Severe pneumonia in children: causes, diagnosis, and treatment: are you prepared for community-acquired MRSA?

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Date: Feb. 2008
From: Journal of Respiratory Diseases(Vol. 29, Issue 2)
Publisher: CMP Medica, LLC
Document Type: Disease/Disorder overview
Length: 4,409 words
Lexile Measure: 2130L

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ABSTRACT: Vaccines have substantially reduced the incidence of pediatric pneumonias caused by Haemophilus influenzae type b and certain serotypes of Streptococcus pneumoniae. However, other organisms are being identified more frequently, including methicillin-resistant Staphylococcus aureus (MRSA) and serotypes of S pneumoniae that are not covered by the pneumococcal vaccine. Although chest radiographs are still a basic component of the assessment of pneumonia, CT scans are increasingly being used to differentiate effusion from empyema and consolidation and to evaluate for pleural fluid loculations, lung abscesses, and lung necrosis. [beta]-Lactams, particularly extended-spectrum cephalosporins, remain an important cornerstone of the treatment of complicated pneumonia. In areas where community-acquired MRSA is a concern, empirical coverage for this pathogen should be considered in patients with a severe or necrotizing pneumonia.

KEY WORDS: Pneumonia, Pediatrics, Streptococcus pneumoniae, Staphylococcus aureus, MRSA

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Pneumonia is common in childhood--the incidence is 40 per 1000 among children younger than 5 years, with a gradual decline to 7 per 1000 in the early teenage years. (1) Discussion of pneumonia in children is complicated by several factors, such as the overlap in clinical signs and symptoms of bronchiolitis, differences in definitions used in various studies, and the absence of a gold standard diagnostic test.

Pneumonia is commonly defined as the presence of fever or acute respiratory symptoms and evidence of parenchymal infiltrates on a chest radiograph. (2) Indicators of severe pneumonia among children older than 1 year include hypoxemia (arterial oxygen saturation [Sa[O.sub.2]] of 92% or lower), temperature greater than 38.5[degrees]C (101.3[degrees]F), respiration rate greater than 50 breaths per minute, severe difficulty in breathing, nasal flaring, grunting respiration, and signs of dehydration. (3)

The criteria in infants are similar, except for a respiration rate greater than 70 breaths per minute, moderate to severe retractions, intermittent apnea, and poor feeding. These findings, and the inability of the patient's family to provide adequate observation or supervision, are considered to be indications for hospital admission. (3)

In this article, we focus on community-acquired pneumonia in previously healthy children who are at least 4 months of age and meet the criteria for severe disease.

EPIDEMIOLOGY

The causes of pediatric pneumonia vary greatly by age and epidemiological risk factors (Table 1). (2,4,5) The cause of pneumonia can be established in up to 85% of patients in the research setting when multiple diagnostic methods are used. (6) Viral pathogens are particularly important causes of bronchiolitis or pneumonia among children between 4 months and 5 years of age. Important viral pathogens that have been frequently identified include influenza virus, respiratory syncytial virus (RSV), and parainfluenza virus (particularly type 3). Adenovirus occasionally has been associated with severe pneumonia, including recent reports of severe pneumonia secondary to adenovirus 14 infection in previously healthy adults and children. (7-9)

It is uncertain whether some of the viruses identified-particularly rhinoviruses detected by polymerase chain reaction (PCR) assay -actually caused lower respiratory tract infection or may have predisposed the patient to bacterial infection. (6) However, it is certain that previous influenza predisposes children to pneumococcal pneumonia; a...

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Gale Document Number: GALE|A180349210