Community-acquired pneumonia (CAP) in children in Oslo, Norway

Short-term antibiotic therapy for the most common bacterial respiratory infections in infants and children

Overuse and misuse of antibiotics have strongly accelerated the progressive increase in bacterial antimicrobial resistance (AMR). The evidence that antimicrobial selective pressure was greater the longer the antibiotic therapy was continued has led some experts to reconsider duration of antibiotic therapy testing the use of short-term drug administration. If as effective as long-term therapy, short-term therapy could have been an easy measure to limit AMR emergence. In the present narrative review, whether present knowledge on short-term therapy of acute streptococcal pharyngitis (ASF), acute otitis media (AOM) and mild to moderate community-acquired pneumonia (CAP) allows systematic use of short-term therapy in infants and children with these diseases is discussed. Literature analysis showed that reducing the duration of antibiotic therapy for some of the most common pediatric respiratory infections could be a valid measure to contain the antibiotic abuse and the consequent impact on the emergence of AMR. Several data seem to indicate that this type of intervention is possible, as short-term therapy has been found as effective as the traditionally recommended long-term therapy in some cases of ASF, AOM and mild to moderate CAP. However, further studies are needed to better characterize infants and children who can have benefit with short-term antibiotic therapy in common bacterial respiratory infections.

Hospital Contacts for Infectious Diseases Among Children in Denmark, Finland, Norway, and Sweden, 2008-2017

Purpose

Comparing rates of childhood infectious disease hospitalisations across countries may uncover areas for improvement in the prevention of severe childhood infections. We compared rates of childhood infectious disease hospital contacts across Denmark, Finland, Norway, and Sweden with the overall objective to elucidate potential differences in burden of disease and in organisational and registration practices.

Methods

Using national registries, we estimated incidence rates for infectious disease hospital contacts between 2008 and 2017 among children aged 0–14 years. We investigated the rates for different types of contacts (inpatient or outpatient including emergency room), duration of admission, and by sex.

Results

During the study period, the rate of all hospital contacts per 1000 person-years was highest in Sweden (125.2) followed by Finland (87.1), Denmark (79.0), and Norway (62.1). The rates aligned for inpatient contacts with overnight stays; 19.3 (Denmark), 16.6 (Finland), 16.3 (Norway), and 13.0 (Sweden); these were highest in early infancy in all countries. A peak around 1 year of age was seen in all countries except in Sweden. The rates were higher among boys compared with girls in early childhood, after 13 years of age the rates among girls surpassed the boys.

Conclusion

Large cross-country differences were observed for outpatient and short-term hospital contacts for infectious diseases, affected by differences in organisational structures and coding practices across and within countries over time. Inpatient contacts requiring overnight stays reflected more comparable levels of severe infections across countries. Childhood infectious disease morbidity was greatest among boys and before 2 years of age.

Antibiotic prescribing for children with upper respiratory tract infection: a Finnish nationwide 7-year observational study

Upper respiratory tract infection (URTI) is a self-limiting viral infection and should not be treated with antibiotics. The aim was to evaluate antibiotic prescriptions for children with uncomplicated URTI in a large nationwide private clinic network between 2014 and 2020. Special focus was given to macrolide prescriptions and costs. The data were obtained from the electronic health records (EHR) of the largest private healthcare company in Finland (with about 250,000 paediatric visits annually across the country). The collected variables included diagnoses, age, visit year, speciality of the doctor, and prescribed antibiotics. The number of uncomplicated URTIs in < 18-year-old children was 156,187 (53.0% in boys). The prescription rate of antibiotics decreased from 18.0% in 2014 to 8.8% in 2020, and that of macrolides from 6.1 to 1.7%. The costs decreased accordingly. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists.

CONCLUSION

Antibiotic prescriptions for uncomplicated URTIs, especially macrolides, decreased substantially during the 7-year surveillance period; however, 8.8% of children still received unnecessary antibiotics. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.

WHAT IS KNOWN

• Upper respiratory tract infection (URTI) is the most common infection in children. Uncomplicated URTI is a self-limiting viral infection, and antibiotic treatment is not warranted.

WHAT IS NEW

• Almost 9% of children with uncomplicated URTIs still received unnecessary antibiotics. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.

