INTRODUCTION Childhood pneumonia is an important cause of morbidity

in the developed world, and morbidity and mortality in the developing world.
The epidemiology, microbiology, and pathogenesis of pneumonia in children
will be reviewed here. The clinical features, diagnosis, and treatment of
pneumonia in children are discussed separately, as is pneumonia in
neonates (<28 days of age). (See "Community-acquired pneumonia in
children: Clinical features and diagnosis" and "Community-acquired
pneumonia in children: Outpatient treatment" and "Pneumonia in children:
Inpatient treatment" and "Neonatal pneumonia".)

TERMINOLOGY The terms pneumonia and pneumonitis strictly represent

any inflammatory condition involving the lungs, which include the visceral
pleura, connective tissue, airways, alveoli, and vascular structures. Lower
respiratory tract infection (LRTI) is frequently used interchangeably to
include bronchitis, bronchiolitis, and pneumonia, or any combination of the
three. For the purposes of this review, pneumonia will be defined as a
condition typically associated with fever, respiratory symptoms, and
evidence of parenchymal involvement, either by physical examination or the
presence of infiltrates on chest radiography. Bronchiolitis is discussed
separately. (See "Bronchiolitis in infants and children: Clinical features and
diagnosis", section on 'Clinical features'.)

EPIDEMIOLOGY

Incidence The World Health Organization (WHO) estimates there are 156
million cases of pneumonia each year in children younger than five years,
with as many as 20 million cases severe enough to require hospital
admission [1]. In the developed world, the annual incidence of pneumonia is
estimated to be 33 per 10,000 in children younger than five years and 14.5
per 10,000 in children 0 to 16 years [2].

Approximately one-half of children younger than five years of age with

community-acquired pneumonia (CAP) require hospitalization [3].
Hospitalization rates for pneumonia (all causes) among children younger
than two years in the United States decreased after introduction of the
pneumococcal conjugate vaccine to the routine childhood immunization
schedule in 2000 (from 12 to 14 per 1000 population to 8 to 10 per 1000
population) (figure 1) [4].

Mortality The mortality rate in developed countries is low (<1 per 1000
per year) [5,6]. In developing countries, respiratory tract infections are not
only more prevalent but more severe, accounting for more than 2 million
deaths annually; pneumonia is the number one killer of children in these
societies [1,7].

Seasonality Although both viral and bacterial pneumonia occur

throughout the year, they are more prevalent during the colder months,
presumably because direct transmission of infected droplets is enhanced by
indoor crowding. For reasons that are unknown, different viruses cause
peaks of infection at different times during the respiratory virus season and
these peaks seldom occur simultaneously [8]. In tropical regions, peaks of
infection follow no common pattern and can occur during either the wet or
dry seasons.

Risk factors Lower socioeconomic groups have a higher prevalence of

LRTIs, which correlates best with family size, a reflection of environmental
crowding. School-age children often introduce respiratory viral agents into
households, resulting in secondary infections in their parents and siblings
[8].

Underlying cardiopulmonary disorders and other medical conditions

predispose to pneumonia and contribute to increasing severity. These
include [5,9]:

Congenital heart disease

Bronchopulmonary dysplasia
Cystic fibrosis
Asthma
Sickle cell disease
Neuromuscular disorders, especially those associated with a depressed
consciousness
Some gastrointestinal disorders (eg, gastroesophageal reflux,
tracheoesophageal fistula)
Congenital and acquired immunodeficiency disorders
Cigarette smoke compromises natural pulmonary defense mechanisms by
disrupting both mucociliary function and macrophage activity [10]. Exposure
to cigarette smoke, especially if the mother smokes, increases the risk for
pneumonia in infants younger than one year of age. (See "Secondhand
smoke exposure: Effects in children".)

The use of cigarettes, alcohol, and other substances of abuse in adolescents

may increase the risk of pneumonia by increasing the risk of aspiration
through impairment of the cough and epiglottic reflexes. In addition, the use
of alcohol has been associated with increased colonization of the
oropharynx with aerobic gram-negative bacilli [11].

