Pneumonia (Pedi)


Bacterial Pneumonia

Background

  • Dx in 4% of all US children
    • Rate drops significantly with increase age
    • 4% in infants <1 yo
    • <1% in children >9 yo
  • Etiology undetermined in up to 2/3 cases
  • Children <2 yo
    • 80% viral infection
  • Children >5 yo
    • 37% viral infection
  • Begin empiric antibiotics based on
    • Age
    • Season
    • Clinical factors
    • Labs
    • Epidemiology

Pathophysiology

  • Bacterial agent initiates inflammatory response
    • Fluid, PMNs fill alveoli
    • Fibrin and macrophages infiltrate
    • Bacteria proliferate
  • Can be mixed viral and bacterial pathogens
  • Bacterial sources most common in younger children
    • 0-4 wks
      • Group B strep
      • Gram (-) enteric bacterial
      • L. monocytogenes
    • 4-8 wks
      • C. trachomatis
      • Viruses (RSV/parainfluenza)
      • B. pertussis
      • Group B strep
      • Gram (-) enteric bacterial
      • L. monocytogenes
    • 8-12 wks
      • C. trachomatis
      • Viruses (RSV/parainfluenza)
      • B. pertussis
    • 3 mos-4 yo
      • Viruses
      • S. pneumoniae
      • H. influenzae
      • M. catarrhalis
      • Group A strep
      • M. pneumoniae
      • M. tuberculosis
    • >5 yo
      • M. pneumoniae (5-15 yo)
      • C. pneumoniae
      • S. pneumoniae
      • Viral
      • M. tuberculosis
  • Neonate: from birth canal
  • Aspiration when age or history suggest
  • Hypersensitivity lung reactions
  • Due to underlying disease (cystic fibrosis, sickle cell)
  • Fungal, chlamydial, or protozoal (less common)

History/Sx

  • Most likely pathogen relates to
    • Age
    • Attendance at day-care
    • Vaccination status
    • Presence of underlying dz
  • Infants may have non-specific manifestations
    • Fever
    • Poor feeding, irritability
    • Vomiting, diarrhea
    • URI Sx
    • Cough &/or respiratory distress
  • Older children may have more specific Sx
    • Fever, cough, chest pain
    • +/- nuchal rigidity &/or abdominal pain
    • Tachypnea or tachycardia
    • Nasal flaring &/or chest retractions, grunting
    • Cyanosis usually very late

Physical Exam

  • Chest exam
    • Normal to dullness to percussion
    • Rales
    • Wheezes
    • Crackles
    • Coarse breath sounds

Diagnostic testing

  • Pulse oximetry
  • Consider CBC
  • Consider ABG
    • If severe resp distress
    • If hypoxemic
  • ESR
  • Blood culture
  • Bedside cold agglutinins
  • RSV study
  • Sputum evaluation useful if patient has trach tube
  • PPD
    • If poor response to tx
       
  • Diagnostic imaging
    • CXR if symptomatic
    • Questionable accuracy in differentiating viral vs bacterial source
      • Lobar or segmental consolidation correlates with bacterial source
      • S. aureus strongly suggested by presence of
        • Pneumatocele
        • Pneumothorax
        • Empyema
      • C. trachomatis suggested by
        • Hyperexpansion
        • Diffuse alveolar/perihilar infiltrates
      • M. pneumoniae highly variable

Differential Diagnosis

  • Sepsis
  • Meningitis
  • Pertussis
  • Asthma
  • Cystic Fibrosis
  • Tuberculosis
  • Neoplasm
  • Collagen vascular dz
  • Congenital abnormality

Treatment

  1. ABCs
    • Support O2 & consider Venous access prn
  2. Bronchodilator medications (if wheezing)
  3. Sepsis evaluation if <8 wks old & fever on toxic child
  4. Consider use of antibiotics if bacterial pathogen likely
    • Empiric antibiotics based on
      • Age
      • Season
      • Clinical factors
      • Labs
      • Epidemiology
  5. Antibiotic Recommendations
    • Outpatient ABx dosages
      • Age 1-3 mo
        • Erythromycin 10 mg/kg/d q6hr
          OR
          Azithromycin 10 mg/kg x1 then 5 mg/kg d
      • Age 4 mo-5 yo
        • Amoxicillin 100 mg/kg/d div q8hr
      • Age 5-15 yo
        • Amoxicillin 100 mg/kg/d
          PLUS
           
