The New England Journal of Medicine
Review Article
Current Concepts
Volume 346:429-437
February 7, 2002
Number 6
Community-Acquired Pneumonia in Children
Kenneth McIntosh, M.D.
Community-acquired pneumonia is a common and potentially serious infection
that afflicts children throughout the world; it is fundamentally different
in children and in adults. The annual incidence of pneumonia in children
younger than 5 years of age is 34 to 40 cases per 1000 in Europe and North
America, higher than at any other time of life, except perhaps in adults
older than 75 or 80 years of age. 1
<http://content.nejm.org/cgi/content/short/346/6/#R1> , 2
<http://content.nejm.org/cgi/content/short/346/6/#R2> , 3
<http://content.nejm.org/cgi/content/short/346/6/#R3> , 4
<http://content.nejm.org/cgi/content/short/346/6/#R4> In the developing
world, pneumonia is not only more common than it is in Europe and North
America 5 <http://content.nejm.org/cgi/content/short/346/6/#R5> , 6
<http://content.nejm.org/cgi/content/short/346/6/#R6> , 7
<http://content.nejm.org/cgi/content/short/346/6/#R7> ; it is also more
severe and is the largest killer of children. 8
<http://content.nejm.org/cgi/content/short/346/6/#R8> , 9
<http://content.nejm.org/cgi/content/short/346/6/#R9>
Definitions of pneumonia vary widely. Some require only the presence of
infiltrates on a chest radiograph, 2
<http://content.nejm.org/cgi/content/short/346/6/#R2> whereas others
require only certain respiratory symptoms or signs. 3
<http://content.nejm.org/cgi/content/short/346/6/#R3> The World Health
Organization has defined pneumonia solely on the basis of clinical findings
obtained by visual inspection and timing of the respiratory rate. 10
<http://content.nejm.org/cgi/content/short/346/6/#R10> Definitions are a
particular problem in the case of small infants, since pneumonia and
bronchiolitis are both common in this age group, and the features of these
two diseases often overlap. Many studies, particularly those in the
developing world, use the term "acute lower respiratory tract illness" and
make no attempt to differentiate pneumonia from bronchiolitis. 7
<http://content.nejm.org/cgi/content/short/346/6/#R7> For the purposes of
this review, and particularly with respect to recommendations for treatment,
pneumonia will be defined as the presence of fever, acute respiratory
symptoms, or both, plus evidence of parenchymal infiltrates on chest
radiography. Even this definition overlaps somewhat with that of
bronchiolitis and leaves some room for disagreement among clinicians.
Causes
A very large number of microorganisms can cause childhood pneumonia ( Table
1 <http://content.nejm.org/cgi/content/short/346/6/#T1> and Table 2
<http://content.nejm.org/cgi/content/short/346/6/#T2> ), and determining the
cause of an individual case may be difficult. The lung itself is rarely
sampled directly, and sputum representing lower-airway secretions can rarely
be obtained from children. In addition, as is the case in adults, culture of
secretions from the upper respiratory tract is not useful, since the normal
flora includes the bacteria commonly responsible for pneumonia.
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Table 1. Common Causes of Community-Acquired Pneumonia in Otherwise Healthy
Children.
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Table 2. Uncommon Causes of Community-Acquired Pneumonia in Otherwise
Healthy Children.
