and as
sociated morbidity, the long term outcome in most children is favorable. Mortality rates are
5.5-7% [28,65].
13. Prevention
In order to prevent pneumonia several measures can be taken, starting with general recom
mendations like improving nourishment, housing conditions, heating systems, reducing to
bacco smoke exposure, promoting breast-feeding for the first 6 months of age, to more
specific infection control measures like hand-washing, avoiding individuals with signs of
respiratory tract infections, and vaccinations. For prevention of pneumonia immunization
against the following microorganisms is recommended:
influenza virus
Streptococcus pneumoniae (conjugate and non-conjugate vaccine)
Haemophilus influenzae (conjugate vaccine)
measles virus
varicella virus
Bordatella pertussiss
Mycobacterium tuberculosis
High risk infants: prematurely born (<35 week of GA), with hemodynamically significant
congenital heart disease, bronchopulmonary dysplasia, congenital abnormalities of the air
ways and neuromuscular diseases should receive immune prophylaxis with RSV specific
monoclonal antibody (palivizumab) in RSV season [68].
AAP recommends the routine use of 13-valent pneumococcal conjugate vaccine (PCV13) for
healthy children 2 through 59 months of age and for children 60 through 71 months of age
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with an underlying medical condition that increases the risk of invasive pneumococcal dis
ease (IPD) [69]. Underlying medical conditions that indicate the need for pneumococcal im
munization comprise:
chronic heart disease, in particular cyanotic congenital heart disease and cardiac failure
chronic lung disease including asthma if treated with prolonged high-dose oral corticoste
roids
diabetes mellitus
cerebrospinal fluid leaks
cochlear implant
functional or anatomical asplenia including children with sickle cell disease and other he
moglobinopathies
immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syn
drome, diseases associated with treatment with immunosuppressive drugs or radiation
therapy (including malignant neoplasms, leukemias, lymphomas, Hodgkin disease, solid
organ transplantation) and congenital immunodeficiency (including B- (humoral) or Tlymphocyte deficiency; complement deficiencies, particularly C1, C2, C3 and C4 and
phagocytic disorders excluding chronic granulomatous disease).
Healthy children <5 and children with underlying medical conditions <6, who are fully
immunized with PCV7 should receive a single supplemental dose of PCV13. Children
between 6 and 18 with medical conditions favoring IPD (listed above) should receive a
single dose of PCV13 regardless of whether they have previously received PCV7 or
PPSV23 (2 doses of PPSV23 recommended). PCV13 which in addition to the 7 serotypes
included in PCV7 (4,6B,9V,14,18C,19F,23F) contains the 6 pneumococcal serotypes
(1,3,5,6A,7F,19A) responsible for 63% of cases of invasive pneumococcal disease occur
ring in children <5 in the USA has been licensed by the US Food and Drug Administra
tion in 2010 for use in children between 2 and 71 months of age. Because of the
expended coverage provided it is meant to replace PCV7 [69].
14. Specific bacterial causes of pneumonia