          Clarithromycin 7.5 mg/kg q12hr
          OR 
          Azithromycin 10-12 mg/kg/d

          OR 

          Amoxicillin 25-50 mg/kg/d div TID
          PLUS
          Doxycycline 2-4 mg/kg BID >8 yo
          OR 
          Erythromycin 10 mg/kg q6hr
      • If >16 yo
        • Fluoroquinolones
    • Inpatient antibiotic therapy
      • Neonatal Sepsis < 4 weeks
        • Ampicillin
          • 50 mg/kg q12h < 7d/<2000g
          • 50 mg/kg q8h < 7d/>2000g or > 7d/<2000g
          • 50 mg/kg q6h > 7d/>2000g
        • PLUS Gentamycin
          • 2.5 mg/kg q 18-24h <7d
          • 2.5 mg/kg q 12h >7d
        • +/- Cefotaxime
          • 50 mg/kg q12h < 7d
          • 50 mg/kg q8h >7d
        • Vancomycin if MRSA suspected
          • 12-22 mg/kg q12h
        • Erythromycin if chlamydia
          • 12.5 mg/kg po or IV qid x 14d
      • 1-3 months
        • Afebrile
          • Erythromycin 10 mg/kg IV q6h
            OR
            Azithromycin 2.5 mg/kg IV q 12h
        • Febrile
          • ADD cefotaxime 200 mg/kg/d div q8h
      • 4 mos - 5 yrs
        • Ampicillin 200 mg/kg/d div q6h
        • ICU
          • Cefotaxime 200 mg/kg/d div q8h
            OR
            Ceftriaxone 50-75 mg/kg/d QD
        • Can add vancomycin 40-60mg/kg/d div q6h
      • 2-18 yrs
        • Ceftriaxone 50mg/kg/d IV (max dose 2g/d)
          PLUS 
          Azithromycin 10mg/kg/d div q12h (max 500 mg)
        • May add anti-staph if lung necrosis suspected
        • If resistance to azithromycin/ceftriaxone
          • No doxycycline < 8yrs
            • > 8yrs 2-4mg/kg/d IV div BID
          • Vancomycin 40-60mg/kg/d IV div q6h
            OR
            linezolid (Zyvoxx)
            • <12 yrs 10mg/kg/d q8h
            • > 12 yrs 600mg po or IV q12h
          • OR FQ off-label

Disposition

  1. Admit if
    • <3 months
    • 02 sats <90-93 (at sea level)
      • O2 desaturation on exertion
    • Grunting with respiration
    • Toxic appearance
    • Risk of dehydration
      • Unable to drink
      • Vomiting
    • Immune compromised
      • Hgb SS
      • HIV
      • Malignancy with chemo
    • Any question of likely progression
    • Pre-existing lung disease
      • Cystic fibrosis
    • Hx of apnea or cyanosis
    • Hx of prematurity
    • Lack of response to oral or empiric antibiotics
    • Questionable outpatient follow-up
      • Risk of noncompliance with medication
  2. Discharge with follow-up in 1-2 d if
    • Not in respiratory distress
    • Not under consideration for sepsis
    • Discharge on PO Abx
    • Age 1-3 mo
      • Erythromycin 10 mg/kg/d q6hr
        OR
        Azithromycin 10 mg/kg x1 then 5 mg/kg d
    • Age 4 mo-5 yo
      • Amoxicillin 100 mg/kg/d div q8hr
    • Age 5-15 yo
      • Amoxicillin 100 mg/kg/d
        PLUS
         