Multiple investigations of pediatric pneumonia during the 1960s and 1970s in
North America and Europe emphasized the importance of infections with
respiratory viruses (respiratory syncytial virus, influenzavirus,
parainfluenza viruses, and adenovirus) in preschool children, Mycoplasma
pneumoniae in school-age children, and Chlamydia trachomatis in infants
between two weeks and four months of age. Multiple studies have confirmed
the capacity of these agents to cause pneumonia, although their role in
individual cases may sometimes be unclear. More recently, C. pneumoniae has
been found in school-age children with pneumonia, 12
<http://content.nejm.org/cgi/content/short/346/6/#R12> , 13
<http://content.nejm.org/cgi/content/short/346/6/#R13> , 14
<http://content.nejm.org/cgi/content/short/346/6/#R14> , 15
<http://content.nejm.org/cgi/content/short/346/6/#R15> but the strength of
arguments for an etiologic role is diluted by the frequency of asymptomatic
infections. 16 <http://content.nejm.org/cgi/content/short/346/6/#R16>
Similarly, the roles of cytomegalovirus, Ureaplasma urealyticum,
Pneumocystis carinii, 17
<http://content.nejm.org/cgi/content/short/346/6/#R17> and more recently,
rhinoviruses 11 <http://content.nejm.org/cgi/content/short/346/6/#R11> as
causes of community-acquired pneumonia in otherwise healthy infants and
children remain controversial, in view of the absence of confirmatory
studies or, in some instances, the high frequency of prolonged carriage or
asymptomatic infection — features that make it difficult to demonstrate a
causal role.
The role of bacteria as a cause of severe pneumonia is best documented in
lung-puncture studies, which have been conducted largely in the developing
world. 18 <http://content.nejm.org/cgi/content/short/346/6/#R18> , 19
<http://content.nejm.org/cgi/content/short/346/6/#R19> , 20
<http://content.nejm.org/cgi/content/short/346/6/#R20> , 21
<http://content.nejm.org/cgi/content/short/346/6/#R21> , 22
<http://content.nejm.org/cgi/content/short/346/6/#R22> , 23
<http://content.nejm.org/cgi/content/short/346/6/#R23> , 24
<http://content.nejm.org/cgi/content/short/346/6/#R24> , 25
<http://content.nejm.org/cgi/content/short/346/6/#R25> , 26
<http://content.nejm.org/cgi/content/short/346/6/#R26> These have confirmed
the importance of Streptococcus pneumoniae, Staphylococcus aureus, and
Haemophilus influenzae, including nontypable strains, as causes of severe
pneumonia. In some studies, S. pyogenes and gram-negative enteric bacteria
also appear. 22 <http://content.nejm.org/cgi/content/short/346/6/#R22> , 23
<http://content.nejm.org/cgi/content/short/346/6/#R23> Other series that
have focused on severe or complicated disease, particularly cases involving
parapneumonic effusions, have also demonstrated the importance of bacteria
as causes of pneumonia. 27
<http://content.nejm.org/cgi/content/short/346/6/#R27>
The precise role of bacteria, particularly in less severe disease, remains
controversial. There have been efforts over the past decade to define this
role more clearly, largely through the measurement of bacterial antigens,
nucleic acid (by means of the polymerase-chain-reaction assay), antibodies,
or immune complexes in blood or urine. 11
<http://content.nejm.org/cgi/content/short/346/6/#R11> , 28
<http://content.nejm.org/cgi/content/short/346/6/#R28> , 29
<http://content.nejm.org/cgi/content/short/346/6/#R29> , 30
<http://content.nejm.org/cgi/content/short/346/6/#R30> , 31
<http://content.nejm.org/cgi/content/short/346/6/#R31> , 32
<http://content.nejm.org/cgi/content/short/346/6/#R32> , 33
<http://content.nejm.org/cgi/content/short/346/6/#R33> , 34
<http://content.nejm.org/cgi/content/short/346/6/#R34> , 35
<http://content.nejm.org/cgi/content/short/346/6/#R35> , 36
<http://content.nejm.org/cgi/content/short/346/6/#R36> , 37
<http://content.nejm.org/cgi/content/short/346/6/#R37> The value of these
tests is, however, questionable. Antigen tests lack specificity, 38
<http://content.nejm.org/cgi/content/short/346/6/#R38> and evidence of the
sensitivity and specificity of bacterial antibody tests in children is
either absent (in the case of nontypable H. influenzae and Moraxella
catarrhalis) or severely limited (S. pneumoniae). 26
<http://content.nejm.org/cgi/content/short/346/6/#R26> One point is clear:
the more tests that are done, the more potential causes emerge. Two
contrasting studies illustrate this point. In one large, early series, no
serologic tests were performed, and mycoplasma or viruses were identified by
culture of respiratory secretions. 3
<http://content.nejm.org/cgi/content/short/346/6/#R3> In only 24 percent of
cases was a potential cause identified, and only 0.3 percent involved
combined infections. In contrast, a recent case series included antibody
tests for S. pneumoniae and H. influenzae, as well as sensitive solid-phase
immunoassays for respiratory viruses and a polymerase-chain-reaction assay
for rhinoviruses. 11 <http://content.nejm.org/cgi/content/short/346/6/#R11>
A potential cause was identified in 85 percent of cases, and combined
infections, usually bacterial and viral, were seen in 41 percent.