Ceftaroline Fosamil for Treatment of Pediatric Complicated Skin and Soft Tissue Infections and Community-Acquired Pneumonia

Community-acquired pneumonia (CAP)/community-acquired bacterial pneumonia (CABP) and complicated skin and soft tissue infection (cSSTI)/acute bacterial skin and skin structure infection (ABSSSI) represent major causes of morbidity and mortality in children. β-Lactams are the cornerstone of antibiotic treatment for many serious bacterial infections in children; however, most of these agents have no activity against methicillin-resistant Staphylococcus aureus (MRSA). Ceftaroline fosamil, a β-lactam with broad-spectrum in vitro activity against Gram-positive pathogens (including MRSA and multidrug-resistant Streptococcus pneumoniae) and common Gram-negative organisms, is approved in the European Union and the United States for children with CAP/CABP or cSSTI/ABSSSI. Ceftaroline fosamil has completed a pediatric investigation plan including safety, efficacy, and pharmacokinetic evaluations in patients with ages ranging from birth to 17 years. It has demonstrated similar clinical and microbiological efficacy to best available existing treatments in phase III-IV trials in patients aged ≥ 2 months to < 18 years with CABP or ABSSSI, with a safety profile consistent with the cephalosporin class. It is also approved in the European Union for neonates with CAP or cSSTI, and in the US for neonates with ABSSSI. Ceftaroline fosamil dosing for children (including renal function adjustments) is supported by pharmacokinetic/pharmacodynamic modeling and simulations in appropriate age groups, and includes the option of 5- to 60-min intravenous infusions for standard doses, and a high dose for cSSTI patients with MRSA isolates, with a ceftaroline minimum inhibitory concentration of 2-4 mg/L. Considered together, these data suggest ceftaroline fosamil may be beneficial in the management of CAP/CABP and cSSTI/ABSSSI in children.

Half of all hospitalised children treated with antibiotics for pneumonia did not fulfil radiological, microbiological or laboratory criteria

AIM

Evaluating the management of paediatric pneumonia is important. We aimed to estimate the proportion of children receiving antibiotics for suspected community-acquired pneumonia (CAP) that were likely to have a bacterial infection. Furthermore, we described antibiotic use in relation to guidelines.

METHODS

We conducted a prospective observational study from a paediatric department in Norway. During 2017, all admitted children aged 0-17 years receiving antibiotics for CAP were enrolled in the study. We collected relevant data and defined likely CAP as one or more of the following: radiologically confirmed pneumonia, c-reactive protein of at least 100 mg/L, positive bacterial culture from blood or pleura, detection of bacteria from the nasopharynx associated with atypical pneumonia.

RESULTS

In total, 70 episodes of suspected CAP were included. Median age was 41.5 months, and 36 (51%) were girls. Of all treatments, 38 (54%) fulfilled our criteria for likely CAP. Median duration of treatment was 10 days. Of empirical treatments, 36 (57%) only involved penicillin. None of the children had neutropenia or complications, and only two needed intensive care.

CONCLUSION

Only half of children receiving antibiotics for suspected CAP were likely to have bacterial infection. Despite no obvious reason, antibiotic treatment was longer than currently recommended.

Complications in community acquired pneumonia: magnitude of problem, risk factors, and management in pediatric age

Introduction: In the last decades, the large use of several effective vaccines has dramatically reduced the incidence of community acquired pneumonia (CAP) in infants and children. Moreover, the availability of new antibiotics effective against emerging resistant strains of bacteria has greatly improved the early and long-term prognosis of this disease.Areas covered: The aim of this manuscript is to evaluate the burden of complicated CAP in pediatric age and to discuss its appropriate management.Expert opinion: Complicated CAP remains a problem for children in industrialized and developing countries. A larger use of lung ultrasonography (US) as first diagnostic approach could significantly improve early identification of cases at higher risk of complications. Difficult to solve, is the problem of the use of an antibiotic therapy able to assure adequate control in all the CAP cases, including those at high risk of or with already established complications. All these findings reveal that control of the incidence of complicated CAP remains difficult and will not be significantly changed in the next few years. Any attempt to improve complicated CAP management must be made. Consensus documents on better definition of the use of corticosteroids, fibrinolytic agents, and interventional procedures (including surgery) can allow us to reach this goal.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Effectiveness of Lung Ultrasound in Comparison with Chest X-Ray in Diagnosis of Lung Consolidation

BACKGROUND:

Lung ultrasound (US) is an available and inexpensive tool for the diagnosis of community-acquired pneumonia (CAP); it which has no hazards of radiation and can be easily used.

