BTS guideline 2002 describes:
- Strep pneumoniae is the most common bacterial cause of pneumonia in childhood.
- Age is a good guide to cause: most younger children have a viral cause.
- In older children, the next most common bacterial causes are Mycoplasma and Chlamydia.
- A significant proportion (up to 40%) have a mixed infection.
- A significant proportion (up to 60%) have no identified cause.
In terms of clinical presentation:
- Wheeze in a preschool child makes a bacterial cause unlikely.
- Up to the age of 3yrs, a fever >38.5 together with recession and tachypnoea makes bacterial pneumonia likely.
- In older children, a history of difficulty breathing is more helpful than clinical signs (ie can be subtle and easily missed!).
Investigations:
- CXR not useful in mild cases. I would consider if hypoxia was disproportionate to degree of breathlessness (suggests collapse), suspicion of effusion (stony dullness on percussion) or pneumothorax.
- CXR is not useful in establishing viral vs bacterial vs atypical aetiology
- Repeat CXR in convalescence is only required for persisting symptoms, lobar collapse or round pneumonia.
Treatment:
- No antibiotics required for mild illness!
- Under 5yrs, amoxicillin is first line - effective, cheap.
- Over 5yrs, macrolide is an alternative
- Oral antibiotics are effective. Use IV if unable to tolerate orally or if severe (co-amoxiclav, cefuroxime, cefotaxime unless Pneumococcus is isolated in which case penicillin or amoxicillin).
