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Bacterial Pneumonia
Amanda I. Messinger, MD,* Oren Kupfer, MD,* Amanda Hurst, PharmD, Sarah Parker, MD
Divisions of *Pulmonary Medicine and Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
Department of Pharmacy, Childrens Hospital Colorado, Aurora, CO
Practice Gaps
Management of pediatric community-acquired pneumonia should
focus on judicious use of antimicrobial medications, bacterial
diagnostics, and surgical drainage when complicated by large effusion
and empyema. Treatment in adherence to national guidelines produces
favorable outcomes.
INTRODUCTION
Reproduced with permission from Gereige RS, Laufer PM. Pneumonia. Pediatr Rev. 2013;(34):19. (5)
represents a failure of many layers of extrinsic and intrinsic invasion. Secreted and humoral immunoglobulins, as well as
defense. Physical barriers to infection include upper respi- intrinsic antimicrobial properties of alveolar uid, work with
ratory tract nasal hairs and turbinate architecture, as well as the phagocytic alveolar macrophages to eradicate bacteria.
complex respiratory airway branching that inhibits access to When these defenses are overwhelmed in some capacity,
distal airways. In the large airways, cough and mucociliary bacterial pathogens penetrate and cause disease. (13)
clearance of secretions and humoral and cell-mediated Many factors may contribute to overwhelming of these
defenses work to defend the lower respiratory tract from defenses and subsequent pneumonia, but the inuence of
Bacillus anthracis Exposure to contaminated hides (including drum covers); Incubation: 243 d
often will have skin manifestation (eschar), as well Diagnostic: cultureb and PCR
Treatment: ciprooxacin, doxycycline
Blastomyces Travel to Central United States Incubation: 2 wk to 3 mo
dermatitidis Diagnostic: cultureb, serologic analysis
Treatment: amphotericin
Chlamydophila Exposure to sick birds Incubation: 514 d
psittaci Diagnostic: serologic analysis
Treatment: doxycycline, azithromycin second line
Coccidioides immitis Travel to endemic area (Arizona, Nevada, California, Texas, Incubation: 14 wk for primary infection, disseminated
Utah, Mexico, Central and South America) disease weeks to years
Diagnostic: cultureb, serologic analysis
Treatment: not always needed, but uconazole,
itraconazole, amphotericin B
Coxiella burnetti Exposure to infected birthing uids or excreta (including Incubation: 1422 d
unpasteurized milk) from sheep, cattle, and goats Diagnostic: PCR and serologic analysis, best if acute and
convalescent
Treatment: doxycycline best, second-line TMP-sulfa
Cryptococcus gatii Travel to endemic area (Pacic Northwest) Incubation: 8 wk to 13 mo
Diagnostic: cultureb
Treatment: amphotericin
Entamoeba Exposure to contaminated food, most commonly in Incubation: days to years, most commonly 24 wk
histolytica resource-limited settings, institutionalized settings, or Diagnostic: identication of organisms in sample,
men who have sex with men; occurs in conjunction serology
with liver abscess or triad of liver abscess, Treatment: metronidazole plus luminal amebicide
parapneumonic effusion, pericardial effusion
Francisella tularensis Exposure to ticks and potentially horseies or sick animals Incubation: 121 d (typically 35 d)
(most notoriously rabbits); history of lawn-mowing Diagnostic: cultureb, PCR of blood or source, serologic
over carcasses analysis
Treatment: aminoglycoside, ciprooxacin
Hantavirus Exposure to mice feces and/or urine in endemic area Incubation: 16 wk
(Colorado, Utah, New Mexico, Arizona); often Diagnostic: serologic analysis
hemoconcentration with thrombocytopenia Treatment: supportive
Histoplasmosis Travel to endemic area (Central United States), exposure Incubation: 13 wk for primary infection, disseminated
to birds and/or bird excrement disease weeks to years
Diagnostic: cultureb, serologic analysis, urine antigen
Treatment: not always needed, but if so amphotericin B,
itraconazole
Legionella Exposure to contaminated water supply Incubation: 210 d
pneumophila Diagnostic: culture, antigen in urine, serologic analysis
Treatment: azithromycin, levooxacin
Leptospira spp Exposure to urine (or water contaminated with urine) of Incubation: 230 d, usually 514 d
infected animals; usually some liver involvement, as Diagnostic: serologic analysis
well Treatment: penicillin
Mycobacterium Exposure to infected persons or high-risk settings or to Incubation: highest risk for disease rst 2 y after infection,
tuberculosis persons with chronic cough with such exposures but can be years
Diagnostic: culture, rapid diagnostics, clinical
Treatment: 4 drugs, see references
Mycoplasma Exposure to infected person 14 weeks ago Incubation: 14 wk (usually 23 wk)
pneumoniae Diagnostic: PCR (preferred), serum immunoglobulin M
Treatment: azithromycin
Continued
Yersinia pestis Exposure to infected animals, including prairie dogs, Incubation: 18 days
squirrels, ill cats and dogs, eas
85% of US cases are in New Mexico, Colorado, Arizona, Diagnostic: cultureb, PCR, serologic analysis
and California
Treatment: doxycycline, ciprooxacin second-line TMP-
sulfa
TMP-sulfatrimethoprim/sulfamethoxazole.