AIM:

To evaluate the efficacy of lung ultrasound in the diagnosis and follow-up of CAP.

PATIENTS AND METHODS:

100 patients aged from 40 to 63 years with a mean age of 52.3 ± 10 years admitted to the Critical Care Department, Cairo University with pictures of CAP. Lung US was performed for all patients initially, then a plain chest X-ray (CXR) was performed. Another lung ultrasound was performed on the 10th day after admission.

RESULTS:

Initial chest X-ray was correlated with the initial chest ultrasound examination in CAP diagnosis (R-value = 0.629, P < 0.001). Cohen’s κ was run to determine if there is an agreement between the findings of the initial chest X-ray findings and those of the initial chest ultrasound in CAP diagnosis. A moderate agreement was found where κ = .567 (95% CI, 0.422 to 0.712) and P < 0.001. Upon initial examination, the CXR diagnosed CAP in 48.0% of patients, while lung US diagnosed the disease in 70% of patients. Moreover, lung US was more sensitive than CXR (P-value < 0.001). Compared to the accuracy of computed tomography (CT) chest (100%) which is the gold standard for CAP diagnosis, the accuracy of lung US was 95.0%, while the accuracy of CXR was 81.0%.

CONCLUSION:

This study proved the effectiveness of lung ultrasound in CAP diagnosis.

Effects of air pollution on hospital visits for pneumonia in children: a two-year analysis from China

Although the effect of air pollution on respiratory health has been identified, few studies can be available to evaluate the association of air pollution with hospital visits for children's pneumonia in China. To explore whether high concentrations of air pollutants (including PM_2.5, PM₁₀, NO₂, and SO₂) are related to hospital visits for pneumonia in children, we conducted a population-based time-series study in Ningbo, China, from January 1st, 2014 to November 1st, 2015. We used a generalized additive Poisson regression model to calculate risk ratios and 95% confidence intervals for the associations of air pollutants and hospital visits for pneumonia in children and found that these four pollutants were associated with the increased hospital visits for pneumonia in children (1.3% for PM2.5, 1.0% for PM10, 2.9% for NO₂, 5.0% for SO₂ per 10-μg/m³ increase in PM2.5, PM10, NO₂, and SO₂, respectively). Stronger associations were observed in the cold seasons and among children under 5 years.

Trends in Hospitalization of Children with Bacterial Pneumonia in Poland

AIM

The aim of the study was to evaluate the hospitalization trends in children aged 0-6 suffering from bacterial pneumonia in the years 2007-2011 in Poland.

METHODS

The data pertained to the hospitalized patients diagnosed with the diseases registered as J13-J15 according to ICD-10.

RESULTS

In the years 2007-2011, the hospitalization rate increased from 16.3/10,000 to 44.1/10,000 for boys and from 13.8/10,000 to 33.0/10,000 for girls. The most frequently hospitalized children were between 1 and 2 years of age (90.6/10,000 for boys and 58.0/10,000 for girls in 2011). The average length of stay (LOS) of the investigated children fell from 10.1 days in 2007 to 8.2 days in 2011. The longest stays were recorded for the youngest children, under 2 years of age (from almost 11 days in 2007 to around 9 days in 2011).

CONCLUSION

Bacterial pneumonia is a serious problem of public health and especially babies are at high risk of this disease. Given the effects of vaccinations against Streptococcus pneumoniae conducted all over the world and to a limited extend in Poland as well, further steps towards vaccinating children against pneumococci should be taken in Poland.

Procalcitonin for Diagnostics and Treatment Decisions in Pediatric Lower Respiratory Tract Infections

Mortality and morbidity remain high in pediatric lower respiratory tract infections (LRTIs) despite progress in research and implementation of global diagnostic and treatment strategies in the last decade. Still, 120 million annual episodes of pneumonia affect children younger than 5 years each year leading to 1.3 million fatalities with the major burden of disease carried by low- and middle-income countries (95%). The definition of pneumonia is still challenging. Traditional diagnostic measures (i.e., chest radiographs, C-reactive protein) are unable to distinguish viral and from bacterial etiology. As a result, common antibiotic overuse contributes to growing antibiotic resistance. We present an overview of current evidence from observational and randomized controlled trials on a procalcitonin (PCT)-based diagnosis of pediatric LRTIs and discuss the need for an adequate PCT threshold for antibiotic treatment decision-making.