Effect of vaccines Immunization with the Haemophilus influenzae type b

(Hib) and pneumococcal conjugate vaccines protects children from invasive
disease caused by these organisms. Hib was once a common cause of
pneumonia in young children in the United States. However, it has been
virtually eliminated as a result of routine immunization with Hib conjugate
vaccines. (See "Prevention of Haemophilus influenzae infection", section on
'Efficacy/effectiveness'.)

The universal immunization of infants in the United States with the 7-valent
pneumococcal conjugate vaccine has effectively decreased the incidence of
pneumonia requiring hospitalization and other invasive Streptococcus
pneumoniae infections in children younger than two years (figure 1) [12-15].
Rates of ambulatory visits for pneumonia in children younger than two years
also declined after the introduction of pneumococcal conjugate vaccine [16],
but the rates for children aged 1 to 18 years remained stable [17]. (See
"Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in
children", section on 'Pneumonia'.)

It is anticipated that the 13-valent pneumococcal conjugate vaccine that

replaced the 7-valent pneumococcal conjugate vaccine in 2010 and affords
additional coverage against serotypes 1, 3, 5, 6A, 7F, and 19A will further
decrease the incidence of pneumonia requiring hospitalization because
these serotypes are responsible for the majority of pneumococcal
pneumonia cases among children worldwide [18,19]. Early data from the
United States Pediatric Multicenter Pneumococcal Surveillance Group
demonstrate a 53 percent reduction in cases of pneumonia compared with
the average number of cases for 2007-2009 [20]. (See "Pneumococcal
(Streptococcus pneumoniae) conjugate vaccines in children", section on '13valent vaccine'.)

Pneumococcal vaccination also protects against viral pneumonia. This was

shown in a double-blind, randomized, placebo-controlled trial in which full
immunization with a nine-valent pneumococcal conjugate vaccine was
associated with a 31 percent reduction (95% CI 15-43) in the incidence of
pneumonia associated with any of seven respiratory viruses (influenza,
parainfluenza, respiratory syncytial virus (RSV), adenovirus) in hospitalized
children [21]. This observation suggests that the pneumonias associated
with these viruses in hospitalized children are often because of concurrent
pneumococcal infection.

PATHOGENESIS Pneumonia occurs because of an impairment of host

defenses, invasion by a virulent organism, and/or invasion by an
overwhelming inoculum.

In the typical scenario, pneumonia follows an upper respiratory tract illness

that permits invasion of the lower respiratory tract by bacteria, viruses, or
other pathogens that trigger the immune response and produce
inflammation [3,22]. The lower respiratory tract air spaces fill with white
blood cells (WBC), fluid, and cellular debris. This process reduces lung
compliance, increases resistance, obstructs smaller airways, and may result
in collapse of distal air spaces, air trapping, and altered ventilation-perfusion
relationships [3]. Severe infection is associated with necrosis of bronchial or
bronchiolar epithelium [23], and/or pulmonary parenchyma [24].

Acquisition The agents that cause lower respiratory tract infection (LRTI)
are most often transmitted by droplet spread resulting from close contact
with a source case. Contact with contaminated fomites also may be
important in the acquisition of viral agents, especially respiratory syncytial
virus (RSV).

Most typical bacterial pneumonias are the result of initial colonization of the
nasopharynx followed by aspiration or inhalation of organisms. Invasive
disease most commonly occurs upon acquisition of a new serotype of the
organism with which the patient has not had previous experience, typically
after an incubation period of one to three days. Occasionally, a primary
bacteremia may precede the pneumonia. Atypical bacterial pathogens
attach to respiratory epithelial membranes through which they enter cells
for replication.

The viral agents that cause pneumonia proliferate and spread by contiguity
to involve lower and more distal portions of the respiratory tract.

Normal host defense The pulmonary host defense system is complex and
includes anatomic and mechanical barriers, humoral immunity, phagocytic
activity, and cell-mediated immunity [25,26], as discussed below, with a
focus on bacterial infection. The host response to respiratory viral infection
is beyond the scope of this review; more information can be obtained from
reference [27].

