Childhood community-acquired pneumonia

Abstract

Community-acquired pneumonia (CAP) is a common disease in children, and its aetiological and clinical diagnosis are challenging for physicians in both private practice and hospitals. Over the past three decades, conjugate vaccines have successfully reduced the burden of the former main causes of CAP, Streptococcus pneumoniae and Haemophilus influenzae type b. Today, viruses are by far the most commonly detected pathogens in children with CAP. Conclusion: New insights into the aetiology and treatment of CAP in children in recent years have influenced management and are the focus of this review. In addition to reducing diagnostic uncertainty, there is an urgent need to reduce antibiotic overuse and antimicrobial resistance in children with CAP. What is Known: • Conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae type b have shifted the epidemiology of childhood CAP to predominantly viral pathogens and Mycoplasma pneumoniae. • Clinical, laboratory, and radiological criteria cannot reliably distinguish between bacterial and viral aetiology in children with CAP. What is New: • Test results and epidemiological data must be carefully interpreted, as no single diagnostic method applied to non-pulmonary specimens has both high sensitivity and high specificity for determining pneumonia aetiology in childhood CAP. • This review provides a simple and pragmatic management algorithm for children with CAP to aid physicians in providing optimal and safe care and reducing antibiotic prescribing.

Keywords: Antibiotics; Antimicrobial resistance; Colonisation; Diagnosis; Respiratory tract infection; Vaccine.

Fig. 1

Milestones and changes in the aetiology of childhood pneumonia. Abbreviations: Hib, Haemophilus influenzae type b; PCR, polymerase chain reaction; PCV, pneumococcal conjugate vaccine. Pie charts adapted from Feikin et al. [3] and Jain et al. [1]. Surnames of inventors/discoverers are shown in parentheses. *Nobel laureates. The history of defined pneumonia dates back only to 1800. “Peripneumonia” was used prior to that to describe a clinical pattern with no distinction between pneumonia and pleuritis. The first milestones included a precise clinical description with the invention of the stethoscope (auscultatory findings) and autopsy (differentiation between lobar pneumonia and bronchopneumonia). This was followed by other milestones, such as the first description of pneumonia-causing pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae), the invention of X-ray technology, and initiation of the antibiotic era with the discovery of penicillin. The invention of PCR allowed the detection of several bacterial and viral pathogens, the distribution of which was significantly influenced by the development and introduction of conjugate vaccines against H. influenzae type b (Hib) and S. pneumoniae (PCV)

Fig. 2

Specimens and diagnostic methods for the microbiological diagnosis of CAP in children. Abbreviations: ASC, antibody-secreting cell; ELISA, enzyme-linked immunosorbent assay (serology); ELISpot, enzyme-linked immunospot assay (cell-based assay); PCR, polymerase chain reaction. Figure adapted from Meyer Sauteur [10]. Samples taken directly from the lungs are shown in bold and are the “gold standard” for the microbiological diagnosis of CAP. *The detection of pathogen-specific ASCs by ELISpot is not yet a validated method for the microbiological diagnosis of CAP

Fig. 3

Algorithm for the management of CAP in children. Abbreviations: CRP, C-reactive protein; MIRM, M. pneumoniae–induced rash and mucositis; PCR, polymerase chain reaction; PCT, procalcitonin; PO, oral treatment; RIME, reactive infectious mucocutaneous eruption; RTI, respiratory tract infection; SpO₂, saturation of peripheral oxygen. Figure adapted from Haq et al. [6]. *No specific score is available to assess the severity of CAP in children. **Details on dosage and duration of antibiotic treatment are given in Table 2. ***Parents are advised that they should call for a follow-up appointment at 48–72 h in case of non-response to empirical treatment. No follow-up is required if the child has already improved previously. In case of clinical deterioration, immediate presentation is required