Immunogenicity of 13-Valent Pneumococcal Conjugate Vaccine in Pediatric Patients with Inflammatory Bowel Disease

BACKGROUND

There are only a few studies on immune response to pneumococcal vaccines in patients with inflammatory bowel disease (IBD); all of them assessed polysaccharide vaccines only. The aim of the study was to evaluate the immunogenicity and safety of 13-valent pneumococcal conjugate vaccine (PCV13) in IBD pediatric patients compared with healthy controls.

METHODS

This was a multicenter, prospective, and controlled study on children and adolescents aged 5 to 18 years with IBD with no history of pneumococcal immunization. The subjects for the study belonged to one of the following groups: patients with IBD on no immunosuppressive therapy (group A), those on tumor necrosis factor agents or immunomodulators (group B), and healthy controls (group C). The study population received 1 intramuscular injection of PCV13. The primary outcome measure was adequate vaccine response defined as postvaccination titer ≥0.35 μg/mL to all 13 serotypes. Geometric mean titers and geometric mean titer rises were measured for all serotypes. The evidence of local and systemic adverse effects for 5 days after the vaccine was registered.

RESULTS

A total of 178 subjects (122 patients and 56 controls) completed the study course. There was no significant difference in the rate of adequate vaccine response between patients with IBD and controls measured 4 to 8 weeks after vaccination (90.4% versus 96.5%, P = 0.5281). Children in group A had higher geometric mean titer rises than children in group B (P = 0.0369). There were no serious adverse events related to PCV13 during the study.

CONCLUSIONS

PCV13 is both immunogenic and safe in pediatric patients with IBD.

Impact of the socioeconomic status on the severity and outcome of community-acquired pneumonia among Egyptian children: a cohort study

BACKGROUND

Community-acquired pneumonia (CAP) is one of the five leading causes of death among children in developing countries, accounting for approximately three million deaths per year. Identification of the modifiable risk factors of CAP may help to reduce the burden of this disease. In this study, the impact of the socioeconomic status (SES) on the severity and outcome of CAP among Egyptian children was studied.

METHODS

This was a prospective longitudinal cohort study which included 1,470 children diagnosed with CAP, aged two to 15 years (median age 5.4 years). The diagnosis of CAP was based on clinical and radiological findings. A structured questionnaire and the patients' medical records were used for the data collection. The subjects were divided into two groups: mild and severe CAP. Social and demographic variables were compared, and a multivariate logistic regression analysis was performed.

RESULTS

THE MULTIVARIATE ANALYSIS SHOWED THAT A LOW MATERNAL EDUCATION LEVEL (OR: 3.8; 95% CI: 2.12 -6.70; P = .0001), unavailability of adequate medical care (OR: 3.1; 95% CI: 1.99 -4.88; P = .0001), a low family income (OR: 2.2; 95% CI: 0.99 -4.78; P = .047), and parents' smoking habits (OR: 2.0; 95% CI: 1.15 -3.55; P = .014) were significant independent predictive risk factors for severe CAP among Egyptian children.

CONCLUSION

Public health measures against these socio-demographic risk factors should be identified as priorities in order to help reduce the disease burden of deaths from severe CAP among Egyptian children.

Hospitalization rates of complicated pneumococcal community-acquired pneumonia is increasing in Tuscan children

To provide epidemiological data on community-acquired pneumonia (CAP) and complicated CAP, a retrospective study was conducted on a partially vaccinated paediatric population. Data from children hospitalized for CAP in Tuscan hospitals between January 1st, 1999 and December 31st, 2009 were analysed. A total of 5,450 children with CAP were hospitalized. Annual hospitalization rates for CAP did not change significantly over the study period (X2 for trend= 0.652; p=0.419). The total annual hospitalization rate for pneumococcal CAP varied according to age (28.04 per 100,000 children aged less than 5 years, 10.06 per 100,000 children aged 6-12 years and 0.98 per 100,000 children aged greater than13years). Hospitalization rates for pneumococcal CAP increased from12.84 (95 percent CI:7.35-18.34) in 2001 to 45.4 (95 percent CI:35.93-54.90) per 100,000 children aged less than 5 years in 2009 (p less than 0.0001). In addition, a significant increase of hospitalization rates for complicated CAP (from 6.07 in 1999 to 13.66 in 2009 per 100,000 children; P less than 0.0001) and pneumococcal complicated CAP (from 0.19 in 1999 to 3.41 in 2009 per 100,000 children) over the study period were highlighted. Our epidemiological data confirm the decision to introduce the PCV13 vaccine, to satisfy the need to prevent a wider group of pneumococcal serotypes.