14.1. Streptococcus pneumoniae
Streptococcus pneumoniae is the most common pathogen in CAP in children and the most
common cause of pneumonia mortality in children worldwide. It is responsible for at least
1.2 million deaths in infants annually, mostly in sub-Saharan Africa and Asia [45]. There are
92 known pneumococcal serotypes that differ by polysaccharide capsule. It was found that
serotypes are correlated with different pneumonia outcomes, study results are not however
equivocal. In pediatric patients serotypes 7F, 23F and 3 were correlated with the highest risk
of death in the course of invasive pneumococcal disease [70]. In another study serotypes
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1,6,14,19 were the most prevalent among children with complicated pneumonia, with sero
type 1 causing 24.4% of the complicated cases versus 3.6% of the uncomplicated cases [71].
S. pneumoniae commonly colonizes epithelium of nasopharynx in 20 - 40% of healthy chil
dren and > 60% of infants and children in day-care settings. After colonization a new strain
eliminates other competing pneumococcal serotypes and persists for months in a carrier
state. Bacteria with so called persistent colonization phenotype, with low risk of tissue in
vasion are responsible for perpetual transmission within human populations and induce ac
quired B-cell mediated immunity to reinfection. To facilitate their stay within nasopharynx
and evade host defenses they use different mechanisms like surface adhesions, IgA1 pro
tease and inhibitors of antibacterial peptides. Defects in host defense mechanisms can de
stroy the balance and lead to infection in immunocompromised host. Another phenotype
so called invasive pneumococcal disease phenotype is able to spread efficiently from per
son to person by coughing and rapidly induce the disease. Its main virulence factor is poly
saccharide capsule that prevents mechanical clearance by mucous secretions, restricts
autolysis, reduces exposure to antibiotics and facilitates invasion and dissemination. Other
virulence factors include: pore-forming cytotoxin pneumolysin that among other patho
logical effects is able to inhibit cilliary movement of epithelial cells and impairs respiratory
burst of phagocytic cells. Recent acquisition of an invasive serotype is more important in
terms of further infection than long-term colonization and is in fact recognized as one of def
inite risk factors for pneumococcal pneumonia [45].
Some of the host immune mechanisms essential for defense against pneumococcal pneumo
nia are toll-like receptors (TLRs). Children with genetic deficiency of the common TLRadaptor protein myeloid differentiation primary-response protein 88 (MyD88) or
interleukin-1 receptor associated kinase 4 (IRAK4), a kinase acting directly downstream
from MyD88, are especially susceptible to invasive pneumococcal disease. Another genetic
factor predisposing to invasive pneumococcal disease is polymorphism of genes coding in
hibitors of nuclear factor and defects in the complement C3 pathway crucial for opsoni
zation and consequently clearance of pneumococci [45].
Pneumonia usually begins with viral upper respiratory tract infection. The pathogen most
commonly associated with dual infections with Streptococcus pneumonia is influenza virus.
Co-infection with influenza virus attenuates host immune response diminishing its ability to
clear pneumococcus. Influenza virus possesses neuraminidase that by exposing certain re
ceptors facilitates pneumococcus adherence to respiratory epithelium [72]. Local innate im
mune defense systems like mucociliary clearance, cough reflex, antimicrobial peptides
usually succeed in eliminating the pathogen. Should they fail, pneumonia ensues. Clinical
symptoms are characteristic for bacterial pneumonia with high fever, chills, malaise, cough
and dyspnoea. Cough becomes productive in older children, with purulent, blood tinged
sputum. Pleural involvement is quite common. Untreated pneumococcal pneumonia may
progress to respiratory failure, septic shock and consequently death.
The usual radiological presentation of pneumococcal pneumonia is lobar pneumonia, fre
quently accompanied by small pleural effusion. Changes may be confined to a single seg
ment or involve several segments or lobes or present as bronchopneumonia [41].
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Since universal introduction of pneumococcal conjugated 7-valent vaccine in 2000, there has
been a decrease in incidence of pneumococcal pneumonia in children <5 [7]. There is, how
ever, concern that the serotypes included in the vaccine can be replaced with previously