Anatomic and mechanical barriers Anatomic and mechanical barriers in

the upper airway form an important part of the host defense. Particles
greater than 10 microns are efficiently filtered by the hairs in the anterior
nares or impact onto mucosal surfaces. The nasal mucosa contains ciliated
epithelium and mucus-producing cells. The cilia beat synchronously, clearing
the entrapped organisms through the nasopharynx via expulsion or
swallowing. In the oropharynx, salivary flow, sloughing of epithelial cells,
local production of complement and IgA, and bacterial interference from the
resident flora serve as important factors in local host defense.

An intact epiglottic reflex helps to prevent aspiration of infected secretions,

and the cough reflex helps to expel materials that may be aspirated. The
sharp angles at which the central airways branch cause 5 to 10 micron
particles to impact on mucosal surfaces, where they are entrapped in
endobronchial mucus. Once entrapped, the ciliary system moves the
particles upward out of the airways into the throat, where they are normally
swallowed.
Humoral immunity Secretory IgA is the major immunoglobulin produced
in the upper airways and accounts for 10 percent of the total protein
concentration of nasal secretions. Although it is not a very good opsonizing
agent, it does possess antibacterial and antiviral activity. IgG and IgM enter
the airways and alveolar spaces predominantly via transudation from the
blood and act to opsonize bacteria, activate complement, and neutralize
toxin. Immunoglobulins, surfactant, fibronectin, and complement act as
effective opsonins to help eliminate microorganisms (0.5 to 1 micron
particles) that reach the terminal airways and alveoli. Free fatty acids,
lysozyme, and iron-binding proteins also are present and may be
microbicidal.
Phagocytic cells There are two populations of phagocytic cells in the
lung: polymorphonuclear leukocytes (PMNs) from the blood and
macrophages. There are several distinct populations of macrophages, which
vary in their location and function:
The alveolar macrophage is located in the alveolar fluid and is the first
phagocyte encountered by inert particles and potential pathogens entering
the lung. If this cell is overwhelmed, it has the capacity to become a
mediator of inflammation and produce cytokines that recruit neutrophils.
Interstitial macrophages are located in the lung connective tissue and
serve both as phagocytic cells and antigen-processing cells.
The intravascular macrophage is located in capillary endothelial cells and
phagocytizes and removes foreign material entering the lungs via the
bloodstream.
Cell-mediated immunity Cell-mediated immunity is especially important
against certain pathogens, including viruses and intracellular
microorganisms that can survive within pulmonary macrophages. Although
relatively few in number (5 to 10 percent of the total lung parenchyma cell
population), lymphocytes play three critical roles: the production of
antibody, cytotoxic activity, and the production of cytokines.
Patterns of pneumonia There are five patterns of bacterial pneumonia
[22]:

Lobar pneumonia involvement of a single lobe or segment of a lobe; this

is the classic pattern of S. pneumoniae pneumonia

Bronchopneumonia primary involvement of airways and surrounding

interstitium; this pattern is sometimes seen in Streptococcus pyogenes and
Staphylococcus aureus pneumonia
Necrotizing pneumonia (associated with aspiration pneumonia and
pneumonia resulting from S. pneumoniae, S. pyogenes, and S. aureus)
(image 1)
Caseating granuloma (as in tuberculosis pneumonia)
Interstitial and peribronchiolar with secondary parenchymal infiltration
this pattern typically occurs when a severe viral pneumonia is complicated
by bacterial pneumonia
There are two patterns of viral pneumonia [22]:

Interstitial pneumonitis (image 2)

Parenchymal infection with viral inclusions
Examination findings The examination findings vary depending on the
site of infection as follows [3]:

Inspiratory crackles, also called rales and crepitations [28], are more
common in lobar pneumonia and bronchiolitis/pneumonia
Decreased breath sounds may be noted in areas of consolidation
Coarse, low-pitched continuous breath sounds (rhonchi) are more common
in bronchopneumonia
Expiratory wheezes, high-pitched breath sounds, are caused by oscillation
of air through a narrowed airway; they are more common in bronchiolitis
and interstitial pneumonitis
ETIOLOGIC AGENTS A large number of microorganisms have been
implicated as etiologic agents of pneumonia in children (table 1A-B). The
agents commonly responsible vary according to the age of the child and the
setting in which the infection is acquired.