Respiratory health outcomes 1 year after admission with severe lower respiratory tract infection

Severe lower respiratory infection (LRI) is believed to be one precursor of protracted bacterial bronchitis, chronic moist cough (CMC), and chronic suppurative lung disease. The aim of this study was to determine and to describe the presence of respiratory morbidity in young children 1 year after being hospitalized with a severe LRI. Children aged less than 2 years admitted from August 1, 2007 to December 23, 2007 already enrolled in a prospective epidemiology study (n = 394) were included in this second study only if they had a diagnosis of severe bronchiolitis or of pneumonia with no co-morbidities (n = 237). Funding allowed 164 to be identified chronologically, 131 were able to be contacted, and 94 agreed to be assessed by a paediatrician 1 year post index admission. Demographic information, medical history and a respiratory questionnaire was recorded, examination, pulse oximetry, and chest X-ray (CXR) were performed. The predetermined primary endpoints were; (i) history of CMC for at least 3 months, (ii) the presence of moist cough and/or crackles on examination in clinic, and (iii) an abnormal CXR when seen at a time of stability. Each CXR was read by two pediatric radiologists blind to the individuals' current health. Results showed 30% had a history of CMC, 32% had a moist cough and/or crackles on examination in clinic, and in 62% of those with a CXR it was abnormal. Of the 81 children with a readable follow-up X-ray, 11% had all three abnormal outcomes, and 74% had one or more abnormal outcomes. Three children had developed bronchiectasis on HRCT. The majority of children with a hospital admission at <2 years of age for severe bronchiolitis or pneumonia continued to have respiratory morbidity 1 year later when seen at a time of stability, with a small number already having sustained significant lung disease.

Community-Acquired Pneumonia in the Conjugate Vaccine Era

Community-acquired pneumonia (CAP) remains one of the most common serious infections encountered among children worldwide. In this review, we highlight important literature and recent scientific discoveries that have contributed to our current understanding of pediatric CAP. We review the current epidemiology of childhood CAP in the developed world, appraise the state of diagnostic testing for etiology and prognosis, and discuss disease management and areas for future research in the context of recent national guidelines.

Community-acquired lobar pneumonia in children in the era of universal 7-valent pneumococcal vaccination: a review of clinical presentations and antimicrobial treatment from a Canadian pediatric hospital

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of pediatric admission to hospital. The objectives of this study were twofold: 1) to describe the clinical characteristics of CAP in children admitted to a tertiary care pediatric hospital in the pneumococcal vaccination era and, 2) to examine the antimicrobial selection in hospital and on discharge.

METHODS

A retrospective review of healthy immunocompetent children admitted to a tertiary pediatric hospital from January 2007 to December 2008 with clinical features consistent with pneumonia and a radiographically-confirmed consolidation was performed. Clinical, microbiological and antimicrobial data were collected.

RESULTS

One hundred and thirty-five hospitalized children with pneumonia were evaluated. Mean age at admission was 4.8 years (range 0-17 years). Two thirds of patients had been seen by a physician in the 24 hours prior to presentation; 56 (41.5%) were on antimicrobials at admission. 52 (38.5%) of patients developed an effusion, and 22/52 (42.3%) had pleural fluid sampled. Of 117 children who had specimens (blood/pleural fluid) cultured, 9 (7.7%) had pathogens identified (7 Streptococcus pneumoniae, 1 Group A Streptococcus, and 1 Rhodococcus). 55% of patients received 2 or more antimicrobials in hospital. Cephalosporins were given to 130 patients (96.1%) in hospital. Only 21/126 patients (16.7%) were discharged on amoxicillin. The median length of stay was 3 days (IQR 2-4) for those without effusion and 9 (IQR 5-13) for those with effusion. No deaths were related to pneumonia.

CONCLUSIONS

This study provides comprehensive data on the clinical characteristics of hospitalized children with CAP in the pneumococcal 7-valent vaccine era. Empiric antimicrobial choice at our institution is variable, highlighting a need for heightened antimicrobial stewardship.

