Community Acquired Pneumonia
DR. HARDIK SHAH
Pneumonia is the leading killer of children, causing
an estimated 1.9 million deaths worldwide under
the age of 5 years.
Pneumonia is an inflammation of the parenchyma
of the lungs.
In developed countries, the diagnosis is usually
made on the basis of radiographic findings.
The WHO has defined pneumonia solely on the
basis of clinical findings obtained by visual
inspection and counting the respiratory rate, for
The lower respiratory tract is normally kept sterile by
physiologic defense mechanisms, including
mucociliary clearance, the properties of normal
secretions such as secretory immunoglobulin A
(IgA), and clearing of the airway by coughing.
Immunologic defense mechanisms of the lung that
limit invasion by pathogenic organisms include
macrophages that are present in alveoli and
bronchioles, secretory IgA, and other
Viral pneumonia usually results from spread of
infection along the airways, accompanied by direct
injury of the respiratory epithelium, which results in
airway obstruction from swelling, abnormal
secretions, and cellular debris.
M. pneumoniae attaches to the respiratory
epithelium, inhibits ciliary action, and leads to cellular
destruction and an inflammatory response in the
S. pneumoniae produces local edema that aids in
the proliferation of organisms and their spread into
adjacent portions of lung, often resulting in the
characteristic focal lobar involvement.
S. aureus pneumonia manifests in confluent
bronchopneumonia, which is often unilateral and
characterized by the presence of extensive areas of
hemorrhagic necrosis and irregular areas of
cavitation of the lung parenchyma, resulting in
pneumatoceles, empyema, or, at
times, bronchopulmonary fistulas.
Any patient presenting with cough and difficult or
rapid breathing should be considered as a case of
Neonates present with tachypnea, and signs of
respiratory distress such as grunting, flaring and
Fever and cough may be absent; however
hypothermia and temperature instability may be
Nonspecific complaints, such as irritability or poor
feeding may be the presenting symptoms
Cyanosis may be present in severe cases
Chlamydia trachomatis pneumonia should be
considered in infants aged 2–4 wks and is often
associated with conjunctivitis.
After the first month of life, cough is the most common
Infants may have a history of antecedent upper
Depending upon the degree of illness, tachypnea,
grunting, and retractions may be noted.
Vomiting, poor feeding, and irritability are also common.
Infants with bacterial pneumonia often are febrile, but
those with viral or atypical pneumonia may have
lowgrade fever or could be afebrile.
Wheezing or noisy breathing. Wheeze suggests a viral
Toddlers and Preschool Children
A history of antecedent upper respiratory illness is
Cough is the most common presenting symptom.
The presence and degree of fever is dependent
upon the organism involved.
Vomiting, particularly post-tussive, may be present.
Chest pain may be observed with inflammation of or
near the pleura.
Abdominal pain or tenderness is often seen in
children with lower lobe pneumonia.
Older Children and Adolescents
Atypical organisms, such as Mycoplasma are
common in this age group.
In addition to the symptoms observed in younger
children, adolescents may have other constitutional
symptoms, such as headache, pleuritic chest
pain, and vague abdominal pain.
Headache, fever and myalgia are associated with M.
Vomiting, diarrhea, pharyngitis, and otalgia/otitis are
also common symptoms.
Assess for Contributing Etiology
Contact with person(s) having respiratory infection
Possibility of foreign body aspiration
Possibility of primary aspiration
Stools consistent with malabsorption (may suggest cystic
Growth and nutritional status
Risk Factors of CAP
young age (<6 months),
absence of (or inadequate) breastfeeding,
solid fuel use.
Hospital acquired infection/pneumonia include
hospitalization for ≥48 h, broad spectrum antibiotic
therapy for ≥7 days in the preceding 30
days, immunosuppressive therapy including
glucocorticoid therapy, neutropenia and severe
structural lung disease.
Any infant with age ≤2 months with symptoms
suggestive of pneumonia should be considered as
having severe pneumonia. Such a child needs
Tachypnea (respiratory rate >60/min) in this age
group is often associated with hypoxemia.
There is no validated criteria for severity assessment
in children >5 years.
In this age group, pneumonia is considered severe if
the following features (of severe respiratory distress)
o Respiratory rate >30/min
o Chest wall retraction
o Use of accessory muscles of respiration
o Altered sensorium
Chest radiographs are not needed routinely in all children with
Specific indications include:
1. When the diagnosis is in doubt (bronchiolitis, asthma, developmental
malformation, foreign body inhalation, aspiration pneumonia etc.)
2. Asymmetrical findings on chest examination
3. Suspected complications of pneumonia (pleural
effusion, empyema, lung abscess etc.)