Community-acquired pneumonia

Overview The true prevalence of the various etiologic agents in

community-acquired pneumonia (CAP) in children is uncertain [29]. Studies
investigating the etiology of childhood pneumonia have been performed in
populations of various ages, in various settings, and using a variety of
microbiologic techniques [6,30-41]. Because direct culture of infected lung
tissue requires invasive techniques, published studies primarily use
laboratory tests that provide indirect evidence of etiology. These indirect
methods include nasopharyngeal culture, blood culture, polymerase chain

reaction, and serology. In addition to the use of indirect methods,

interpretation of the results is hampered by the failure to identify an
organism in 15 to 35 percent of cases and the frequency of mixed infections
(in 23 to 33 percent of cases) [2,6]. Most of these studies were performed
before the licensure of the pneumococcal conjugate vaccine [42].

Despite these problems, systematic reviews have identified some consistent

trends and conclusions regarding the etiology of CAP in children, which are
listed below [2,29]:

S. pneumoniae is the most common bacterial cause of pneumonia in

children [9,43]
Viruses alone account for 14 to 35 percent of cases, and up to 50 percent
of cases in young children
Viruses are more commonly identified in children younger than five years
In children older than five years, Mycoplasma pneumoniae and Chlamydia
pneumoniae are more common [6,44,45]
In some areas in which community-associated methicillin-resistant
Staphylococcus aureus (CA-MRSA) is a major issue, CA-MRSA is becoming an
important cause of CAP complicated by empyema and necrosis [46,47].
When associated with influenza, MRSA CAP can be particularly severe
[48,49]. (See "Epidemiology; clinical presentation; and evaluation of
parapneumonic effusion and empyema in children" and "Seasonal influenza
in children: Clinical features and diagnosis", section on 'Bacterial coinfection'
and "Methicillin-resistant Staphylococcus aureus infections in children:
Epidemiology and clinical spectrum", section on 'Epidemiology and risk
factors'.)

In neonates The etiology of pneumonia in neonates (infants <28 days of

age) is discussed separately. (See "Neonatal pneumonia", section on
'Microbiology'.)

In infants As described below, viruses are the most common etiology of

CAP in children younger than five years, including infants. However, infants
younger than one year also may develop "afebrile pneumonia of infancy."
Afebrile pneumonia of infancy is a syndrome generally seen between two
weeks and three to four months of life. It is classically caused by Chlamydia
trachomatis, but other agents, such as cytomegalovirus (CMV), Mycoplasma
hominis, and Ureaplasma urealyticum, also are implicated. (See "Chlamydia
trachomatis infections in the newborn", section on 'Pneumonia'.)

Infants with severe Bordetella pertussis infection also may develop

pneumonia. (See "Bordetella pertussis infection in infants and children:
Clinical features and diagnosis", section on 'Complications'.)

In children <5 years

Viruses Viruses are the most common etiology of CAP in older infants and
children younger than five years of age [2,6,29]. However, bacterial
pathogens, including S. pneumoniae, S. aureus, and S. pyogenes, also are
important because they are associated with increased morbidity and
mortality [47,48,50].

Respiratory syncytial virus (RSV), a member of the Paramyxoviridae virus

family, is the most common viral pathogen responsible for pneumonia in
children younger than five years [6,36]. RSV pneumonia frequently
represents an extension of bronchiolitis. (See "Bronchiolitis in infants and
children: Clinical features and diagnosis", section on 'Clinical features' and
"Respiratory syncytial virus infection: Clinical features and diagnosis",
section on 'Clinical manifestations'.)

