1. Community acquired pneumonia (CAP) presents differently in children and adults, with two main challenges being defining CAP in young children who often have viral and bacterial co-infections, and identifying the pathogen to avoid unnecessary antibiotic use. 2. The most prominent bacterial pathogens causing CAP across all age groups are Streptococcus pneumoniae and atypical organisms like Mycoplasma pneumoniae, while viruses account for the majority of CAP in children under 2 years old. 3. Clinical diagnosis and treatment of CAP in children is typically based on age, with guidelines recommending antibiotics for presumed bacterial CAP and observation without antibiotics for presumed viral CAP in preschool aged children.

2.  Community acquired pneumonia (CAP) -
different in children & adults.
 2 main challenges in diagnosis of CAP:
defn of CAP-young children-viral & bacterial
infections .
Identification of pathogen-unnecessary antibiotic
use.
 Challenge for general pediatrician –recognize
lower respiratory tract illness-treat with
antibiotics if bacterial pneumonia suspected.

3. WHO cough or difficult breathing
Fast breathing 2month-1yr : >50 br/min
1 yr-5yr : >40 br/min
BTS Persistent or repetitive fever >38.5C with chest
recession & increased respiratory rate.
IDSA Signs & symptoms of pneumonia in previously
healthy child caused by infection that has been
acquired outside hospital.

4.  First clinical issue- diagnose CAP & determine
which pathogen responsible.
 Streptococcus pneumoniae & Haemophilus
influenza type b (Hib) –fatal pneumonia in
children.
 Hib & pneumococcal vaccine-decline in Hib
 Atypical organisms –mycoplasma
pneumoniae, chlamydia pneumoniae-one
third of cases.

5.  Viral pathogens accounts for clinical
pneumonia- children < 1yr: 77 %
>2 yr:59 %
 Influenza A virus, RSV, para influenza virus
1,2,3.
 Study by Singleton & colleagues recovered
respiratory virus from 90 % of Alaskan
children younger than 3yrs-hospitalized with
respiratory infections.

6.  Case control study of 865 children –RSV,PIV,
hMPV & Influenza virus –common in
hospitalized cases than control children.
 Rhino virus –associated with bronchiolitis,
asthma & wheezing.
 HMPV –isolated from nasopharyngeal & throat
specimens of hospitalized children with CAP.
 Human Boca virus
 WU & KI polyoma viruses

7.  SARS –associated corona virus
 Dominguez & colleagues detected corona
virus RNAs -5% pediatric respiratory
specimens.
 Presented with vomiting or diarrhoea & 8%
with meningoencephalitis or seizures.
 Fungal pathogens-Histoplasma, Blastomyces,
Cryptococcus-pneumonia in
immunocompromised.

8. AGE TESTS
BIRTH-20 DAYS
Group B Streptococci Blood culture-progressive symptoms
& clinically deteriorate.
Gram negative Enteric Bacteria
Listeria Monocytogenes
21-90 DAYS
Chlamydia trachomatis NP culture or NP PCR
RSV, PIV3 NP swab for PCR, DFA staining,
immunofluorescence
Streptococcus pneumoniae Blood culture
Bordetella pertussis Blood culture, immunofluorescence
Staphylococcus aureus Blood & pleural fluid culture

9. AGE TESTS
4 MONTHS-4 YR
RSV, Para influenza virus, Influenza
virus, Adeno virus, Rhino virus
NP swab for PCR or
immunofluorescence, viral culture,
DFA staining
Streptococcus pneumoniae Blood culture, Urinary antigen,
Pneumolysin based PCR of blood
Haemophilus Influenza Blood & Pleural fluid culture
Mycoplasma Pneumoniae Quadrupling of acute &
convalescent serology, IgM
antibody in serum, throat or NP
swab PCR
Mycobacterium tuberculosis Sputum culture , Gastric aspirate,
Positive Tuberculin skin test

10. AGE TESTS
5 YR-15 YRS
Mycoplasma pneumoniae Quadrupling of acute & convalescent
serology, IgM antibody in serum,
Throat or NP swab PCR.
Chlamydia pneumoniae Quadrupling, NP culture or NP PCR
Streptococcus pneumoniae Blood culture, Urinary antigen,
Pneumolysin based PCR
•Influenza A or B, Adeno virus NP swab for PCR or
immunofluorescence, viral culture,
DFA staining
Haemophilus influenza Blood & Pleural fluid culture
Mycobacterium tuberculosis Sputum or gastric aspirate, positive
tuberculin skin test, Interferon
gamma release assay.