Risk factors for community-acquired pneumonia in pre-school-aged children

AIM

To identify risk factors for children developing and being hospitalised with community-acquired pneumonia.

METHODS

Children <5 years old residing in urban Auckland, New Zealand were enrolled from 2002 to 2004. To assess the risk of developing pneumonia, children hospitalised with pneumonia (n= 289) plus children with pneumonia discharged from the Emergency Department (n= 139) were compared with a random community sample of children without pneumonia (n= 351). To assess risk of hospitalisation, children hospitalised with pneumonia were compared with the children discharged from the Emergency Department. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were used to estimate the risk of pneumonia and hospitalisation with pneumonia.

RESULTS

After adjustment for season, age and ethnicity there was an increased risk of pneumonia associated with lower weight for height (OR 1.28, 95% CI 1.10-1.51), spending less time outside (1.96, 1.11-3.47), previous chest infections (2.31, 1.55-3.43) and mould in the child's bedroom (1.93, 1.24-3.02). There was an increased risk of pneumonia hospitalisation associated with maternal history of pneumonia (4.03, 1.25-16.18), living in a more crowded household (2.87, 1.33-6.41) and one with cigarette smokers (1.99, 1.05-3.81), and mould in the child's bedroom (2.39, 1.25-4.72).

CONCLUSIONS

Lower quality living environments increase the risk of pneumonia and hospitalisation with pneumonia in New Zealand. Poorer nutritional status may also increase the risk of pneumonia. Improving housing quality, decreased cigarette smoke exposure and early childhood nutrition may reduce pneumonia disease burden in New Zealand.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Pneumonia in the developed world

In this paper, we review the literature on the management of pneumonia in the developed world setting. Pneumonia is usually diagnosed on the basis of a cough, respiratory distress, a fever, and chest X-ray changes. Pneumonia affects all paediatric age groups, though the highest incidence is in the under 5s. There is a significant burden of primary and secondary care illness, although mortality is low. Inpatient admission rates for pneumonia may have increased in recent years in some regions. Pneumonia is unlikely if a child presents with solely wheeze. In routine clinical practice, a microbiological diagnosis is often not made, because current tests are insensitive. Aetiology varies with geographical location, but approximately half of cases are viral. The mainstay of management of moderate pneumonia (the commonest group presenting to secondary care) is careful assessment, and oral antibiotics, followed by early discharge when the patient shows signs of improvement. We summarise the available clinical trial data from the developed world; most of these trials are not adequately powered. Patients with moderately severe pneumonia do not require invasive investigation, but clinical judgement should be used to identify and investigate more complex cases. We discuss several pathogens that have gained importance as causal agents, including non-vaccinated strains of S. pneumoniae, Panton Valentine leucocidin S. aureus, H1N1 Influenza A and Human Bocavirus. The importance of antimicrobial resistance is considered, and we review recent data on long term effects of pneumonia in childhood. By reviewing the available literature, we demonstrate that there are clear evidence gaps, and we suggest future areas for clinical research.

Community-acquired pneumonia in children: what's old? What's new?

Community-acquired pneumonia (CAP) still remains a significant cause for childhood morbidity worldwide. Streptococcus pneumoniae is the most important causative agent at all ages. Respiratory syncytial virus is common in young children, and Mycoplasma pneumoniae in schoolchildren. Paediatric CAP is universally treated with antibiotics; amoxicillin is the drug of choice for presumably pneumococcal and a macrolide for presumably atypical bacterial cases. Because of globally increased resistances, macrolides are not safety for pneumococcal CAP. At present, available prospective research data on the epidemiology of paediatric CAP in western countries are from 1970s to 1980s; correspondingly, data on bacterial aetiology are mainly from 1980s to 1990s. Current concepts on pneumococcal aetiology are mostly based on poorly validated antibody assays. Most data on clinical characteristics in children's CAP, as well as on antibiotic treatment come from developing countries, thus not being directly applicable in western communities. Recent viral studies have revealed the role of rhinoviruses, metapneumovirus and bocavirus in the aetiology of paediatric CAP. This review critically summarizes the available data on epidemiology, aetiology, clinical presentation, treatment and outcome of CAP in children, with special focus on the newest microbial findings, the age and applicability of the data and the need of new studies.