        Clarithromycin 7.5 mg/kg q12hr
        OR 
        Azithromycin 10-12 mg/kg/d

        OR 

        Amoxicillin 25-50 mg/kg/d div TID
        PLUS
        Doxycycline 2-4 mg/kg BID >8 yo
        OR 
        Erythromycin 10 mg/kg q6hr
    • If >16 yo
      • Fluoroquinolones

 

Viral Pneumonia

Background

  • Up to 50% of pneumonias thought to be viral in origin
    • In children < 2 years
      • 80% viral infection
    • In children > 5 years
      • 37% viral infection
  • Usually less severe than bacterial pneumonias
    • Often self-limiting
    • Highly contagious
  • Increase in vaccination rate
    • Has reduced frequency and complications
    • If patients has not been vaccinated
      • Refer to pediatrician for follow-up

Pathophysiology

  • Can be mixed viral and bacterial pathogens
  • Neonate- from birth canal
  • Exacerbated by underlying or chronic disease
    • SCD
    • Congenital
  • Common causative agents
    • Influenza A, B
    • RSV
    • Other
      • Parainfluenza
      • Adenovirus
      • Rhinovirus
      • HSV
      • Hantavirus
      • Cytomegalovirus
    • Non-viral
      • Other: Fungal, chlamydial, or protozoal (less common)
  • Potential complications
    • Dehydration
    • Bronchiolitis obliterans
    • Apnea

History/Signs & Symptoms

  • Infants may have non-specific manifestations
    • Fever
    • Poor feeding/irritability
    • Vomiting/diarrhea
    • URI Sx
    • Cough &/or respiratory distress
  • Older children may present with
    • Cough
    • Sore throat
    • Fever, chills, malaise
    • SOB
    • Muscle ache/stiffness
  • May also see
    • Sweating/clammy skin
    • Nausea & vomiting
    • Joint stiffness

Physical Exam

  • Dyspnea
  • Tachypnea
  • Cyanosis
  • Chest exam
    • Diffuse fine rales,
    • Wheezes
    • crackles
    • Coarse breath sounds

Diagnostics

  • Diagnostic Testing
    • Pulse oximetry
    • Consider CBC
    • Consider ABG
      • If severe resp. distress
      • If hypoxemic
    • Specific viral antibody testing
    • Bedside cold agglutinins
    • RSV study
    • Sputum evaluation
  • Diagnostic Imaging
    • CXR if symptomatic- may see:
      • Lobar or segmental consolidations
      • Diffuse interstitial infiltrates
      • Hyperinflation
      • Peribronchial thickening
      • Areas of atelectasis
      • Questionable accuracy in differentiating viral v. bacterial source

Differential Diagnosis

  • Sepsis
  • Meningitis
  • Pertussis
  • Asthma
  • Cystic Fibrosis
  • Tuberculosis
  • Neoplasm
  • Collagen Vascular Disease
  • Congenital abnormality

Treatment

  1. ABCs: support O2 & consider venous access prn
  2. Symptomatic treatment
    • Fever control
    • Hydration
  3. Bronchodilator medications if wheezing present
  4. Consider use of antibiotics if bacterial or mixed pathogen likely
  5. Treatment based on causative agent/host factors
    • Immunocompromised, varicella
      • Acyclovir (per PI)
        • 0-3 mos: 10 mg/kg IV over 1 hr q8h x 10days
        • 3 mos - 12 yrs: 20 mg/kg IV over 1 hr q8h x 7days
        • > 12 yrs: 10mg/kg IV over 1 hr q8h x 7 days
    • RSV
      • Ribavirin 20 mg/mL aerosol only 12-18 h/day x3 days
      • Administer 6 g reconstituted w/300mL sterile water without preservative
      • Up to 7 days
    • HIV with interstitial pneumonia
      • Zidovudine-300 mg po bid adult
        • Neonate:
          • PO 2mg/kg/dose q6h
          • or IV 1.5mg/kg/dose q6h
          • Dosage range 90-180 mg/m2 q6-8h po
        • Child:
          • PO 160mg/m2/dose q8h
          • IV 20 mg/m2/hr continuous infusion
          • OR IV 120 mg/m2/dose q6h
      • and Prednisone
        • Neonate: 500 mg/kg/day qd x 2, then 1x week
        • Child: 500-1000 mg/kg/week
    • CMV
      • Ganciclovir > 3 months
        • 2.5 mg/kg IV over 1 hr q8h x3wks
          • Then 5mg/kg IV qd
          • OR valganciclovir po 900mg
          • and gamma-globulin
        • CMV retinitis dosage
          • 5 mg/kg IV over 1 hr q 12h