rare, potentially more virulent serotypes like serotype 1 or 19A [73,74]. Fortunately, these se
rotypes have been included in the newer conjugated 13-valent vaccine.
There is a problem of increasing antibacterial resistance up to 10% of cultured pneu
mococcal isolates in 2008 in Europe are not susceptible to penicillin, though the impact
of in vitro resistance on clinical outcome of patients is not that clear. Fortunately, there
was no increase in mortality or complication rate reported in children infected with re
sistant strains [71,73,74].
14.2. Staphylococcus aureus
The incidence of Staphylococcus aureus pneumonia has increased significantly during the
past 20 years. An increasing number (up to 76% in Texas) of community-associated S.
aureus is methicillin resistant (CA-MRSA) and in some regions it has become the main
cause of complicated CAP in children [75-77]. CA-MRSA were described for the first
time in the 1990s as a cause of infection in previously healthy young children and ado
lescents with no prior hospitalization or record with chronic healthcare facilities [77].
There is also significant increase in nasal colonization of healthy children with MRSA
in another study from the USA 36.4% of healthy children were colonized with S. aureus
and 9.2% with MRSA. CA-MRSA has its own genotype different from hospital acquired
strains [77]. It is worth noticing that 22% of MRSA strains had gene locus for PVL, and
in a British study 11% of all S. aureus isolates from pneumonia patients carried the gene
[78,79]. Even if the impact of nasal colonization on the risk of pneumonia is not clear,
since 1/3 of patients with staphylococcal infection had no prior colonization documented
[80], these data show a wide distribution of MRSA in the community.
Primary S. aureus pneumonia results from direct invasion of the lungs through the tracheo
bronchial tree, and secondary pneumonia results from hematogenous spread. S. aureus CAP
typically occurs in very young infants: 30% of cases occur in children younger than 3
months of age and 70% in those <1 year of age, more often in boys [60].CA-MRSA CAP fre
quently occurs in previously healthy children and adolescents and in many cases is preced
ed by influenza or flu-like illness or skin and soft tissue infection. Severe respiratory
symptoms and hypotension develop rapidly. The USA300 clone is associated with venous
thrombosis and subsequent septic pulmonary emboli [77].
S. aureus possesses a variety of virulence factors including surface proteins (eg. protein A)
that promote adherence and hence colonization of host tissues, invasions (leukocidin, kinas
es and hyaluronidase) that promote bacterial spread in tissues and membrane damaging
toxins (eg. mentioned above leukocidin). There have been several reports in previously
healthy children and adolescents of pneumonia caused by Panton Valentine leukocidin
producing Staphylococcus aureus. The poreforming toxin encoded by luk-S-PV and luk-F-PV
genes lyses neutrophils causing exaggerated though ineffective inflammatory response. Pa
tients present with rapidly progressing necrotizing pneumonia manifested by fever, leuco
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penia and hemoptysis preceded by viral infection, most common influenza [75]. Leucopenia
is characteristic for PVL and is thought to be secondary to leukocidin destroying white
blood cells [77]. Radiographic appearance is multiple nodular infiltrates, usually unilateral
that may transform into cavitary lesions and pneumatocele. Radiographic progression of in
filtrates may be very rapid and should raise possibility of S. aureus pneumonia. Another
characteristic radiographic sign pneumatoceles occurs in over half of cases and both its
size and number may change hourly [61]. Staphylococcal pneumonia is often complicated
with empyema, formation of lung abscesses, pneumothorax and acute respiratory distress
syndrome (ARDS).
Given the severe and potentially fatal nature of the infection, prompt initiation of appropri
ate antibiotic therapy is crucial. For hospitalized patients with pneumonia caused by methi
cillin susceptible S. aureus PIDS recommends intravenous therapy with -lactamase stable
penicillin (oxacillin, cloxacillin, flucloxacillin or nafcillin) or the first generation cephalospor
in (cefazolin). For more severe infections some experts recommend combination therapy
with an aminoglycoside or rifampin although data from controlled clinical studies support
ing these recommendations are lacking [19]. The first line treatment for hospitalized chil
