Bacterial Pneumonia in Children

Bacterial pneumonia in children is lobar or bronchopneumonic infection by pyogenic bacteria, usually Streptococcus pneumoniae, with a more abrupt and severe course than viral pneumonia.

• Streptococcus pneumoniae is the commonest cause worldwide, then Haemophilus influenzae type b (in unimmunised children), Staphylococcus aureus, Group A Streptococcus and Klebsiella.
• Immunisation with pneumococcal conjugate and Haemophilus influenzae type b vaccines has cut incidence substantially.
• Risk factors include malnutrition, HIV, sickle cell disease, preceding viral infection (including measles and influenza), and indoor smoke.
• Complications are more frequent than with viral pneumonia.

Onset is abrupt with toxic appearance.

• High fever above 39 °C with rigors, productive or dry cough, chest or abdominal pain.
• Fast breathing, chest indrawing, grunting and nasal flaring.
• Focal signs: dullness, bronchial breathing, crackles, reduced air entry.
• Pleuritic chest pain and reluctance to lie on the affected side.
• Referred pain to the abdomen or shoulder from lower lobe or diaphragmatic disease.
• Staphylococcal pneumonia: rapid deterioration, pneumatoceles, empyema, pneumothorax and skin infection.
• Differential diagnosis: viral pneumonia, atypical pneumonia, tuberculosis, foreign body, pulmonary oedema, appendicitis, bronchiolitis obliterans and lung abscess.
• Complications: parapneumonic effusion, empyema, necrotising pneumonia, lung abscess, pneumothorax, bacteraemia, meningitis, osteomyelitis, septic arthritis and respiratory failure.

Diagnosis combines clinical and radiological findings.

• Chest X-ray: lobar or segmental consolidation, air bronchograms, effusion, pneumatocele.
• Full blood count (leucocytosis with neutrophilia), C-reactive protein and procalcitonin.
• Blood culture before antibiotics. Sputum or pleural fluid culture where obtainable.
• Pleural ultrasound for effusion, with diagnostic aspiration (pH, glucose, protein, lactate dehydrogenase, Gram stain, culture).
• Urinary pneumococcal antigen testing in older children (it is unreliable in young children, who carry the organism in the nose).
• HIV test and tuberculosis assessment if indicated.

Prompt antibiotics and treatment of complications.

• Supportive: oxygen to keep saturation above 92 percent, analgesia, fluids, nutrition and antipyretics.
• Pharmacological, oral for mild disease: amoxicillin 40 to 45 mg/kg twice daily (maximum 4 g/day) for 5 to 7 days.
• Intravenous for severe disease: benzylpenicillin 50,000 units/kg every 6 hours or ampicillin 50 mg/kg every 6 hours, or ceftriaxone 50 to 100 mg/kg once daily. Switch to oral when improving and afebrile for 24 to 48 hours. Total duration is 7 to 10 days, longer (2 to 4 weeks) in complicated disease.
• Staphylococcal infection: flucloxacillin 50 mg/kg every 6 hours (maximum 2 g per dose); vancomycin 15 mg/kg every 6 to 8 hours or clindamycin 10 mg/kg every 8 hours if methicillin-resistant strains.
• Penicillin allergy: clindamycin 10 mg/kg every 8 hours or a macrolide.
• Procedures: chest drain with intrapleural fibrinolytic (alteplase 0.1 mg/kg twice daily for 3 days) for empyema, or video-assisted thoracoscopic debridement. Drain a tension pneumothorax urgently.
• Special groups: infants and malnourished children need parenteral treatment initially. Children with sickle cell disease need antibiotics covering pneumococcus and exclusion of acute chest syndrome.
• Red flags: toxic appearance, cyanosis, persistent fever after 48 to 72 hours, large effusion, pneumatocele, shock, grunting and failure to feed.
• Follow-up: review at 48 hours. Follow-up X-ray at 4 to 6 weeks if complicated, round, recurrent or slow to resolve. Complete vaccines.