4. Known case of recurrent chest infection (asthma,cystic
fibrosis, immunodeficiency etc.)
5. Severe and very severe pneumonia
Findings to be looked for in chest radiograph include:
Parenchymal infiltrates (evidence of consolidation)
Features of atypical pneumonia (bilateral streaky infiltrate)
Presence of pneumatocele
Any evidence of foreign body inhalation
Pleural spaces for pneumothorax, effusion
Arterial blood gas (ABG):
The indications are:
1. Severe and very severe pneumonia
2. Hypoxemia on pulse oxymetry (SpO2 <94% on 40%
Other Investigations in Hospitalized
Hemogram with total and differential leukocyte count
Serum electrolytes and renal function test
Blood culture: These are positive in 10%–20% of children with
Other diagnostic investigations:
In atypical pneumonia: Serology—
RSV, Mycoplasma, Chlamydia
CMV serology (if suspected like immune-compromised and
TORCH group of infection)
Atypical H1N1 (swine flu) testing during epidemics
CSF (if feasible) in case of
ii. Infants presenting with altered sensorium
The indications for hospitalization are:
Age <2 months
Severe and very severe pneumonia (as per WHO
Signs of shock
Hypoxemia (requirement for supplemental oxygen)
Moderate to severe malnutrition because it increases the
risk of mortality
Recurrent chest infection (cardiopulmonary
disease, anatomical defects in airway, neurological
Not accepting orally, dehydration, vomiting
No response or increased severity (treatment failure) on
appropriate oral antibiotic therapy
Family unable to provide appropriate care at home.
Resuscitation if required as per the Pediatric Assessment Triangle and
O2 inhalation by nasal prongs, at flow rate 1–5 l/min (depending on age) if
child has lower chest wall indrawing or SpO2 ≤92%.
First dose of antibiotic as early as possible; preferably after obtaining a
sample for blood culture. However, administration of the first dose should not
be delayed for this.
Hydration (intravenous or nasogastric tube feed)
i. If child is accepting orally well—allow orally (ad libitum)
ii. If not accepting well orally (but feeding not contraindicated)—Nasogastric
or orogastric feed can be started
iii. Start 0.45 Saline in 5% dextrose as 2/3rd to 3/4th maintenance if there is
respiratory distress (where feed cannot be started) or underlying dehydration
or ongoing losses through vomiting etc.
Treatment of other emergent co-morbidities
ii. Electrolyte imbalance
The choice of first-line antibiotic therapy is guided by:
Age of the child
Severity of pneumonia
Associated clinical features suggesting specific etiology
e.g. pustules suggesting Staphylococcal infection
Immune-suppressed or immunocompromised state (such
as post-measles state)
Underlying chronic lung disease e.g. cystic fibrosis
Radiographic pointers towards a specific etiology
(necrotizing pneumonia, pneumatoceles suggest
Staphylococcal infection, parahilar streaky infiltrates are
more common in atypical pneumonia.)
Presence of complication such as
Treatment of Non-severe Pneumonia (at home)
Non-severe pneumonia can be treated at home with
oral antibiotics in most cases.
Amoxicillin (50 mg/Kg/day) in 2 divided doses for 3– 5
Advise to return immediately if the child develops lower
chest indrawing, is unable to drink/feed, is excessively
sleepy or sick looking.
Follow-up after 2 days
If the child has persistent raised respiratory rate but no
indication for admission, change to Amoxicillin-
clavulanic acid (80–90 mg/kg of amoxicillin) in 2
divided doses for 5 days or add Azithromycin 5 mg/kg
for 5 days if clinical and radiological features suggest
If lower chest indrawing or a general danger sign
appears, hospitalize urgently for treatment as severe /
very severe pneumonia
Treatment of Severe Pneumonia
Hospitalize, continue oxygen.
Injectable ampicillin (50 mg/kg/dose) IV 6 hourly.
Add Cloxacillin (100–200 mg/kg/day in 4 four divided
doses) if clinical features (presence of
pustules, postmeasles state, severe
malnutrition, empyema) and radiographic features
(pneumatoceles, necrotizing pneumonia) suggest
Assess and monitor for oral intake/feeding, respiratory
rate, chest indrawing, and oxygenation (by pulse oximetry)
If at any time danger signs of very severe pneumonia
develop treat as very severe pneumonia
After 48 h—if improved: continue: on oral amoxicillin for 5
more days, if not improved in 48 h/deteriorated: treat as
Treatment of Pneumonia in infants
≤2 months old
Indications for PICU Transfer
At any stage, the following should be considered for
transfer to ICU:
Very severe pneumonia
Patients requiring intubation/ventilation
Presence of shocky failure