dren suspected of CA-MRSA is vancomycin. There is a concern, however, of adequate
concentration of the drug in lung epithelial lining fluid in adults it has been shown to ach
ieve 18% of serum levels [77]. Alternative choices are linezolid and clindamycin that have an
additional advantage of blocking the production of PVL toxin and staphylococcal exotoxins
so they are the drugs of choice in treatment of PVL-CA infections. Clindamycin should be
used with care considering local susceptibility data and it should not be used in high inocu
lum infections such as empyema since in that case there is high risk that the bacteria will
constitutively produce methylase [19]. Linezolid achieves higher concentrations in epithelial
lining of the lung [80].
14.3. Mycoplasma pneumoniae
Mycoplsamas are the smallest self-replicating organisms able to live outside the host cells.
They do not have cell wall, but a cell membrane containing sterols and do not stain well
with Gram stain and antibiotics disrupting bacterial cell wall like -lactams are inactive
against these organisms. Mycoplasma pneumoniae pneumonia is usually a mild disease.
Transmission occurs via person to person contact and incubation period is usually 1 to 2
weeks. Epidemics occur in approximately 4 - 7 year cycles. Recurrent infections are usual.
Infections with Mycoplasma pneumonia are common. Antibodies are present in 1/3 of all
infants between 7 to 12 month of life and over 90% of adolescents. Very few infections
occur in infants in the first 6 months of life probably due to presence of maternal anti
bodies. Recent studies show that contrary to previous reports M. pneumoniae CAP is also
quite common in children <4 years. These microorganism are responsible for of infec
tions in this age group [81].
Microorganisms are acquired via respiratory route. In the airways they attach to a receptor
on respiratory epithelium via adhesions. Lung injury in M. pneumoniae pneumonia is associ
ated with cell-mediated immunity of the host and it is also accompanied by ciliostasis [81].
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Patients present with symptoms of upper respiratory tract infection, fever, malaise, head
ache. Symptoms ensue gradually. Cough, which is initially unproductive, appears 3 to 5
days from the onset of disease. Associated symptoms include hoarsness, chills, chest pain,
vomiting, nausea, diarrhea and myalgia. Coryza is a rare finding, and pleural effusion oc
curs in 5-20% of patients. On auscultation crackles, wheezes and bronchial breathing may be
present. Mycoplasma pneumonie may present with extrapulmonary involvement including:
nonexudative pharyngitis, cervical lymphadenopathy, otitis media, conjunctivitis, arthritis
and rash. Illness usually resolves within 3 - 4 weeks, but it might be more severe in children
with sickle cell disease and in Down syndrome. Mycoplasma may cause exacerbations in
asthmatic patients [28].
Radiological findings vary from reticular and interstitial pattern to lobar consolidations. Hi
lar adenopathy is present in 1/3 of patients. Characteristic is poor correlation between clini
cal symptoms and physical and radiological findings.
Treatment of choice consists in macrolide antibiotics.
In rare cases Mycoplasma pneumoniae pneumonia may be severe with massive lobar consoli
dation, pleural effusion, lung abscess or pneumatocele formation. Occasionally, fever and
radiological changes progress, despite standard macrolide therapy. There is one report of
successful treatment of refractory pneumonia with methylprednisolone in children [82].
Rare complications obliterative bronchiolitis and diffuse interstitial fibrosis have been
described. In 1/3 of children 1 - 2 years after Mycoplasma pneumoniae infection abnormal find
ings including mosaic perfusion, bronchiectasis, bronchial wall thickening, decreased vascu
larity and air trapping are observed [81]. Extrapulmonary complications of Mycoplasma
pneumonia provoke signs from a variety of organs and systems. These include:
neural system: meningoencephalitis, transverse myelitis, cranial neuropathy, myeloradi
culopathy, a poliomyelitis-like syndrome, psychosis, Guillain-Barr syndrome
skin: erythematous maculopapular or vesicular exanthems, erythema multiforme, Stevens
Johnson syndrome
heart: pericarditis, myocarditis, congestive heart failure, heart block
gastrointestinal tract: nausea, vomiting, diarrhea, hepatic dysfunction, jaundice
hematologic: hemolytic anemia, thrombocytopenia, disseminated intravascular coagula
tion
musculoskeletal: myalgias, arthralgias
genitourinary: glomerulonephritis, interstitial tubulonephritis
15. Hospital acquired pneumonia