Disposition

  1. Admit if :
    • < 3 months
    • 02 sats < 90-93 (at sea level)
      • O2 desaturation on exertion
    • Toxic appearance
    • Risk of dehydration
      • Unable to drink
      • Vomiting
    • Immune compromised
      • Hgb SS
      • HIV
      • Malignancy with chemo
    • Any question of likely progression
    • Pre-existing lung disease
      • Cystic fibrosis
    • Hx of apnea or cyanosis
    • Hx of prematurity
  2. Discharge with follow-up in 1-2 d if
    • Not in respiratory distress
    • Not under consideration for sepsis

 

Mycoplasma

Background

  • Definition
    • Interstitial lung infection by Mycoplasma pneumoniae
  • Mycoplasma are small bacteria that do not contain a cell wall
  • They are difficult to grow in culture media and their growth is slow
  • The are unidentifiable in gram stains of sputum samples
  • One of the most common causes of pneumonia in children older than 5 years old

Pathophysiology

  • Pathology
    • M. pneumoniae produces a protein that allows attachment to a receptor on the respiratory epithelium
      • This complex induces an antibody response - Cold agglutinin
      • Cold agglutinins react with the I antigen of RBC glycoproteins
      • They will be detected one week after infection and may last for six weeks
      • The height of the titer may correlate with the seriousness of the illness
    • Mycoplasma will induce damage to respiratory epithelium from the trachea to bronchioles
    • Manifestations of illness are mostly confined to the respiratory system, but some cases are associated with extrapulmonary involvement
    • Incubation period
      • 1-3 weeks
    • Spread
      • Respiratory droplets
  • Incidence and prevalence
    • Incidence greatest in
      • Older children
      • Adolescents
      • Young adults
    • Increased utilization of daycare facilities has lowered the age of susceptible children
  • Risk factors
    • Close populations
      • Schools
      • Homeless shelters
      • Army barracks
  • Morbidity/ mortality
    • Mycoplasma infections are frequent triggers of reactive airway disease (asthma)
    • Meningoencephalitis

History

  • Insidious onset
    • Headache
    • Malaise
    • Fever
    • Pharyngitis
  • After 3-5 days
    • Large airway involvement
    • Cough
    • Hoarseness
    • Fever
  • Dyspnea
    • Progression to bronchopneumonia

Physical examination

  • Auscultation
    • Rales
    • Rhonchi
    • No signs of consolidation
  • Extrapulmonary symptoms
    • Thought to be autoimmune induced
    • Include
      • Rashes
      • Stevens Johnson Syndrome
      • Meningoencephalitis
      • Arthritis
      • GI symptoms
  • Acute otitis media and sinusitis
    • Rare complication

Diagnostics

  • Diagnostic testing
    • Sputum
      • Scant PMNs
      • No bacteria on Gram stain
    • Cold agglutinin titers
      • >1/64 found in 50% of adolescent and adult cases
      • Not reliable in children <12 years of age
      • Difficult to perform
      • Usually limited to diagnosis of older patients
      • Other atypical pneumonias may induce low titers of cold agglutinins
    • IgM
      • Must wait until 8-10 days of illness before detected
      • Not clinically helpful in most situations
    • PCR
      • Not readily available
  • Diagnostic imaging
    • CXR
      • Multifocal, bilateral diffuse infiltrates most common
      • Often looks worse than the clinical picture
      • Occasionally lobar pneumonia picture
      • Pleural effusions uncommon