It is not clear what these multiple microbial associations mean. For
example, in spite of the demonstration of possible pneumococcal involvement
(with the use of serologic methods) in 39 percent of hospitalized children
with respiratory syncytial virus infection, 39
<http://content.nejm.org/cgi/content/short/346/6/#R39> experience dictates
that antibiotics are rarely indicated in the treatment of such children. 40
<http://content.nejm.org/cgi/content/short/346/6/#R40> Although by damaging
the respiratory tract, a respiratory virus or M. pneumoniae might facilitate
the aspiration of bacteria into the lungs or the escape of bacterial
components into the lymph or bloodstream, triggering the production of
antibody or immune complexes, this mechanism does not mean that these
bacteria are the cause of pneumonia, nor does it mean, on a more practical
level, that they need to be treated with antibiotics. In fact, the apparent
35 percent reduction in the incidence of disease associated with the use of
the recently licensed pneumococcal conjugate vaccine may provide the
clearest estimate of the role of S. pneumoniae in causing childhood
pneumonia in Europe and the United States. 41
<http://content.nejm.org/cgi/content/short/346/6/#R41> , 42
<http://content.nejm.org/cgi/content/short/346/6/#R42>
In the developing world, bacteria, particularly S. pneumoniae, H.
influenzae, and S. aureus, play a critical part in causing life-threatening
pneumonia, usually with lobar consolidation. Bacteria are also the chief
cause of severe or complicated pneumonias in children in Europe and North
America, although widespread immunization has nearly eliminated pneumonia
due to H. influenzae type b in the United States. In the future,
immunization may reduce the frequency of pneumonia due to S. pneumoniae.
Certain respiratory viruses, C. trachomatis, and M. pneumoniae are also
important causes of disease in preschool and school-age children. Emerging
evidence indicates that C. pneumoniae infection may be the cause of a
substantial fraction of cases of pneumonia among school-age children and
adolescents. 12 <http://content.nejm.org/cgi/content/short/346/6/#R12>
Diagnosis
Establishing a microbiologic diagnosis, despite its limitations, may be
important in children with severe or complicated pneumonia or in those with
unusual but treatable causes. A guide to preferred diagnostic procedures is
presented in Table 3 <http://content.nejm.org/cgi/content/short/346/6/#T3> .
As a practical matter, however, the cause of pneumonia can usually be
surmised on the basis of clinical and epidemiologic data, findings on chest
radiography, and a few laboratory tests such as a complete blood count,
erythrocyte sedimentation rate, and levels of C-reactive protein. Although
it is difficult to determine the accuracy of such nonmicrobiologic
diagnostic approaches because of the lack of an etiologic gold standard,
there have been many attempts to correlate them with microbiologic causes.
The results of these attempts have been confusing.
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Table 3. Microbiologic Diagnosis of Pneumonia in Children.