Hospital acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more
after admission in a patient who had no signs of disease at the time he or she was presenting
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to the hospital [83]. It may be further divided into early onset (48-96 hours after admission)
usually caused by pathogens responsible for CAP and late onset (> 96 hours after admission)
caused by multidrug resistant nosocomial pathogens [84].
Ventilator associated pneumonia (VAP), a type of HAP affecting mechanically ventilated
patients is defined as pneumonia that occurs more than 48 hours after intubation [83].
A third type, only recently described, represents health-care associated pneumonia (HCAP)
that develops in patients who fulfill one of the following conditions:
hospitalization for 2 or more days within 90 days of the infection
residence in a nursing home or long-term care facility
antibiotic therapy or chemotherapy or wound care within 30 days of the infection
attending haemodialisis center [83].
Definition of HCAP has not been validated in children, although, due to a growing number
of pediatric patients with chronic medical conditions (eg. cerebral palsy, congenital malfor
mation syndromes, chronic pulmonary, heart and renal disease) who frequently have con
tacts with healthcare personnel, HCAP poses a significant problem in this population.
HAP occurs in 16-29% of pediatric patients and accounts for 10-15% of all nosocomial infec
tions in children and up to 67% of nosocomial infections in children admitted to pediatric
intensive care units [85-87]. VAP occurs in about 3 to 32% of ventilated pediatric ICU pa
tients [87,88]. In Europe it is the most common and in the USA second most common noso
comial infection in children treated in intensive care units [88-90]. Mortality in HAP is much
higher than in CAP and ranges from 10 to 70% depending on the etiological factors and co
morbidities [85,86,88]. HAP and VAP in particular increase length of hospital stay and hos
pital costs [86,88,91].
The most common etiological factors of pediatric HAP are respiratory viruses including res
piratory syncytial virus, adenovirus, influenza and parainfluenza viruses. Bacteria responsi
ble for late onset HAP comprise Gram-negative bacilli: Pseudomonas aeruginosa, Escherichia
coli, Klebsiella pneumonia, Acinetobacter spp., Serratia spp.., Gram positive organisms esp.
Staphylococcus aureus and coagulase - negative Staphylococci. P. aeruginosa is the most com
mon bacterial pathogen in pediatric intensive care units associated with mortality rates up
to 80% [90]. Most bacteria responsible for nosocomial infections are multidrug resistant,
among them methicillin resistant Staphylococci (MRSA) and extended spectrum -lactamase
(ESBL) producing Gram negative bacilli. Immunocompromised children are at particular
risk of infection caused by fungi, esp. Aspergillus, Candida and Pneumocystis jiroveci. In 38% of
cases etiology of VAP in children is polymicrobial [88].
Risk factors for hospital acquired pneumonia comprise intubation and mechanical ventila
tion (increases the risk 6 to 21-fold increased risk), neuromuscular blockade, length of hospi
tal stay, immunosuppression, recent treatment with antibiotics and H2 blockers as well as
overcrowding and understaffing of hospital wards [85,86]. Genetic syndrome, female gen
der, reintubation, transport out of the intensive care unit, surgery before ICU admission, en
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teral feeds, use of narcotic medications were found to be independent risk factors of VAP in
children [88,91].
Nosocomial pneumonia should be suspected in any child with new respiratory symptoms
during hospital stay, hypoxemia, increased oxygen or ventilation requirements, increased
amount or altered characteristic of respiratory secretions. Most definitions include clinical
and radiological signs, some additional bacteriological and laboratory data [83,92]. Accord
ing to National Healthcare Safety Network of Centers for Disease Control (CDC), HAP can
be diagnosed in patients with new radiological changes (infiltrate, consolidation, cavitation,
pneumatocele in infants in the 1st year of life) and at least three clinical criteria (clinically de
fined pneumonia) or two clinical and one laboratory criteria. For children with underlying
pulmonary or heart disease radiologic changes must be confirmed in at least two serial xrays. Clinical criteria, that must be fulfilled include:
fever > 380C with no other cause or
leucopenia (<4,000/mm3) or leucocytosis (12,000/mm3) and at least one (or two for clini
cally defined pneumonia) of the following:
new onset of purulent sputum,
increase in respiratory secretions,
change in the character of sputum or respiratory secretions,
new onset or worsening of respiratory symptoms: cough, tachypnea, dyspnea,
auscultary findings: rales, bronchial sounds,
increased oxygen requirements, PaO2/FiO2 240.
In children up to12 years of age clinical criteria are slightly different and at least three (two
in infants 1 year of age) must be fulfilled. These include:
fever > 38 0C or hypothermia < 36.50C (or temperature instability for infants 1 year of age)
with no other cause or
leucopenia (<4,000/mm3) or leukocytosis (15,000/mm3) and 10% immature forms (in
fants 1 year of age)
new onset of purulent sputum,
increase in respiratory secretions,
change in the character of sputum or respiratory secretions,
new onset or worsening of respiratory symptoms: apnea, cough, tachypnea, dyspnea,
nasal flaring with chest wall retractions or grunting, wheezing - infants 1 year of age
auscultary findings: rales, bronchial sounds,
bradycardia (<100 beats/minute) or tachycardia (>170 beats per minute) - infants 1 year
of age
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increased ventilation requirements, hypoxemia (Sat <94%) this condition is obligatory