Other viral causes of pneumonia in children younger than five years include
[6]:
Influenza A and B viruses. (See "Seasonal influenza in children: Clinical
features and diagnosis", section on 'Pneumonia'.)
Parainfluenza viruses, usually type 3. (See "Parainfluenza viruses in
children", section on 'Clinical presentation'.)
A number of adenovirus serotypes (1, 2, 3, 4, 5, 7, 14, 21, and 35) have
been reported to cause pneumonia; serotypes 3, 7, and 21 have been
associated with severe and complicated pneumonia [51]. (See
"Epidemiology and clinical manifestations of adenovirus infection", section
on 'Clinical presentation'.)
Human metapneumovirus, identified in 2001, is a common cause of lower
respiratory tract infections in children; most children have been infected by
five years of age. (See "Human metapneumovirus infections".)
Rhinovirus has been implicated as a cause of pneumonia using PCR assays
[52], but its etiologic role is questioned [53].
Coronaviruses, including the severe acute respiratory syndrome (SARS),
the Middle East respiratory syndrome, and the New Haven coronaviruses,
also cause respiratory tract infections in children younger than five years
[54,55]. However, their clinical impact has yet to be fully determined [56].
(See "Coronaviruses", section on 'Respiratory' and "Severe acute respiratory
syndrome (SARS)", section on 'Clinical manifestations' and "Middle East
respiratory syndrome coronavirus", section on 'Clinical manifestations'.)

Human bocavirus and human parechovirus types 1, 2, and 3 also have

been implicated as a cause of lower respiratory tract infections in children
[57-59].
Bacteria Important bacterial causes of pneumonia in preschool children
include S. pneumoniae, H. influenzae type b, nontypeable H. influenzae,
Moraxella catarrhalis, S. aureus, S. pyogenes, and atypical bacteria.
S. pneumoniae is the single most common bacterial pathogen causing
pneumonia in all patients beyond the first few weeks of life [9,43]. (See
"Pneumococcal pneumonia in children", section on 'Epidemiology'.)
H. influenzae type b is a rare cause of pneumonia in countries with
universal childhood immunization.
S. aureus (particularly community-associated MRSA, CA-MRSA) and S.
pyogenes are becoming increasingly frequent causes of CAP, particularly
those complicated by necrosis and empyema [47,60]. In addition, these
organisms occasionally cause pneumonia and frequently are seen following
influenza and chickenpox, respectively [48,49]. (See "Clinical features of
varicella-zoster virus infection: Chickenpox" and "Seasonal influenza in
children: Clinical features and diagnosis", section on 'Pneumonia'.)
The prevalence of M. pneumoniae and C. pneumoniae may be increasing in
preschool children with CAP [29,61]. (See "Pneumonia caused by Chlamydia
species in children" and "Mycoplasma pneumoniae infection in children",
section on 'Epidemiology'.)
In children 5 years

S. pneumoniae is the most common typical bacterial cause of pneumonia

in children older than five years (see "Pneumococcal pneumonia in
children", section on 'Epidemiology')
M. pneumoniae is more common among children 5 years than among
younger children (see "Mycoplasma pneumoniae infection in children",
section on 'Epidemiology')
C. pneumoniae also is emerging as a frequent cause of pneumonia in older
children and young adults (see "Pneumonia caused by Chlamydia species in
children")
Aspiration pneumonia When there is a predisposition to aspiration,
pneumonia may be caused by anaerobic oral flora, including:

Anaerobic streptococci (eg, Peptostreptococcus)

Fusobacterium spp
Bacteroides spp
Prevotella melaninogenica

Risk factors for aspiration include a history of seizure, anesthesia, or other

episode of reduced level of consciousness, neurologic disease, dysphagia,
gastroesophageal reflux, alcohol or substance abuse, use of a nasogastric
tube, or foreign body aspiration.