Differential Diagnoses

  • Viral infections
    • Adenoviruses
    • Parainfluennza
    • Influenza
  • Chlamydia pneumonia
  • Legionnaire's disease
  • Bacterial pneumonias

Treatment

  1. Erythromycin (estolate, ethylsuccinate or stearate)
    • 30-50 mg/kg/d PO div q8hr x7-10days
    • Also effective against other community acquired infections
      • Pneumococcal pneumonia
  2. Clarithromycin
    • >6 mo
      • 7.5 mg/kg PO bid x10d
  3. Azithromycin
    • >6 mo
      • Initial: 10 mg/kg PO
      • Maint.: 5 mg/kg PO qD x5d; max 250 mg/d
  4. Tetracycline
    • >10 yo
      • 25-50 mg/kg div bid/qid
  5. Organism may be isolated for months after treatment

Age-Related

  • Children under 5 yo
    • Rarely affected

Prognosis

  • Complete recovery in 3-4 weeks without treatment

Prevention & Screening

  • Avoidance of crowded areas
  • Routine prophylaxis for close contacts
    • Only for patients with
      • Sickle cell dz
      • Immune deficiency
    • All others
      • Not recommended

 

Pretussis

Background

  • Definition
    • Highly infectious disease of the respiratory tract
    • "Whooping cough"
    • Caused by Bordetella pertussis
  • Whooping cough syndrome also caused by
    • Bordetella parapertussis
    • Mycoplasma pneumoniae
    • Chlamydia trachomatis
    • Chlamydia pneumoniae
    • Adenoviruses

Pathophysiology

  • Pathology
    • B. pertussis
      • Gram negative, aerobic, non- motile, pleomorphic rod
      • Spread by aerosolized droplets
      • Attaches and damages ciliated respiratory epithelium
      • Humans are the only known host and reservoir
    • Pertussis toxin
      • Very potent
      • Causes lymphocytosis
  • Incidence and prevalence
    • Cyclical 3-5 yrs
    • Highest in infants < 1yo
    • 89% aged < 6 months
    • Attack rate in unvaccinated household members: 90%
    • Incubation period: 3-12 days
    • Increase among adolescents and adults
      • Outbreak 2005 - 2010
        • 8,000-25,000 cases / yr
    • Treatment with Erythromycin will decrease infectivity and cultures will be negative within 5 days
  • Risk factors
    • Infants <6 months too young for full immunizations
    • Family members usually infect infants
  • Morbidity/ mortality
    • Premature Infants
      • Cyanosis
      • Seizures -3% cases
      • Pneumonia
      • Encephalopathy
    • Adolescents and adults
      • Pneumonia
      • Syncope
      • Sleep disturbance
      • Rib fractures
    • Mortality
      • 1% aged <2 months
      • 0.5% aged 2-11 months

Clinical diagnosis

  • Usually based on history & PE

History

  • "6 week disease"
  • Catarrhal phase (1-2 wks)
    • Highest infectivity
    • Nasal congestion
    • Rhinorrhea
    • Sneezing
    • low-grade fever
  • Paroxysmal phase (1-2 wks)
    • Intense cough with bouts lasting several minutes
    • Older infants, toddlers
      • Paroxysmal cough culminating in loud whoop
    • Infants < 6 months
      • Do not have whoop
      • Apneic episodes
      • Risk for exhaustion
      • Posttussive emesis
  • Convalescent phase
      • Chronic cough lasting for weeks
      • Anorexia
      • Lasts up to 7 days
  • Immunization history

Physical Exam

  • Fever absent
  • Dehydration
  • Hypoxia
  • Facial petechiae
  • Conjunctival hemorrhages

Diagnostics

  • Diagnostic testing
    • Leukocytosis w/ absolute Lymphocytosis (>70%)
      • Non specific
      • Lymphocytes may have characteristic "baby bottom" nuclei
    • Nasopharyngeal aspirate culture
      • Dacron swab deep nasopharyngeal x 15-30 sec or until cough
      • Pertussis will grow in 3-10 days and greatest chance of culturing are in the early phases
      • Culture media (Regan-Lowe, Bordet-Gengou)
    • PCR
      • Great specificity / sensitivity
      • Rapid results
    • DFA
      • Not recommended
      • Poor specificity / sensitivity
    • EIA
      • Not readily available
  • Diagnostic imaging
    • CXR
      • Perihilar infiltrates or edema
      • Patchy atelectasis