for infants 1 year of age.
Laboratory criteria include positive cultures of blood (not related to other infections), pleu
ral fluid or specimens from lower respiratory tract (bronchoalveolar lavage - BAL or protect
ed specimen brushing), intracellular bacteria seen in 5% of cells obtained from BAL on
direct microscopic exam, histopathologic evidence of abscess formation, focal consolida
tions, intensive polymorphonuclear cell accumulation in the small airways, lung parenchy
ma invasion by hyphae or pseudohyphae. Diagnostic value of BAL in children with VAP is
found to be 50-72% and specificity 80-88%, and of quantification of intracellular organisms
in BAL samples 30-55% and 89-95% respectively [93-96]. Laboratory criteria for HAP caused
by atypical bacteria (Mycoplasma spp., Chlamydophila spp., Legionella spp.) or viruses include:
positive culture from respiratory secretions, positive detection of antigen or antibody in res
piratory secretions, 4-fold IgG rise in paired sera, positive PCR, detection of Legionella pneu
mophila serogroup 1 antigens in urine [92].
Bacteriological diagnosis is often difficult, since hospitalized patients are commonly colon
ized with pathogenic flora. Therefore a quantitative criterion of bacterial yield (104 cfu/mL,
or 104cfu/g tissue in case of lung parenchyma specimen) has been established to aid the
etiological diagnosis of pneumonia [92]. Applicability of invasive diagnostic techniques
(lung biopsy) remains controversial for the fear of complications in unstable or severely sick
patients and lack of data confirming their influence on clinical course or mortality rates.
Patients with HAP are most often debilitated individuals with multiple underlying condi
tions. HAP is a severe disease with high mortality rates. Therefore diagnosis should be es
tablished as quickly as possible using a wide array of diagnostic tools and techniques and
empiric treatment should be implemented promptly while cultures and other microbiologi
cal studies are pending. Antibiotics should have spectrum broad enough to cover gram neg
ative and gram positive bacteria considering previous antibiotic exposure, local flora,
antimicrobial susceptibility patterns and guidelines from the infectious diseases specialist.
Risk factors for acquisition of antibiotic-resistant gram negative bacteria in pediatric inten
sive care unit (PICU) patients include younger age, severe general condition (appreciated
based on PRISM {pediatric risk of mortality} score), intravenous antibiotics administration
in the previous 12 months, PICU admission in the past, contacts with chronic care facilities
[87,94]. Inappropriate antibiotic treatment is associated with increased mortality in patients
with HAP [90]. Children with early onset HAP might be treated as those with CAP provid
ed they do not have specific risk factors for HCAP, VAP or colonization with multi-drug re
sistant bacteria. PICU patients should receive coverage against Pseudomonas aeruginosa
(aminoglycoside with an appropriate -lactam: piperacillin, ceftazidime or cefepime) and in
hospital wards where incidence of methicillin resistant staphylococci or ESBL producing
gram negative bacilli exceeds 5% vancomycin and carbapenems or ureidopenicillin deriva
tive plus -lactamase inhibitor respectively should be included in empiric treatment regimes
[92]. In children with immunodeficiencies antifungals should be administered. As soon as
the causative organism and its sensitivity is known, therapy should be tailored using the
http://dx.doi.org/10.5772/54052
agent of the narrowest spectrum available. Antibiotics should be administered intravenous