a
Information for consideration of differential only; practitioners should refer to the AAP Red Book and national guidelines. Timing of positive serologic
ndings varies, and some diseases require acute and convalescent sera. Some organisms require specic culture conditions. Treatment regimens may
depend on location and severity of disease.
2
Alert the laboratory if a specimen will be sent for culture that has a high risk of infection for laboratory personnel.
viral coinfection on bacterial pneumonia is an important pulmonary abscesses, bronchopleural stulas, and necro-
concept. Animal models suggest that respiratory viruses tizing pneumonia.
destroy the respiratory epithelium and change the landscape
of the cell surface to exhibit more antigen receptors. These
CAUSATIVE PATHOGENS AND THEIR IDENTIFICATION
changes impair the cough reex and mucociliary clearance.
In addition, viruses may inhibit normal macrophage func- Denitive identication of bacterial etiologic origins in CAP
tion. Inuenza is most commonly associated with subse- is limited by lack of a primary sample for culture or PCR
quent bacterial superinfection, but suspicion for this entity from the lower respiratory tract. This in turn limits our
should be high in any child with a viral prodrome who ability to describe with condence the microbial and epi-
exhibits abrupt worsening of clinical status in a time frame demiological patterns of bacterial pneumonia. That said,
in which a viral infection should be resolving. (14) A public bacterial causes of CAP continue to include Streptococcus
health example of this viral-bacterial interplay is readily avail- pneumoniae, S aureus, and S pyogenes. Overall, with the
able, in that pneumococcal vaccines decrease the morbidity advent of S pneumoniae vaccines, the incidence of unequiv-
of inuenza infections, while some viral vaccines decrease ocal bacterial CAP is decreasing, although of those who
the incidence of radiographic ndings of pneumonia. (15) develop CAP, S pneumoniae remains the most common
Bacterial pneumonia can be classied according to sev- cause. Multiple studies in which antigen detection and
eral pathophysiological denitions based primarily on radio- nucleic acid PCR were used on culture-negative empyemas
logic and physical ndings. Lobar pneumonia involves a demonstrated that most culture-negative empyemas are
single discrete lobe or lung segment of parenchymal inam- caused by penicillin-susceptible, nonvaccine serotypes of
mation, a discrete opacity on chest radiographs, and focal S pneumoniae. (13)(16)(17) For S aureus, there is some
ndings of crackles, bronchial breath sounds, and dimin- evidence that pediatric lung infections from methicillin-
ished aeration at auscultation. This classic pattern is typical resistant S aureus (MRSA) are increasing. (18)(19)(20)
of pneumococcal infection. Bronchopneumonia involves Because of immunization, herd immunity, and partial
inammation of the airways and interstitium and appears immune responses to even 1 dose of vaccine, invasive
more diffuse on images, with scattered crackles, rhonchi, disease due to Haemophilus inuenzae type B is now exceed-
and asymmetrical aeration at examination, commonly asso- ingly uncommon. Nontypeable H inuenzae strains are
ciated with Streptococcus pyogenes or Staphylococcus aureus. now responsible for most cases of invasive Haemophilus dis-
Mixed peribronchial and interstitial disease with focal ease, including pneumonia. (21) Between 2003 and 2012,
parenchymal inammation is observed in cases of viral the annual incidence of invasive, nontypeable H inuenzae
pneumonia that become subsequently bacterial (in patients disease was 1.6 cases per 100,000 children younger than 5
with inuenza, for example). Cavitary pneumonia is a result years of age. Invasive disease with Moraxella catarrhalis
of tissue necrosis associated with Mycobacterium tuberculo- is similar. Studies on the evaluation of the role of these
sis, although it can occur with other pathogens. (13) Com- organisms are marred by easy contamination from the
plicated pneumonia includes parapneumonic effusions, upper airway, and results are difcult to interpret. It is likely
are also consistent with viral disease or if providers are already Many centers now have rapid diagnostics to target M pneumo-
treating the patient for other bacterial causes. In adult popula- niae, so treatment might logically be reserved for hospitalized
tions, the desire to cover both Mycoplasma and bacterial causes patients with positive PCR test ndings.
