Introduction
Community-acquired pneumonia (CAP), a commonly occurring condition, is described as “an acute infection of the pulmonary parenchyma that has been acquired outside of the hospital.” Because it is challenging to retrieve a specific sample of the infected tissue for culture, the exact cause of CAP frequently remains unknown. This could make it difficult to diagnose and treat CAP. Though some adults with CAP typically present with a cough, fever, sputum production, and pleuritic chest pain, along with the presence of an acute infiltrate on a chest radiograph, diagnosing children with CAP can be challenging due to the wide range of presentation. While CAP can present in some children as an acute febrile illness with clinical decompensation, a small proportion of pediatric patients younger than five years may only experience fever.
This article will review the most recent clinical recommendations for treating children who have developed community-acquired pneumonia.
What Is the Prevalence of Community-Acquired Pneumonia?
Acute infections of the lower airways, known as pneumonia, have the potential to cause serious respiratory distress, such as tachypnea and increased work of breathing. All newborns and kids with moderate to severe illnesses marked by hypoxemia and respiratory distress should be admitted to the hospital. Over 100,000 pediatric patients are admitted to hospitals in the US (United States) each year due to community-acquired pneumonia (CAP), which is a leading cause of pediatric hospitalization. The disease burden is greatest in children under the age of five, who also make up two-thirds of all pediatric pneumonia hospitalizations. A child is more likely to get pneumonia if they are young or born preterm. Having a crowded home, being around secondhand smoke, and having poor nutrition are all modifiable risk factors for pediatric CAP.
The etiology of pneumonia varies with age, underlying diseases, location, vaccination history, and season. The epidemiology of CAP in the US and around the world has changed as a result of the inclusion of pneumococcal conjugate vaccines (PCV) in childhood immunization schedules. The enormous burden of viruses causing pneumonia in children is being highlighted by advances in methods for identifying viral pathogens.
What Is the Diagnosis of Community-Acquired Pneumonia?
To diagnose CAP in children correctly, a thorough physical examination and history taking are essential. The patient’s history should include the patient's age, the nature of their symptoms, when they started, their immunization status (especially for Influenza and Streptococcus pneumonia), and whether they have recently been exposed to tuberculosis. The severity of pneumonia is frequently ascertained through a thorough physical examination that includes vital signs. Children who are very ill should be checked for parapneumonic effusion or empyema symptoms, such as dyspnea (shortness of breath), a dry cough, pleuritic chest pain, frictional rub on auscultation, or a decrease in breath sounds. The mentioned combinations of clinical features are the most indicative of severe CAP in children who are critically ill. Each and every child with suspected hypoxemia (low oxygen levels in blood) and pneumonia should have their pulse oximetry checked. Decisions about the location of care and additional diagnostic testing should be made based on the presence of hypoxemia.
Only clinical findings and a high index of suspicion should be used to order additional laboratory tests and imaging studies, like a chest X-ray. The value of a complete blood count (CBC) in children with pneumonia signs and symptoms has not been highly supported by research, so it should only be taken into consideration if this further information can help justify the use of antibiotics. In bacterial infections, the white blood cell count is typically 15,000 per mm or higher. Based on the clinical guidelines Texas children's hospital, blood cultures are generally not advised for uncomplicated bacterial pneumonia, particularly in the outpatient setting. However, it is gathered before antibiotics are given, and it may be useful for kids with more severe illnesses.
If travel and family history indicates a potential exposure to tuberculosis, a tuberculin skin test should be performed. For children with a cough lasting longer than two weeks, a pertussis polymerase chain reaction (PCR) can be collected from a nasopharyngeal swab.
How Is Community-Acquired Pneumonia Treated?
A drug belonging to the macrolide class or Doxycycline is a suitable first-line medication for the outpatient treatment of adults without comorbidities. Adults with comorbidities like diabetes, cancer, chronic obstructive pulmonary disease, or other long-term illnesses can receive monotherapy with either a respiratory Fluoroquinolone (like Moxifloxacin, Gemifloxacin, or Levofloxacin) or an advanced Macrolide (like Azithromycin or Clarithromycin). Another option is to combine beta-lactams with macrolides, such as high-dose Amoxicillin or Amoxicillin Clavulanate. Patients with or without comorbidities should receive treatment with a respiratory Fluoroquinolone or a combination of antibiotics in areas where the prevalence of high-level macrolide-resistant Streptococcus pneumoniae infection is 25 percent or higher.
The antibiogram of the particular hospital should be consulted by the clinician to determine the susceptibility and resistance pathways of common CAP pathogens in an inpatient setting. Adult CAP should be treated with respiratory Fluoroquinolone as a monotherapy in the medical ward. For some people, a combination of an advanced Macrolide and a beta-lactam agent like Cefotaxime, Ceftriaxone, Ampicillin, or Ertapenem may be beneficial. If the pseudomonas infection is a specific concern, anti-pneumococcal - antipseudomonal beta-lactams such as Cefepime, Imipenem, Meropenem, or Piperacillin and Tazobactam should be given in combination with Ciprofloxacin or Levofloxacin.
What Are the Safety Response and Criteria For Discharge?
Children should be allowed to stop taking oral antibiotics when they defecate, get better at breathing on their own, and do not need extra oxygen or intravenous fluids. Most kids with uncomplicated pneumonia who are hospitalized are released after two or three days. However, there is some evidence to support this recommendation, national and international guidelines advise a brief course of IV (intravenous) antibiotics before switching to oral therapy. In reality, the majority of kids receive IV therapy while they are in the hospital, switching to oral therapy is done just before they are released.
Conclusion
New studies from the developing world focuses on initial empiric oral therapy role in severe diseases, but more research is required. As always, patients with complicated pneumonia, pleural effusion, or those in need of intensive care should receive extra consideration.