Nosocomial pneumonia Nosocomial bacterial pneumonia is usually

caused by gram-negative bacilli or S. aureus. Nosocomial pneumonia
frequently occurs in intensive care units where mechanical ventilation,
indwelling catheters, and administration of broad-spectrum antibiotics are
common. (See "Pneumonia in children: Inpatient treatment", section on
'Nosocomial pneumonia'.)

In addition, during the winter respiratory viral season, all patients in a

medical care environment are at risk for nosocomial pneumonia caused by
RSV, parainfluenza, and influenza viruses. (See "Seasonal influenza in
children: Clinical features and diagnosis" and "Parainfluenza viruses in
children", section on 'Clinical presentation' and "Respiratory syncytial virus
infection: Clinical features and diagnosis", section on 'Transmission'.)

Special populations

Immunocompromised The causes of pneumonia in immunocompromised

hosts include all of the pathogens mentioned above, as well as a variety of
other organisms, as discussed below.

Gram-negative bacilli and S. aureus are common etiologies in neutropenic

patients or in those with white blood cell (WBC) defects. Clinically significant
Legionellosis usually is seen only in immunocompromised hosts with an
exposure to an aquatic reservoir of Legionella pneumophila, such as a river,
lake, air-conditioning cooling tower, or water distribution systems [62].
However, seroepidemiologic studies suggest that subclinical or minor
infections occur in children [63,64]. (See "Epidemiology and pathogenesis of
Legionella infection".)

Opportunistic fungi, such as Aspergillus spp and Fusarium spp, also are a
concern in neutropenic patients and in those receiving immunosuppressive
therapies that impair the cell-mediated response. One of the more common
pneumonia pathogens diagnosed in HIV-infected patients is Pneumocystis
jirovecii, which was formerly called Pneumocystis carinii [65]. (See
"Epidemiology and clinical manifestations of invasive aspergillosis" and
"Mycology, pathogenesis, and epidemiology of Fusarium infection" and
"Natural history and classification of pediatric HIV infection", section on
'Pneumocystis jirovecii pneumonia'.)

Viral causes of pneumonia, which may be life-threatening in the

immunocompromised host, including the post-solid organ and stem cell
transplant populations include:

Common community-acquired viral agents such as RSV, adenovirus,

influenza, parainfluenza, rhinovirus, and human metapneumovirus [66,67]
(see appropriate topic reviews)
Rubeola (Hecht giant-cell pneumonia) (see "Clinical manifestations and
diagnosis of measles", section on 'Immunocompromised patients')
Varicella-zoster virus (VZV) (see "Clinical features of varicella-zoster virus
infection: Chickenpox", section on 'Pneumonia')
CMV (see "Acquired cytomegalovirus infection in infants, children, and
adolescents", section on 'CMV infection in immunocompromised hosts')
Epstein-Barr virus (EBV), which may be the trigger for lymphocytic
interstitial pneumonitis, an indolent but progressive process that occurs in
children infected with HIV (see "Clinical manifestations and treatment of
Epstein-Barr virus infection" and "Lymphocytic interstitial pneumonia in
children", section on 'Pathogenesis')
Cystic fibrosis Young children with cystic fibrosis frequently are infected
with S. aureus, P. aeruginosa, and H. influenzae (mostly nontypeable
strains). Later in the course of the disease, multiple drug-resistant gramnegative organisms, such as Burkholderia cepacia, Stenotrophomonas
maltophilia, and Achromobacter xylosoxidans, can be recovered. Aspergillus
spp and nontuberculous mycobacteria also may cause disease in this
population. Cystic fibrosis lung disease is discussed in detail separately. (See
"Cystic fibrosis: Clinical manifestations of pulmonary disease" and "Cystic
fibrosis: Overview of the treatment of lung disease" and "Cystic fibrosis:
Antibiotic therapy for lung disease".)

Sickle cell anemia The prevalence of pneumonia is increased in children

with sickle cell anemia [68]. Atypical bacterial pathogens appear to be most
frequent and are more commonly associated with the acute chest
syndrome. Other bacterial causes of pneumonia in children with sickle cell
anemia include S. pneumoniae, S. aureus, and H. influenzae [9]. (See "The
acute chest syndrome in children and adolescents with sickle cell disease",
section on 'Infection'.)