ly and switched to oral route if possible once the patient improves.
Infection control measures that should be meticulously implemented in order to decrease
the number of HAP include:
appropriate hand hygiene, use of gloves
personal protective equipment face masks, especially in the periods of increased inci
dence of respiratory viruses
cohorting patients infected or colonized with resistant microorganisms
nursing practices: semirecumbent position for ventilated patients, mouth care
use of non-invasive ventilation instead of mechanical ventilation in appropriate patients
care of medical equipment: ventilator circuits, suction devices, pulmonary function test
ing equipment
avoiding overcrowding and understaffing
avoiding H2 antagonists
judicious use of antibiotics
immunization practices (as described above for CAP).
Acknowledgements
The authors wish to thank Katarzyna Joczyk-Potoczna MD, PHD for her excellent assis
tance with radiological examinations.
Author details
Irena Wojsyk-Banaszak and Anna Brborowicz
*Address all correspondence to: [email protected]
Department of Pulmonology, Pediatric Allergy and Clinical Immunology, Karol Marcin
kowski University of Medical Sciences, Szpitalna, Pozna, Poland
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Chapter 6

Respiratory Disease and Infection - A New Insight

Community Acqiured Pneumonia (CAP)

Hospital Acquired Pneumonia (HAP).

3. Community acquired pneumonia

substantial morbidity. Incidence of radiologically confirmed pneumonia in previously

Respiratory Disease and Infection - A New Insight

6. Risk factors for cap

Table 1. Tachypnoe defined according to WHO criteria [1]

Respiratory Disease and Infection - A New Insight

Signs of pneumonia & 1

Very severe pneumonia

Signs of severe pneumonia & 1

Determination of etiology microbiological investigations

Respiratory Disease and Infection - A New Insight

Figure 2. Round focus of consolidation in the left upper lobe. Pneumonia.

Respiratory Disease and Infection - A New Insight

10. General management

11. Antibiotic treatment

Respiratory Disease and Infection - A New Insight

Respiratory Disease and Infection - A New Insight

Pleural fluid, if obtained during thoracocentesis or video-assisted thoracoscopic surgery

Small: < 10 mm on lateral decubitus radiograph or opacifies < hemithorax

Respiratory Disease and Infection - A New Insight

The mainstay of treatment is conservative antibiotic therapy with spectrum covering S.

Respiratory Disease and Infection - A New Insight

14. Specific bacterial causes of pneumonia

Respiratory Disease and Infection - A New Insight

Respiratory Disease and Infection - A New Insight

15. Hospital acquired pneumonia

Respiratory Disease and Infection - A New Insight

Respiratory Disease and Infection - A New Insight

increased ventilation requirements, hypoxemia (Sat <94%) this condition is obligatory

agent of the narrowest spectrum available. Antibiotics should be administered intravenous

Respiratory Disease and Infection - A New Insight

[16] Tsolia MN, Psarras S, Bossios A, Audi H, Paldanius M, Gourgioyis D, Kallergi K, Ka

Respiratory Disease and Infection - A New Insight

[27] Thomson AH. Treatment of community-acquired pneumonia in children. Clin Pulm

Respiratory Disease and Infection - A New Insight

[54] Carter E, Waldhausen J, Zhang W, Hoffman L, Redding G. Management of children

Respiratory Disease and Infection - A New Insight

[93] Gauvin F, Dassa C, Chaibou M, Proulx F, Farrel CA, Lacroix J. Ventilator-associated

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