For example, although the differentiation between typical (i.e., bacterial)
pneumonia and atypical (i.e., viral or mycoplasmal) pneumonia may be
clinically useful in the case of adolescents and adults, these syndromes are
not well defined in infants and preschool children. In four large series in
which investigators looked carefully at the cause of pediatric pneumonia in
relation to clinical or epidemiologic findings, the signs and symptoms were
surprisingly uniform throughout the etiologic spectrum. 34
<http://content.nejm.org/cgi/content/short/346/6/#R34> , 35
<http://content.nejm.org/cgi/content/short/346/6/#R35> , 36
<http://content.nejm.org/cgi/content/short/346/6/#R36> , 43
<http://content.nejm.org/cgi/content/short/346/6/#R43> In one study,
pneumonias related to bacterial infection and those related to viral
infection differed only with respect to the incidence of conjunctivitis (27
percent, as compared with 8 percent) and otitis media (42 percent, as
compared with 22 percent). 35
<http://content.nejm.org/cgi/content/short/346/6/#R35> In two other
studies, wheezing was found more frequently in patients with viral pneumonia
than in those with bacterial pneumonia (43 percent vs. 16 percent 34
<http://content.nejm.org/cgi/content/short/346/6/#R34> and 56 percent vs.
16 percent 43 <http://content.nejm.org/cgi/content/short/346/6/#R43> ), but
the features that we usually associate with viral respiratory tract
infection, such as rhinorrhea, illness in family members, and myalgia, were
not. 34 <http://content.nejm.org/cgi/content/short/346/6/#R34> , 43
<http://content.nejm.org/cgi/content/short/346/6/#R43>
When chest radiographs are subjected to blinded readings, they also cannot
be used to differentiate between viral and bacterial disease. Several
studies flatly state that there are no radiologic features that can be used
to differentiate between these two major etiologic classes. 44
<http://content.nejm.org/cgi/content/short/346/6/#R44> , 45
<http://content.nejm.org/cgi/content/short/346/6/#R45> Another study
concludes that radiographic findings have less discriminatory value than
does measurement of C-reactive protein, erythrocyte sedimentation rate, or
the white-cell count and the differential count. 46
<http://content.nejm.org/cgi/content/short/346/6/#R46> In contrast, using
data from a large Finnish series, Korppi and his colleagues 47
<http://content.nejm.org/cgi/content/short/346/6/#R47> concluded, as would
many radiologists, 48 <http://content.nejm.org/cgi/content/short/346/6/#R48>
that an alveolar (equivalent to a "lobar") infiltrate is an insensitive but
reasonably specific indication of bacterial infection. And in cases at
either extreme (from typical bronchiolitis with scattered infiltrates to
dense lobar pneumonia with a large pleural effusion), the level of
diagnostic certainty provided by radiologic findings is quite high. 48
<http://content.nejm.org/cgi/content/short/346/6/#R48> , 49
<http://content.nejm.org/cgi/content/short/346/6/#R49> In addition, there
are helpful series that describe the range and frequency of radiographic
findings in patients with mycoplasmal, 50
<http://content.nejm.org/cgi/content/short/346/6/#R50> viral, 51
<http://content.nejm.org/cgi/content/short/346/6/#R51> chlamydial, 52
<http://content.nejm.org/cgi/content/short/346/6/#R52> and pneumococcal 53
<http://content.nejm.org/cgi/content/short/346/6/#R53> pneumonia.