11.  Streptococcus pneumoniae
 Staphylococcus aureus
 Group A Streptococcus
 Haemophilus influenza type b
 Mycoplasma pneumoniae
 Adeno virus

12.  Viruses-Varicella zoster virus, Corona virus,
Entero viruses (Coxsackie virus, Echo virus),
Cytomegalo virus, Epstein Barr virus, Mumps
virus, Herpes simplex virus, Boca virus,
Polyoma virus, Measles virus, Hanta virus.
 Chlamydia psittaci
 Coxiella burnetii
 Bacteria-streptococcus pyogenes, klebsiella
pneumoniae, E.coli, Legionella, Neisseria
meningitidis, Brucella, Leptospira.

13.  Fungi-Coccidioides immitis, Histoplasma
capsulatum, Blastomyces dermatitidis.
PATIENT HISTORY
 Symptoms of pneumonia-fever, chills, cough
-can overlap with bacterial sepsis or severe
anaemia.
 Signs-crackles, egophony-more specific
 Chest radiography-gold standard for
confirmation of pneumonia.

14. FACTORS AGENTS
HOST FACTOR
SICKLE CELL DISEASE STREPTOCOCCUS PNEUMONIAE
HIV & CD4 + LYMPHOCYTE
COUNT<200
STREPTOCOCCUS PNEUMONIAE,
HAEMOPHILUS INFLUENZA,
CRYPTOCOCCUS NEOFORMANS,
MYCOBACTERIUM TUBERCULOSIS
STRUCTURAL LUNG DISEASE
( BRONCHIECTASIS)
PSEUDOMONAS AEROGINOSA

15. FACTORS AGENTS
TRAVEL
SOUTH EAST ASIA BULKHOLDERIA PSEUDOMALLEI,
MYCOBACTERIUM TUBERCULOSIS
CHINA, TAIWAN, TORONTO,
CANADA, MIDDLE EAST
CORONA VIRUS-SARS
TUBERCULOSIS ENDEMIC AREAS MYCOBACTERIUM TUBERCULOSIS
DESERT REGIONS OF SOUTH
WESTERN UNITED STATES,
CENTRAL & SOUTH AMERICA
COCCIDIODES IMMITIS
OHIO, ST LAWRENCE RIVER
VALLEYS
HISTOPLASMA CAPSULATUM
PERU SPOROTHRIX SCHENCKII

16. FACTOR AGENTS
ENVIORNMENTAL FACTORS
PNEUMONIA OUTBREAK IN A
HOMLESS SHELTER
STREPTOCOCCUS PNEUMONIA,
MYCOBACTERIUM TUBERCULOSIS
LAWN MOWING –SOUTH CENTRAL &
WESTERN STATES, MATHAS
VINEYARD
FRANCISELLA TULARENSIS
EXPOSURE TO CATS, SHEEPS, GOATS,
CATTLE-WESTERN STATES
COXIELLA BURNETII
SLEEEPING IN A ROSE GARDEN-
BALES OF HAY
SPOROTHRIX SCHENCKII
EXPOSURE TO WIND STORM COCCIDIODES IMMITIS, COXIELLA
BURNETII
EXPOSURE TO BATS, EXCAVATION HISTOPLASMA CAPSULATUM

17. ENVIORNMENTAL FACTORS
CAMPING, CUTTING DOWN TREES-
MISSISSIPPI RIVER, OHIO RIVER
VALLEY
BLASTOMYCES DERMATITIDIS
EXPOSURE TO MOUSE DROPPINGS-
FOUR CORNERS & YOSEMITE
NATIONAL PARK
HANTA VIRUS
IMMUNOSUPRESSED & EXPOSURE TO
HOT TUB- GROSERY STORE MIST
MACHINE , RECENT STAY IN HOTEL
OR VISIT TO HOSPITAL WITH
LEGIONELLACEAE CONTAMINATED
DRINKING WATER
LEGIONELLA PNEUMOPHILIA

18.  Cevey –Macherel & colleagues –more than fifth of
patients diagnosed with CAP had completely
normal breath sounds on admission &
ausultation was ruled to be poorly sensitive &
specific in diagnosing WHO guideline defined
pneumonia.
 In another study which defined pneumonia as
presence of crepitations, wheeze, bronchial
breathing, CXR abnormalities –repiratory rate
<40 breaths/min seen in 55% children older than
35 months with diagnosis of pneumonia.

