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Community-Acquired Pneumonia
in Children
KIMBERLY STUCKEY-SCHROCK, MD, Memphis, Tennessee
BURTON L. HAYES, MD, and CHRISTA M. GEORGE, PharmD
University of Tennessee Health Science Center, Memphis, Tennessee
Community-acquired pneumonia is a potentially serious infection in children and often results in

hospitalization. The diagnosis can be based on the history and physical examination results in children with
fever plus respiratory signs and symptoms. Chest radiography and rapid viral testing may be helpful when the
diagnosis is unclear. The most likely etiology depends on the age of the child. Viral and Streptococcus
pneumoniae infections are most common in preschool-aged children, whereas Mycoplasma pneumoniae is
common in older children. The decision to treat with antibiotics is challenging, especially with the increasing
prevalence of viral and bacterial coinfections. Preschool-aged children with uncomplicated bacterial
pneumonia should be treated with amoxicillin. Macrolides are first-line agents in older children. Immunization
with the 13-valent pneumococcal conjugate vaccine is important in reducing the severity of childhood
pneumococcal infections. (Am Fam Physician. 2012;86(7):661-667. Copyright © 2012 American Academy of
Family Physicians.)
C
ommunity-acquired pneumonia
infection accounts for 30 to 50 percent of CAP
(CAP) is a significant cause of
infections in children.7
respiratory morbidity and mortality
in children, especially in developing Streptococcus pneumoniae is the most com-
countries. Worldwide, CAP is the mon bacterial cause of CAP. The widespread
1
use of pneumococcal immunization has
leading cause of death in children younger reduced the incidence of invasive disease.8
than five years. Factors
2
that increase the Children with underlying conditions and
incidence and severity of pneumonia in chil- those who attend child care are at higher risk
dren include prematurity, malnutrition, low of invasive pneumococcal disease. Breast-
socioeconomic status, exposure to tobacco feeding seems to be protective. Penicillin-
smoke, and child care attendance.3 resistant S. pneumoniae infections can occur
Etiology in children with recent antibiotic use.9
Viruses cause a significant percentage of CAP Mycoplasma pneumoniae, Chlamydophila
infections, especially in children younger pneumoniae, and S. pneumoniae are the
than two years (Table 1).3,4 The prevalence of predominant etiologies of CAP in school-
viral pneumonia decreases with age.3 Respi- aged children.3 Haemophilus influenzae and
ratory syncytial virus, influenza A, and para- group A streptococcus are less common
influenza types 1 through 3 are the most causes. Staphylococcus aureus, especially
common viral agents. Other viral pathogens methicillin-resistant S. aureus (MRSA), is
include adenovirus, rhinovirus, influenza B, increasingly common and causes significant
and enteroviruses.5 Human metapneumo- morbidity and mortality.10 Identification of
S. pneumoniae and S. aureus as pathogens
can be problematic because they can be car-
virus has been identified as a ried asymptomatically.4
common cause of CAP in cases STAPHYLOCOCCUS AUREUS
Mycoplasma pneumoniae, previously classified as virus- S. aureus accounts for 3 to 5 percent of CAP
Chlamydophila pneumoniae, negative. The spectrum of infections and is a complication of seasonal
and S. pneumoniae are the illness caused by metapneu- and pandemic influenza in children and
predominant etiologies of movirus is similar to that of young adults.11 Reports of S. aureus infection
CAP in school-aged children. respiratory syncytial virus.6
Mixed viral and bacterial
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661 for
Community-Acquired Pneumonia in Children
associated with influenza-related deaths in

Table 1. Age-Based Etiologies of Childhood children have raised concerns that this
Community-Acquired Pneumonia syn- drome is increasing in
frequency.10,12 In the past decade, case
Age Common etiologies Less common etiologies series have estimated that 41 to 88
percent of patients with S. aureus
2 to 24 months Respiratory syncytial virus Mycoplasma pneumoniae pneumonia have MRSA isolates.10,13
Human metapneumovirus Haemophilus influenzae
Parainfluenza viruses (type B and nontypable)
Influenza A and B Chlamydophila pneumoniae
The potential severity of community-
Rhinovirus
acquired staphylococcal pneumonia in
Adenovirus
children is illustrated by a study of admis-
Enterovirus
sions to three children’s hospitals during
Streptococcus pneumoniae
the autumn and winter of 2006 and 2007.10
Chlamydia trachomatis
Of 30 patients, 25 (83 percent) required
2 to 5 years Respiratory syncytial virus Staphylococcus aureus
intensive care unit treatment, 21 (70 per-
Human metapneumovirus (including methicillin- cent) required mechanical ventilation, five
Parainfluenza viruses resistant S. aureus) (17 percent) required extracorporeal mem-
Influenza A and B Group A streptococcus brane oxygenation, and five (17 percent) died.
Rhinovirus The diagnosis of staphylococcal pneumo-
Adenovirus nia is challenging. No specific symptoms,
Enterovirus clinical signs, or imaging or laboratory
S. pneumoniae findings have been identified as having high
M. pneumoniae specificity for staphylococcal pneumonia.
H. influenzae (B and Cavitation on chest imaging, a pos- sible
nontypable) marker for staphylococcal pneumonia in
C. pneumoniae
adults,14 was identified in only two of 30
children hospitalized for CAP.10 Physicians
M. pneumoniae
Older than H. influenzae (B and should have a high index of suspicion for S.
5 years C. pneumoniae nontypable) aureus infection in children with CAP,
S. pneumoniae S. aureus (including methicillin- especially those who are severely ill, have
Rhinovirus resistant S. aureus)
current or recent influenza, or whose symp-
Adenovirus Group A streptococcus toms do not improve with beta-lactam or
Influenza A and B Respiratory syncytial virus macrolide antibiotic therapy.
Parainfluenza viruses
Human metapneumovirus
Enterovirus
NOTE: Etiologies listed in approximate order of prevalence in the community.

Information from references 3 and 4.
Table 2. World Health Organization Tachypnea Thresholds

for Diagnosing Pneumonia in the Presence of Cough
Normal respiratory rate Tachypnea threshold

Age (breaths per minute) (breaths per minute)
25 to 40 50
2 to 12 months
1 to 5 years 20 to 30 40
Information from reference 18.
662 American Family Physician www.aafp.org/afp Volume 86, Number 7 ◆ October 1, 2012

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Community-Acquired Pneumonia

Community-acquired pneumonia is a potentially serious infection in children and often results in

associated with influenza-related deaths in

NOTE: Etiologies listed in approximate order of prevalence in the community.

Table 2. World Health Organization Tachypnea Thresholds

Normal respiratory rate Tachypnea threshold

Information from reference 18.

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