Nonmicrobiologic laboratory tests have also been widely used in an attempt
to differentiate bacterial from nonbacterial pneumonia. However, they are
not much better than chest radiographs. Several analyses show that the
C-reactive protein level and the absolute neutrophil count are the most
helpful, 46 <http://content.nejm.org/cgi/content/short/346/6/#R46> , 54
<http://content.nejm.org/cgi/content/short/346/6/#R54> , 55
<http://content.nejm.org/cgi/content/short/346/6/#R55> , 56
<http://content.nejm.org/cgi/content/short/346/6/#R56> , 57
<http://content.nejm.org/cgi/content/short/346/6/#R57> , 58
<http://content.nejm.org/cgi/content/short/346/6/#R58> although the
dividing lines are not sharp. Cutoff levels of 40 mg of C-reactive protein
per liter, 56 <http://content.nejm.org/cgi/content/short/346/6/#R56> 60 mg
per liter, 57 <http://content.nejm.org/cgi/content/short/346/6/#R57> and
100 mg per liter 46 <http://content.nejm.org/cgi/content/short/346/6/#R46>
have been used to identify bacterial infection, each with somewhat different
results. In these comparisons, children with pneumococcal pneumonia were
more easily identified than those with other bacterial causes, and the
findings in patients with mycoplasmal pneumonia were similar to those in
patients with viral infections. 46
<http://content.nejm.org/cgi/content/short/346/6/#R46> , 54
<http://content.nejm.org/cgi/content/short/346/6/#R54>
Treatment
Perhaps because of the many controversies that surround the etiologic
process of community-acquired pneumonia in children, there have been few
attempts to devise treatment guidelines in Europe or North America. In
contrast, official recommendations regarding the treatment of pneumonia in
adults have been published in Britain, Canada, and the United States. 59
<http://content.nejm.org/cgi/content/short/346/6/#R59> , 60
<http://content.nejm.org/cgi/content/short/346/6/#R60> , 61
<http://content.nejm.org/cgi/content/short/346/6/#R61> An ad hoc group of
Canadian experts has published guidelines, 62
<http://content.nejm.org/cgi/content/short/346/6/#R62> and numerous
recommendations address subgroups of patients with pneumonia, which are
usually classified according to the cause. 63
<http://content.nejm.org/cgi/content/short/346/6/#R63> , 64
<http://content.nejm.org/cgi/content/short/346/6/#R64> , 65
<http://content.nejm.org/cgi/content/short/346/6/#R65> In contrast, given
the enormous problem of undifferentiated pneumonia in the developing world,
the World Health Organization issued its own treatment guidelines in the
early 1980s. 10 <http://content.nejm.org/cgi/content/short/346/6/#R10>
These guidelines, however, are designed for areas where pneumonia is a major
killer, bacterial pneumonia is probably more common, access to drugs is
limited, and the available diagnostic tools are few. 66
<http://content.nejm.org/cgi/content/short/346/6/#R66>
Treatment decisions should be based on diagnostic algorithms that begin with
the age of the child, then consider clinical and epidemiologic factors, and
finally take into account the results of chest radiography. The Canadian
consensus statement, 62
<http://content.nejm.org/cgi/content/short/346/6/#R62> which is primarily
based on age, serves as an excellent introduction to a discussion of
management and treatment.
The most likely causes of pneumonia according to age are given in Table 4
<http://content.nejm.org/cgi/content/short/346/6/#T4> . Pneumonia during the
first three weeks after birth is uncommon, but when it does occur it is
often related to perinatally associated infections. Between three weeks and
three months of age, two of the most important causes of pneumonia are
macrolide-sensitive organisms: C. trachomatis is also one of the most
common, and Bordetella pertussis is an infrequent cause of pneumonia,
although when it does occur the disease may be very severe. 68
<http://content.nejm.org/cgi/content/short/346/6/#R68> , 69
<http://content.nejm.org/cgi/content/short/346/6/#R69> , 70
<http://content.nejm.org/cgi/content/short/346/6/#R70> These pneumonias
usually have an interstitial pattern of infiltrates, with cough as a
prominent feature. In children who are older than five years of age, two
other macrolide-sensitive organisms, M. pneumoniae and C. pneumoniae, cause
pneumonia that, on chest radiograph, is often not distinguishable from
bacterial pneumonia but that is characterized by cough, a low-grade fever,
and sometimes wheezing. In many surveys, M. pneumoniae is the most common
identified cause of pneumonia among children who are 5 to 15 years of age.
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Table 4. Microbial Causes of Community-Acquired Pneumonia in Childhood,
According to Age.