19.  Canadian guidelines –oxygenation as good
indicator of severity of disease.
 Oxygen saturation recomm. by IDSA as guide for
referral of care.
 Pneumococcal pneumonia-history of fever,
breathlessness, signs of tachypnea, indrawing,
toxic appearance.
 Mycoplasma pneumonia-cough, chest pain,
wheezing, arthralgia, headache. Symptoms more
worse than signs.

20.  Mycoplasma pneumonia-common in children
aged 5yrs or younger –slow progression, sore
throat, low grade fever & cough .
 Many children with CAP have mixed bacterial
& viral infections.

21. INDICATIONS OF SEVERE PEDIATRIC CAP
1.Temperature >38.5 C
2. Respiratory rate: infants >70 breaths/min.
older children >50 breaths/min.
3.Moderate to severe recession.
4.Nasal flaring
5.Cyanosis
6.Grunting respiration.
7.Infants-intermittent apnea & not feeding
8. Tachycardia
9.Signs of dehydration.
10.Capillary refill time 2 seconds or more.

22. CRITERIA FOR HOSPITAL ADMISSION OF A
CHILD WITH CAP
1.Hypoxemia with O2 less than 90%
2.Infants younger than 3-6 months
.
3.Suspected or documented CAP caused by
pathogen with increased virulence-MRSA
4.Unable to be followed up

23. TRANSFER TO INTENSIVE CARE
1.Oxygen saturation >92%
2.Severe respiratory distress
3.Sustained tachycardia, inadequate blood
pressure
4.Exhaustion
5.Apnea
6.Slow breathing
7.Altered mental status

24.  Neither IDSA nor BTS recommends CXR for
confirmation of suspected CAP.
 Prospective study in Switzerland enrolling 99
patients found only 79 % had radiographic
consolidation with poor correlation b/w
radiographic findings & dimnished breath
sounds.
 Study in U.K by Clark & colleagues showed that
lobar CXR changes were not associated with
severity.

25.  Study from Brazil –upper lobe involvement
was shown to have 84% specificity in
predicting severity in children aged 1yr or
younger.
 IDSA guidelines support postero anterior( PA )
& lateral CXR –patients with hypoxemia or
respiratory distress & who have failed an
initial course of antibiotic.

26.  BTS guidelines donot recommend a lateral
CXR should be performed routinely.
 Frontal CXR-100 % sensitive & specific for
lobar consolidation but would under diagnose
non lobar infiltrates.
 Follow up CXRs indicated if child do not
improve clinically & with progressive
symptoms & clinical deterioration after 48-72
hrs of antibiotic therapy.

27.  Most bacterial pneumonia present with lobar
infiltrate.
 Interstitial infiltrates found in bacterial, viral
& atypical pneumonia.
 Mycoplasma pneumoniae –have diffuse
infiltrate radiologically out of propotion with
clinical findings.
 Lobar consolidation, atelectasis, nodular
infiltration & hilar adenopathy.

28.  Mycoplasma pneumoniae-IgM ELISA testing
in serum or plasma
PCR testing –nasal,throat or sputum
specimens.
 PCR testing detects more mycoplasma
infections than IgM ELISA.

29.  Streptococcus pneumoniae : round infiltrates
 Common causes for Round pneumonia :
Streptococcus pneumoniae
Klebsiella pneumoniae
Haemophilus influenza
Coxiella burnetii
Mycobacterium tuberculosis
Fungal infections, Hydatid cyst, Lung abscess

30.  Microbiological recovery sample from
infected region of lung-gold standard
 Tests: Blood culture, urinary antigen,
Pneumolysin based PCR of blood, pleural fluid
& secretions.
 Any child with suspected CAP –no indications
for any general investigations.

31.  Hospitalized child with CAP-testing for
potential pathogens & acute phase reactants-
WBC, CRP, ESR, Procalcitonin helpful.
 Study by Don & colleagues -101 children ,
showed increase of 4 serum nonspecific
inflammatory markers (WBC,CRP,ESR,PCT) was
associated with radiological evidence of CAP.

32.  Study by Lahti & colleagues –children 6
months & older showed inhalation of 5%
hypertonic saline for 5-10 min –provided
good quality sputum sample -90%
microbiological yield.
 New molecular diagnostic tests available-
Rapid antigen detection for respiratory virus.

33.  Age-best predictor of pediatric pneumonia
 Guidelines for treatment categorized by age &
suspected pathogens.
 BTS guidelines recommend children with
clinical diagnosis of pneumonia-antibiotics-
bacterial & viral pneumonia cannot be
differentiated.
 IDSA –no antibiotics-viral pathogens-most
CAP in preschool aged children.