Differential Diagnoses

  • Pneumonia
    • Bacterial
      • Afebrile pneumonia syndrome
      • Mycoplasmal pneumonia
    • Viral
      • Respiratory syncytial virus
    • Chlamydial pneumonia
  • Bronchiolitis

Treatment

  1. Hospitalize infants <6 months w/ risk of severe disease
  2. Observe for apnea after paroxysms
  3. May require
    • Droplet precautions x 5days
    • Oxygen
    • IV fluids
  4. Treat all close contacts to limit transmission
  5. Antibiotics
    • Erythromycin
      • 40-50 mg/kg PO div qid x14d; max 2 g/day
    • Azithromycin
      • 10-12 mg/kg PO total 5d; max 500 mg
    • Clarithromycin
      • 15-20 mg/kg PO div bid x 5-7d; max 1 g/day
    • Trimethoprim-sulfamethoxazole (age >2 months)
      • 6-10 mg/kg PO div bid x 7-10d
    • Antbx during catarrhal phase may ameliorate disease
    • Antbx during paroxysmal phase (cough) may limit spread
    • Short-term azithromycin / clarithromycin
      • Efficacy same as 14d erythromycin therapy

Instructions for Follow-Up

  • Prevention by immunization
  • Tdap booster
    • Every 10 yrs

Prognosis

  • Children >1 yo
    • Good prognosis
  • Infants < 6 months
    • Severe disease likely

Vaccine

  • Immunization
    • DTaP (acellular pertussis)
      • 2,4,6 months
      • 15-18 months
      • 4-6 yo
    • Tdap
      • Ages 11-64 yo
      • booster every 10 yr
      • Women
        • Before pregancy
        • During pregnancy (not contraindicated)
        • Immediately postpartum
      • All family members and caregivers of infant
      • Not necessary to wait 10 yrs
        • 2 yr intervals appropriate

Chlamydia infections in infancy

Background

  • Chlamydia are divided into three species
    • C. psittaci causes psittacosis
      • An interstitial pneumonia contracted from birds
    • C. pneumoniae causes
      • Pneumonia
      • Bronchitis
      • Pharyngitis in school aged children
    • C. trachomatis causes spectrum of diseases related to the serotype
      • Transmission to newborns at delivery from infected mothers
        • Infant conjunctivitis and pneumonia
      • Ocular trachoma
        • Common cause of blindness in developing countries
      • Lymphogranuloma venereum: invasive lymphatic disease
      • Genital infections
        • Urethritis, epididymitis
        • Cervicitis and salpingitis

Chlamydial Conjunctivitis in Infancy

  • History
    • ~50% of infected pregnant women will have neonate that is colonized.
      • About 50% of these neonates will develop conjunctivitis
      • These neonates will also have + nasopharyngeal colonization
    • Usually develops 5-14 days after birth
    • Initially watery discharge that becomes purulent
    • Then will develop lid swelling, conjunctival erythema and swelling
    • Untreated may last for weeks but there is no scar formation and resultant blindness
  • Diagnostic testing
    • Culture organism from the conjunctiva or nasopharynx
      • Need to get specimen with cells because organism is intracellular
      • Purulent material may not have organisms present
    • DFA, EIA, PCR may be available in some labs
  • Differential diagnoses
    • Must differentiate from N. gonorrheainfection
    • Starts earlier and is more rapidly progressive
  • Treatment
    • Erythromycin
      • 50 mg/kg per day PO x 14 days
    • ~20% failure rate and may need retreatment
    • Treat mother and her sexual partner as well
    • Only prevention is treatment of pregnant infected women
      • Topical treatment is unnecessary
      • Erythromycin and Silver Nitrate are not effective prophylaxis
    • May be associated with later development of reactive airway disease