has led to a crisis in the overuse of uoroquinolones, a practice Length of therapy for uncomplicated bacterial CAP
the Food and Drug Administration has strongly discouraged. should not exceed 7 days, and there are data to support 3
(39) Though azithromycin is largely ineffective against the days for nonsevere CAP. (44) Studies have demonstrated
traditional CAP pathogens mentioned earlier, it is often used similar success rates of 7 days when compared with 10 days
in an attempt to treat both typical and atypical infections, which and 5 days. (45)(46) Although all studies involving CAP
contributes to the fact that it is the second most commonly are subject to the Pollyanna phenomenon (positivity bias),
prescribed antimicrobial agent in outpatient pediatrics. (40) (47) the number and consistency of the shorter therapy
Despite a recent publication in which investigators suggest that studies increase the quality of the evidence such that the
azithromycin may decrease subsequent wheezing when used benets (in terms of mitigating resistance, decreased side
in early childhood, (41) the difculties of this research make the effects, and compliance) of 5 or 7 days should make these
results inconclusive, and any potential benet must be weighed lengths standard.
against the need for dual therapy, side effects, development of A patient is considered to have failed outpatient antimi-
resistance, and detrimental effects on the microbiome. (42)(43) crobial therapy for CAP when clinical worsening occurs,
Figure 3. Management of pneumonia with parapneumonic effusion. Adapted from Bradley et al. Clinical Infectious Disease 2011 and from Complicated
Community Acquired Pneumonia, Clinical Care Guidelines, Childrens Hospital Colorado, updated October 11, 2016. (71) CTcomputed tomography,
IRinterventional radiology, IVintravenous, POper os, tPAtissue plasminogen activator, USultrasonography, VATSvideo-assisted thorascopic
surgery.
1. A previously healthy 13-month-old girl who lives in Arizona is brought to the ofce with a REQUIREMENTS: Learners
2-day history of fever and increasing cough. Her mother states that the child has continued can take Pediatrics in Review
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She is alert and mildly ill appearing. Her temperature is 102.1F (38.9C), heart rate is 142 online only at: http://
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physical examination, there is no grunting or chest retractions. There are crackles heard
To successfully complete
over the right lung base. The remainder of the examination ndings are normal. She has no
2017 Pediatrics in Review
known allergies. Which of the following is the most likely pathogen?
articles for AMA PRA
A. Bordetella pertussis. Category 1 CreditTM, learners
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appropriate next step in treatment? and/or objectives of this
activity. If you score less than
A. Admit her to the hospital for intravenous (IV) ceftriaxone and vancomycin.
60% on the assessment, you
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questions until an overall 60%
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3. A previously healthy 18-month-old boy is admitted to the hospital after presenting to the This journal-based CME
emergency department with a 3-day history of fever and cough. His oral intake is activity is available through
decreased. His immunizations are up to date. He has no known allergies. At examination, Dec. 31, 2019, however, credit
he is moderately ill appearing. His temperature is 102.3F (39.0C), his heart rate is 148 will be recorded in the year in
beats/min, his respiratory rate is 48 breaths/min, and his oxygen saturation is 88% on room which the learner completes
air with subcostal retractions. Supplemental oxygen is administered, and his oxygen the quiz.
saturation increases to 98%. There are crackles at the left lung base. A chest
radiograph shows a focal left lower lobe consolidation with a small parapneumonic
effusion. Blood cultures are pending, and a viral respiratory screen yields negative results
for viral pathogens. Which of the following is the most appropriate next step in
management?
A. Chest tube placement and IV ceftriaxone and vancomycin. 2017 Pediatrics in Review now
B. IV ampicillin. is approved for a total of 30
C. IV ceftriaxone and oral azithromycin. Maintenance of Certication
D. IV ceftriaxone and vancomycin. (MOC) Part 2 credits by the
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4. A 4-year-old boy is admitted to the hospital with an 8-day history of increasing cough and 5 Portfolio Program. Complete
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radiograph shows an oval cystic lesion in the right middle lobe with an air-uid level. Blood 30 quizzes of journal CME
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B. Lateral decubitus chest radiography. as October 2017.
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