34.  Streptococcus pneumoniae-most prominent
bacterial pathogen –all age groups.
 Amoxicillin-first line therapy for all healthy
immunized pts.
 IDSA guidelines-Amoxicillin 90 mg/kg/day in
2 divided doses.
 Atypical bacterial pathogens-Mycoplasma
pneumonia-school aged children & older pts.
 Macrolide therapy recomm.

35.  Atypical pneumonia : Azithromycin 10 mg/kg
on day 1 followed by 5mg/kg daily on days
2-5.
 Children aged 5yr or older with presumed
bacterial CAP –donot have clinical, laboratory,
radiographic evidence to distinguish bacterial
from atypical CAP-IDSA recommends
macrolide can be added to beta lactum
antibiotic.

36.  Treatment courses-10 days of beta lactam
antibiotics & 5 days for Azithromycin-
studied.
 Prolonged courses for MRSA.
 Canadian guidelines recomm. switching from
parenteral to oral therapy after 2-4 days, if
child is afebrile without complications.
 IDSA & BTS- no recomm. & no randomized
controlled studies.

37.  Apart from influenza , no data for antiviral
therapy against viruses assoc. pediatric CAP.
 Adamantanes & neuraminidase inhibitors –
effective against influenza A.
 Neuraminidase inhibitors for influenza B.
 Genetic variation in influenza strains from
year to year –resistant to either class of anti
viral agents.

38.  Anti microbial resistant Streptococcus
pneumoniae.
 Penicillin resistant Pneumococcal isolates.
Pneumococcal conjugate vaccine PCV 7 –
5 serotypes -89 % penicillin resistant
pneumococcal isolates.
 IDSA recomm. limiting antibiotic exposure &
using antibiotic with narrow spectrum &
shortest duration.

39.  Fluoroquinolones (FQ) avoided –children
younger than 18 yrs- arthropathy.
 Alternative therapy –serious infectious
diseases.
 Bradley & colleagues -738 children from 6
months to 16 yrs with CAP –levofloxacin &
comparator drug. Similar cure rate
 Musculoskeletal S.E-arthralgia, myalgia.
 Emerging drug resistance-FQ effective
alternate therapy.

40.  Children with CAP on adequate therapy should
clinically improve within 48-72 hrs.
 No improvement-complications pleural effusions,
empyema, necrotising pneumonia, septicemia &
(staphylococcal aureus -osteomyelitis or septic
arthritis ), hemolytic uremic syndrome.
 Children with severe pneumonia, empyema &
lung abscess –followed up untill complete
resolution clinically & on CXR.

41.  Vaccines-crucial role in prevention of
pneumonia.
 Pertussis cause pneumonia in 5 % &
11.8 % in younger than 6 months.
 Pneumonia complicating measles: 27 %-77 %
bacterial superinfection.
 Influenza vacccines prevent 87% of influenza
assoc. pneumonia –pneumococcal & MRSA
superinfection.

42.  13 valent Pnemococcal vaccine (PCV13)-
additional serotypes assoc. with empyema &
necrotizing pneumonia.
 High risk infants-RSV specific monoclonal
antibody decrease risk of pneumonia &
hospitalization.

43.  Diagnosis of CAP –not through
microbiological isolation but from clinical
symptoms & signs –supported by radiography
& serum laboratory tests.
 Causative pathogens challenging to isolate &
age is the best predictor of cause.
 Substantial propotion of CAP-mixed bacterial
& viral pneumonia

44.  IDSA guidelines in children >5 yrs or 5yrs or
more –Amoxicillin 90 mg/kg/day orally in 2
divided doses –presumed bacterial
pneumonia.
 Azithromycin 10 mg/kg on day 1 & 5mg/kg
on days 2-5-presumed Atypical pneumonia.
 Macrolide can be added to beta lactum
antibiotic –difficult to distinguish b/w
bacterial & atypical CAP.

45.  CAP is changing both in cause & management
 More molecular diagnostic techniques are
under trial.

47.  1. Two bacteria predom. responsible for fatal
pneumonia in children ?
 2.Defn. of CAP according to WHO, BTS, IDSA ?
 3.Microbial agents causing CAP in birth-20
days ?
 4.Common differential diagnosis for round
pneumonia ?
 5.Treatment for CAP according to IDSA
guidelines with dosage ?
 6.DFA testing used for which micro organism