Despite their limitations, clinical and epidemiologic findings may be
useful. The presence of symptoms and signs of sepsis, even in the absence of
severe respiratory symptoms, suggests bacterial infection. Localized chest
pain (unlike the retrosternal pain of tracheitis, which tends to occur in
viral or mycoplasma infections) usually signifies pleural irritation, and
pleural irritation in an otherwise healthy child is rarely found in any type
of pneumonia other than bacterial. A child with pneumonia who is wheezing is
likely to have a viral, M. pneumoniae, or C. pneumoniae infection. 34
<http://content.nejm.org/cgi/content/short/346/6/#R34> , 43
<http://content.nejm.org/cgi/content/short/346/6/#R43> In most series,
conjunctivitis has not been found to be characteristic of any type of
pneumonia except in the case of infants less than three months of age; in
this age group, C. trachomatis infection is included in the differential
diagnosis. 71 <http://content.nejm.org/cgi/content/short/346/6/#R71> The
presence of otitis media or diarrhea cannot be used to help make the
diagnosis.
Epidemiologic factors are important considerations for the identification of
geographically restricted or exposure-related pneumonias ( Table 1
<http://content.nejm.org/cgi/content/short/346/6/#T1> and Table 2
<http://content.nejm.org/cgi/content/short/346/6/#T2> ). In temperate
climates, seasonality is a major determinant. Respiratory syncytial virus
infection and influenza are uncommon outside their winter–spring epidemics.
Although M. pneumoniae epidemics are less predictable, cases do occur in
community-wide clusters during the winter. 3
<http://content.nejm.org/cgi/content/short/346/6/#R3> , 72
<http://content.nejm.org/cgi/content/short/346/6/#R72>
There is ample evidence that a chest radiograph is useful to confirm the
diagnosis of pneumonia. Several studies have demonstrated the lack of both
sensitivity 73 <http://content.nejm.org/cgi/content/short/346/6/#R73> and
specificity 74 <http://content.nejm.org/cgi/content/short/346/6/#R74> , 75
<http://content.nejm.org/cgi/content/short/346/6/#R75> of the findings on
history taking and physical examination. The signs and symptoms that have a
high degree of sensitivity (e.g., fever and tachypnea) lack specificity, and
those with a high degree of specificity (e.g., rales and pleuritic pain)
lack sensitivity. Chest radiographs that show consolidative lobar
infiltrates, particularly if either a large pleural effusion or any
parenchymal necrosis is present, are indicative of a bacterial cause. When
the white-cell count, differential count, and C-reactive protein level are
very abnormal, they also have predictive value with respect to bacterial
pneumonia and can corroborate a diagnosis that is based on clinical and
historical information.
These considerations, in conjunction with the knowledge of prevailing
antimicrobial-susceptibility patterns, can be used to determine the
necessity for and the nature of empirical drug treatment ( Table 5
<http://content.nejm.org/cgi/content/short/346/6/#T5> ). In infants who are
3 weeks to 3 months of age and in those who are 5 to 15 years of age, a
macrolide antibiotic is the most reasonable first choice, 69
<http://content.nejm.org/cgi/content/short/346/6/#R69> unless the child
appears to have sepsis or the chest radiograph shows lobar infiltrates (with
or without effusion). The choice of macrolide can be based on availability,
cost, tolerability, and convenience, since in comparative trials they have
similar efficacy. 15 <http://content.nejm.org/cgi/content/short/346/6/#R15>
, 76 <http://content.nejm.org/cgi/content/short/346/6/#R76> A second- or
third-generation cephalosporin should be used for children with sepsis,
except for infants, who should receive both ampicillin and gentamicin, as
well as a third-generation cephalosporin in severe cases. Although
staphylococcal pneumonia is now quite rare in Europe and North America, 77
<http://content.nejm.org/cgi/content/short/346/6/#R77> it is still a
possibility in some instances, and in these circumstances, oxacillin or, in
areas where methicillin-resistant strains of S. aureus have appeared, 78
<http://content.nejm.org/cgi/content/short/346/6/#R78> vancomycin should
then be added to the regimen. If the condition of school-age children does
not improve with the use of cephalosporin or if the findings on the chest
radiograph or the clinical findings are ambiguous, a macrolide should be
added, since patients who have either a M. pneumoniae or C. trachomatis
infection can present with radiographic and clinical findings similar to
those associated with an infection caused by pyogenic bacteria.
