SIGN/BTS pneumonia guideline revised 2011 – microbiology bit more subtle now: yes, anything between 1/3 and 2/3 are viral, particularly under 2 years, and probably a third are mixed, but you still get pneumococcus and mycoplasma in infants.

Bugs

Strep pneumoniae (Pneumococcus) is the most common bacterial cause of pneumonia in childhood.

Pneumococcus causes about one-third of radiologically confirmed pneumonia in children aged <2 years.

PCV7 has dramatically decreased IPD due to vaccine serotypes in the UK, but a steady increase in vaccine serotype replacement is evident in the UK.

Group A streptococci and S aureus disease are more likely than pneumococcal to progress to ICU or empyema.

Overall, viruses account for 30-67% of CAP (community acquired pneumonia) cases in childhood and are more frequently identified in children aged <1 year than in those aged >2 years.

1/3 of cases of CAP (8-40%) represent a mixed infection.

Mycoplasma is not unusual in children aged 1-5 years.

Age is a good predictor of the likely pathogens:

• Viruses alone are found as a cause in younger children in up to 50%.
• In older children, when a bacterial cause is found, it is most commonly S pneumoniae followed by mycoplasma and chlamydial pneumonia

Wheeze used to be seen as excluding pneumonia, but now only comment is that it can be one of the clinical features of pneumonia, none of which is very specific.  Bacterial pneumonia should be considered in children when there is:

• persistent or repetitive fever >38.5C, together with chest recession and a raised respiratory rate. [D].

Clinical presentation

Wheeze and chest pain can be symptoms of pneumonia. But none of the symptoms of pneumonia are very specific for pneumonia.

In children over 3yrs, history of difficulty breathing is an additional valuable symptom.

Consider bacterial pneumonia if recurrent/persistent fever >38.5 together with recession and tachypnoea.

• Re-consultation (in the community) for persistent fever can suggest pneumonia
• Reassess if pneumonia symptoms do not respond to treatment
• Refer to hospital if sats <92%
• Absent breath sounds with dull percussion suggest effusion, refer to hospital
• Children with pneumonia in hospital should be reassessed if fever persists 48hr after starting treatment, or if there is increased work of breathing or agitation/distress
• Microbiogical investigations for pneumonia include blood culture, NPA for PCR/IF, serology for resp viruses, Mycoplasma, Chlamydia, pleural fluid C+S/Pneumococcal antigen/PCR.

Investigations

CXR not useful in mild cases, certainly not necessary if admission not being considered. I would consider if hypoxia was disproportionate to degree of breathlessness (suggests collapse), suspicion of effusion (stony dullness on percussion) or pneumothorax.

CXR is not useful in establishing viral vs bacterial vs atypical aetiology!

Repeat CXR in convalescence is only required for persisting symptoms, lobar collapse or round pneumonia.

CRP etc not useful in establishing viral vs bacterial vs atypical aetiology!

Microbiological investigation not necessary routinely, but important if complications or ICU needed.

Antibiotics

Under 2yrs, mild lower resp tract symptoms are not usually due to pneumonia (esp if pneumococcal immunized) so do not need to be given antibiotics – but review if symptoms persist.

No longer age related antibiotic cut offs.

Amoxicillin is first choice, macrolide is an alternative (as is co-amox).  Macrolide should be added if poor response or if severe (D level recommendations though).

In influenza pneumonia (higher rate of staph), co-amoxiclav is recommended [D].  Similarly for measles.

Oral antibiotics equivalent to IV (if tolerated) even in severe disease (PIVOT trial, Nottingham).  But IV for complicated or signs of septicaemia.  Recommended IV antibiotics include amoxicillin, co-amoxiclav, cefuroxime, cefotaxime, ceftriaxone. Rationalize as able, change to oral when clear evidence of improvement.

CAP-IT trial

2021 trial in UK & Ireland – excluded under 6 months and under 6kg or severe underlying chronic condition. Excluded anybody already treated with beta lactam antibiotics for 48+ hrs or any other antibiotic for any duration.

Twice daily amoxicillin 35-50mg/kg/d for 3 days was equivalent to higher doses for 7 days. Longer course had 2 days less cough. [JAMA 2021]

Susan Lipsett et al from Boston suggest that most of these kids would probably have improved without antibiotics anyway – they discharged 80% of kids who fulfilled CAP-IT criteria but who had normal x-rays without antibiotics (!) and only 2% came back! [JAMA Open 2024]

Management

Strongly against NG tubes in severely ill esp infants.  Use smallest nostril if cannot be avoided

Use oxygen if sats <=92%

Monitor bloods daily if on IV fluids

Chest physio is NOT beneficial – at least, not routinely, potentially if focal collapse identified and slow to come out of oxygen.

If going home, advice on managing fever, preventing dehydration, identifying deterioration.

Follow up severe pneumonia, empyema and lung abscess until recovered completely and CXR near normal.