After initiating therapy, the most important tasks are resolving the symptoms and clearing the infiltrate. With successful therapy, symptoms resolve much sooner that the infiltrate.
The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America created evidence-based guidelines for the management of community-acquired pneumonia (CAP) in infants and children older than 3 months. These guidelines discuss site-of-care management, diagnosis, antimicrobial therapy, adjunctive surgical therapy, and prevention. While these guidelines do not represent the only approach to diagnosis and therapy, these recommendations may assist in decreasing morbidity and mortality rates in children with community acquired pneumonia.
Pulse oximetry should be performed during the prehospital evaluation of children with suspected pneumonia, and supplemental oxygen should be administered, if necessary; however, many school-aged children do not require hospitalization and respond well to oral antibiotics. Usually, these patients are not toxic or hypoxic enough to require supplemental oxygen. Unless they are vomiting, they do not require intravenous fluids or antibiotics. A parapneumonic effusion that requires drainage usually dictates a hospital admission.
Children younger than 5 years are hospitalized more often, but their clinical status, degree of hydration, degree of hypoxia, and need for intravenous therapy dictate this decision. Hospitalization should be considered for infants who are younger than 2 months or premature because of the risk of apnea in this age group.
Children who are toxic-appearing may require resuscitation and respiratory support. Treatment of critically ill children (those requiring ventilation) should include timely administration of appropriate antibiotics.
Drainage of a restrictive or infected effusion or empyema may enhance clearance of the infection and improves lung mechanics. Antibiotic therapy should include vancomycin (particularly in areas where penicillin-resistant streptococci have been identified) and a second- or third-generation cephalosporin.
RBCs should be administered to ensure a hemoglobin concentration of 13-16 g/dL in the acutely ill infant to ensure optimal oxygen delivery to the tissues. Delivery of adequate amounts of glucose and maintenance of thermoregulation, electrolyte balance, and other elements of neonatal supportive care are also essential aspects of clinical care.
Initial priorities in children with pneumonia include the identification and treatment of respiratory distress, hypoxemia, and hypercarbia. Grunting, flaring, severe tachypnea, and retractions should prompt immediate respiratory support. Children who are in severe respiratory distress should undergo tracheal intubation if they are unable to maintain oxygenation or have decreasing levels of consciousness.
Adequate gas exchange depends not only on alveolar ventilation, but also on the perfusion and gas transport capacity of the alveolar perfusate (ie, blood).
Be aware that lung disease is often structurally heterogeneous, with subpopulations of normally inflated, hyperinflated, atelectatic, obstructed, fluid-filled, and variably perfused alveoli that may require multiple adjustments of ventilatory pressures, flows, rates, times, and modalities.
The choice of an initial, empiric agent is selected according to the susceptibility and resistance patterns of the likely pathogens and experience at the institution, and the selection is tempered by knowledge of delivery of drugs to the suspected infected sites within the lung.
The vast majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics.
High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for S pneumoniae. Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives.
Macrolide antibiotics are useful in school-aged children, because they cover the most common bacteriologic and atypical agents (Mycoplasma, Chlamydophila, Legionella).
Hospitalized patients are usually treated with an advanced-generation intravenous cephalosporin, often in combination with a macrolide. This strategy allows broad-spectrum coverage for the common etiologic agents of pneumonia while definitive diagnostic tests are being completed.
Children who are toxic appearing should receive antibiotic therapy that includes vancomycin (particularly in areas where penicillin-resistant pneumococci and methicillin-resistant S aureus [MRSA] are prevalent) along with a second- or third-generation cephalosporin.
Bronchodilators should not be routinely used. Bacterial lower respiratory tract infections rarely trigger asthma attacks, and the wheezing that is sometimes heard in patients with pneumonia is usually caused by airway inflammation, mucus plugging, or both and does not respond to bronchodilator. However, infants or children with reactive airway disease or asthma may react to a viral infection with bronchospasm, which responds to bronchodilators.
Attempts at enteral feeding often are withheld in favor of parenteral nutritional support until respiratory and hemodynamic status is sufficiently stable.