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Table 5. Suggested Drug Treatments for Community-Acquired Pneumonia in
Children, According to Whether They Are Hospitalized.
Treatment of pneumonia due to S. pneumoniae has been the subject of several
studies, 79 <http://content.nejm.org/cgi/content/short/346/6/#R79> , 80
<http://content.nejm.org/cgi/content/short/346/6/#R80> , 81
<http://content.nejm.org/cgi/content/short/346/6/#R81> as well as of
consensus guidelines issued by the American Academy of Pediatrics. 64
<http://content.nejm.org/cgi/content/short/346/6/#R64> The emergence of
strains of S. pneumoniae that are not susceptible to penicillin has had less
of an effect on the treatment of pneumonia than on the treatment of
meningitis, and satisfactory rates of recovery can be achieved with the use
of high doses of many {beta}-lactam antibiotics. 80
<http://content.nejm.org/cgi/content/short/346/6/#R80> For most
nonsusceptible strains, a second-generation cephalosporin (cefuroxime) or a
third-generation cephalosporin (cefotaxime or ceftriaxone) is somewhat more
effective than either ampicillin or penicillin, although a high dose of
amoxicillin (80 to 100 mg per kilogram of body weight per day) is the
preferred treatment for pneumonia in outpatients. The addition of a
beta-lactamase inhibitor conveys no advantage, since the mechanism of
resistance in this organism does not involve this enzyme. Vancomycin is
rarely needed to treat pneumococcal pneumonia, even severe cases.
Use of the recently licensed pneumococcal conjugate vaccine appears likely
to prevent the majority of cases of pneumococcal pneumonia in the United
States, 41 <http://content.nejm.org/cgi/content/short/346/6/#R41> but the
high cost of this vaccine will preclude its use in the parts of the world
where pneumococcal pneumonia is most common and severe. Moreover, there is
already some evidence in vaccinated persons that pneumococcal serotypes not
represented in the vaccine are replacing the serotypes covered by the
vaccine and are causing otitis media. 82
<http://content.nejm.org/cgi/content/short/346/6/#R82> The World Health
Organization's approach to the treatment of pneumonia, despite its success,
83 <http://content.nejm.org/cgi/content/short/346/6/#R83> may well
aggravate the problem of antibiotic resistance in communities that have the
highest rates of death from pneumonia. The development of an affordable
pneumococcal vaccine for infants and children should be a high priority, as
should efforts to reduce the risk factors that lead to a high incidence of
severe pneumonia, such as malnutrition, crowding, and air pollution.
Conclusions
Perhaps because of its etiologic complexity, pneumonia in children has been
relatively refractory to efforts to reduce its incidence and severity and
improve the prognosis. The use of treatment algorithms in the developing
world has led to lower mortality rates, 82
<http://content.nejm.org/cgi/content/short/346/6/#R82> but the future of
this approach, given the rate of development of antimicrobial resistance, is
uncertain. The wider use of new pneumococcal conjugate vaccines over the
next few years may represent an important advance in countries that can
afford it, but the public health effects of universal immunization,
particularly over the long run, are not clear. There is still room for
improvements in the diagnosis of pneumonia and in the elucidation of its
cause in individual cases. Finally, regional consensus guidelines for
management and antimicrobial treatment should be developed, refined over
time, and used by practitioners in their offices and in hospitals.
Supported in part by a grant from the Bruce and Joline McCaw Fund.
Source Information
From the Division of Infectious Diseases, Children's Hospital, Boston.
Address reprint requests to Dr. McIntosh at Enders 609, Children's Hospital,
300 Longwood Ave., Boston, MA 02115, or at [log in to unmask]
<mailto:[log in to unmask]> .
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Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.