Chlamydial Pneumonia in Infancy

  • Incidence and prevalence
    • 5-20% of infected neonates will develop pneumonia
    • Usually between 1-3 months of age
    • ~50% will have a history of conjunctivitis
  • History
    • Often afebrile
    • Insidious onset
      • Stuffy nose
      • Cough (staccato)
      • Tachypneic
      • Do not appear toxic
    • Chest may have diffuse crackles and usually no wheezing
    • Occasionally present with apnea and respiratory failure
  • Diagnosis
    • Nasopharyngeal culture or other nonculture methods (DFA, EIA)
    • Chest radiograph has bilateral interstitial infiltrates and hyperinflation
    • Peripheral eosinophilia
  • Treatment
    • Erythromycin
      • 50mg /kg/ day PO x 14 days

 

Neonatal Pneumonia
Etiology Clinical Presentation Management Approach
Common bacterial [group B Streptococcus (most common), Escherichia coli, Listeria monocytogenes, Haemophilus influenzae B, S. pneumoniae, Klebsiella species, Enterobacter aerogenes Fulminant illness with onset within 48 h of life, with infection likely acquired in utero from contaminated amniotic fluid environment. Full evaluation for sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative. Two culture samples may increase diagnostic yield fourfold.
Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present. A lumbar puncture should be done if there are no contraindications.
Hospitalization, supportive care (O2), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available).
 
Nosocomial infections in premature infants (Staphylococcus aureus, Pseudomonas aeruginosa Same as for common bacterial etiology. Same as for common bacterial etiology.
Chlamydia  Develops in 3%–16% of exposed neonates (in colonized mothers). Sepsis evaluation as indicated.
CXR may show hyperinflation with interstitial infiltrates.
Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon. Definitive diagnosis by nasopharyngeal swab PCR or cultures.
Eosinophilia may be seen on peripheral blood count.
Treatment: macrolide (erythromycin, clarithromycin, or azithromycin).

Bordetella pertussis

In addition to pneumonia, may causes paroxysms of cough, ± cyanosis and post-tussive emesis in otherwise well-looking infant. Characteristic whoop is not present in neonates. Apnea may be the only symptom. Suspect when adult caregiver also has persistent cough. Sepsis evaluation as indicated.
Diagnosis via nasopharyngeal swab for PCR and/or culture.
Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis.
Macrolides are efficient against B. pertussis but is not approved by the U.S. Food and Drug Administration for infants <6 mo.
No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin.
Neonates need to be admitted during treatment and monitored for severe adverse effects.

Mycobacterium tuberculosis

Half of infants born to actively infected mothers develop TB if not immunized or treated. Sepsis evaluation as for bacterial pneumonia.
CXR, culture of urine, gastric and tracheal aspirates.
May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission. Skin testing not sensitive in neonates.
Routine anti-TB treatment.
Supportive treatment as needed.
Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly).
Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza) Initial upper respiratory illness progressing to respiratory distress and feeding difficulty. Sepsis evaluation as indicated.
Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab).
Hypoxia and apnea may be present.
Often indistinguishable from bronchiolitis. Rate of concurrent bacterial infections in confirmed viral infection is low.
CXR for significant respiratory distress.
Supportive therapy; monitoring for apnea in young and premature infants
 
Overview
Noisy Breathing/
Stridor
Croup Congenital Anomaly Airway Hematoma
Atresia
Cysts
Cleft
Stenosis
Webs
Infection
Laryngomalacia
URI Usually viral
Apnea & Periodic Breathing Periodic Breathing May be normal
Apnea
(ADMIT)
-Cessation of breathing > 10-20 sec. Bronchiolitis(RSV)
Chlamydia
Pretussis
Cyanosis & Blue Spells Cyanosis
(ADMIT)
Rapid, unlabored respiration Cyanotic Heart Disease (R to L shunt)
Irregular, Shallow Respiration Sepsis
CNS Disease
Metabolic Disorder
Labored breathing w/grunting & retraction Pulmonary Disease Pneumonia
Bronchiolitis