Environmental considerations

Geography Residence in or travel to specific geographic areas should

suggest endemic pathogens:

Tuberculosis is most common in immigrants from countries with a high

prevalence of infection (eg, countries throughout Asia, Africa, Latin America,
and Eastern Europe) (figure 2). (See "Epidemiology of tuberculosis".)
Measles pneumonia is common in the developing world. (See "Clinical
manifestations and diagnosis of measles".)
Coccidioides immitis is endemic to the southwestern United States,
northern Mexico, and parts of Central and South America. (See "Primary
coccidioidal infection".)
Blastomyces dermatitidis, causing blastomycosis, is endemic in the
southeastern and central states and the midwestern states bordering the
Great Lakes. (See "Mycology, pathogenesis, and epidemiology of
blastomycosis" and "Treatment of blastomycosis".)
Histoplasma capsulatum is endemic in the Ohio, Mississippi, and Missouri
River valleys in the United States; in 2013 it was reported for the first time
in Montana [69]. It also occurs in Canada, Central America, eastern and
southern Europe, parts of Africa, eastern Asia, and Australia. Activities
potentially leading to exposure to bird droppings and bat guano may be
suggestive. These include gardening, construction, cleaning of barns and
outbuildings, and spelunking. (See "Pathogenesis and clinical features of
pulmonary histoplasmosis" and "Diagnosis and treatment of pulmonary
histoplasmosis".)
In the United States, hantavirus cardiopulmonary syndrome (acute febrile
illness associated with respiratory failure, shock, and high mortality) occurs
predominantly west of the Mississippi River (in the four corners region
where the borders of Colorado, New Mexico, Arizona, and Utah meet) after
environmental exposure to infected deer mouse (Peromyscus maniculatus)
saliva, urine, or feces. Activities associated with exposure include cleaning
of barns and outbuildings, trapping rodents, animal herding, and farming
with hand tools. (See "Epidemiology and diagnosis of hantavirus infections"
and "Hantavirus cardiopulmonary syndrome".)
Animal exposures Histoplasmosis is associated with exposure to bird
droppings and bat guano, and hantavirus infection is associated with
exposure to an infected deer mouse. Other causes of pneumonia that are
associated with animal exposure include:

Chlamydia psittaci (psittacosis), which is transmitted to man

predominantly from domestic and wild birds (see "Psittacosis")
Coxiella burnetii (Q fever), which is associated with exposure to parturient
sheep, goats, cattle, and cats (or exposure to dust/soil contaminated by
these animals) (see "Microbiology and epidemiology of Q fever" and "Clinical
manifestations and diagnosis of Q fever")
Other exposures Exposure to individuals at high risk for tuberculosis is a
risk factor for the development of tuberculosis in children. High-risk

individuals include the homeless, recent immigrants from endemic regions

(figure 2), incarcerated individuals, and HIV-infected patients. (See
"Epidemiology of tuberculosis".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient

education materials, The Basics and Beyond the Basics. The Basics
patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)

Basics topics (see "Patient information: Pneumonia in children (The

Basics)")
SUMMARY Pneumonia is more common in children younger than five
years of age than in older children and adolescents. Risk factors for
pneumonia include environmental crowding, having school-aged siblings,
and underlying cardiopulmonary and other medical disorders. (See
'Epidemiology' above.)

Pneumonia can be caused by a large number of microorganisms (table 1AB). The agents commonly responsible vary according to the age of the child
and the setting in which the infection is acquired. (See 'Etiologic agents'
above.)

In children younger than five years, viruses are most common. However,
bacterial pathogens, including S. pneumoniae, S. aureus, and S. pyogenes,
also are important. (See 'In children <5 years' above.)
In otherwise-healthy children older than five years, S. pneumoniae, M.
pneumoniae, and Chlamydia pneumoniae are most common. (See 'In
children 5 years' above.)
Community-associated methicillin-resistant S. aureus (CA-MRSA) is an
increasingly important pathogen in children of all ages, particularly in those
with necrotizing pneumonia. S. pneumoniae is another frequent cause of
necrotizing pneumonia. (See 'Overview' above.)

Aspiration pneumonia is usually caused by anaerobic oral flora. (See

'Aspiration pneumonia' above.)
Nosocomial pneumonia is usually caused by gram-negative bacilli or
Staphylococcus aureus. (See 'Nosocomial pneumonia' above.)

Introduccin: Neumona en la niez es una causa importante de morbilidad

en el mundo desarrollado y morbilidad y mortalidad en el mundo en
desarrollo. La epidemiologa, la microbiologa y la patogenia de la neumona
en los nios se examinarn aqu. Las caractersticas clnicas, diagnstico y
tratamiento de la neumona en nios se discuten por separado, como es la
neumona en recin nacidos (< 28 das de edad). (Ver "pulmona
comunidad-adquirida en nios: caractersticas clnicas y diagnstico" y
"neumona adquirida en la comunidad en nios: tratamiento ambulatorio" y
"neumona en nios: tratamiento hospitalario" y "Neumona Neonatal".)

TERMINOLOGA: Los trminos neumona y neumonitis estrictamente

representan cualquier condicin inflamatoria que involucra los pulmones,
que incluyen la pleura visceral, tejido conectivo, las vas areas, alvolos y
estructuras vasculares. Infeccin de vas respiratorias inferiores (IVRI) con
frecuencia se utiliza indistintamente con bronquitis, bronquiolitis y
neumona o cualquier combinacin de los tres. Para los propsitos de esta
revisin, la neumona se definir como una condicin tpicamente asociada
con fiebre, sntomas respiratorios y evidencia de afectacin
parenquimatosa, ya sea por la presencia de infiltrados en la radiografa de
trax o examen fsico. La bronquiolitis se discute por separado. (Ver la
bronquiolitis en bebs y nios: caractersticas clnicas y diagnstico ",
seccin en caractersticas clnicas.)

EPIDEMIOLOGA

Incidencia, La Organizacin Mundial de la salud (OMS) estima que hay 156

millones casos de neumona cada ao en nios menores de cinco aos, con
casos como 20 millones lo suficientemente graves como para requerir
ingreso hospitalario [1]. En el mundo desarrollado, la incidencia anual de
neumona se estima 33 por 10.000 en nios menores de cinco aos y 14,5
por 10.000 en nios 0 a 16 aos [2].

Aproximadamente la mitad de los nios menores de cinco aos de edad con

pulmona comunidad-adquirida (casquillo) requiere hospitalizacin [3]. Las
tasas de hospitalizacin por neumona (todas las causas) entre los nios
menores de dos aos en los Estados Unidos disminuy despus de la
introduccin de la vacuna antineumoccica conjugada a la inmunizacin
infantil rutinaria programacin en el ao 2000 (de 12 a 14 por 1000
habitantes a 9:52 por 1000 habitantes) (Figura 1) [4].

Mortalidad: La tasa de mortalidad en los pases desarrollados es baja (< 1

por 1000 por ao) [5,6]. En los pases en desarrollo, las infecciones
respiratorias son no slo ms frecuentes pero ms graves, son responsables
de ms de 2 millones de muertes anualmente; la neumona es el asesino
nmero uno de los nios en estas sociedades [1,7].

Estacionalidad Aunque neumona viral y bacteriana se producen durante

todo el ao, son ms frecuentes durante los meses ms fros,
presumiblemente porque la transmisin directa de gotitas infectadas es
realzada por apiamiento interior. Por razones que se desconocen,
diferentes virus causan picos de infeccin en diferentes momentos durante
la temporada de virus respiratorio y estos picos raramente ocurren
simultneamente [8]. En las regiones tropicales, picos de infeccin no
siguen ningn patrn comn y pueden ocurrir durante o las estaciones
secas o mojadas.

Factores de riesgo, grupos socioeconmicos ms bajos tienen una mayor

prevalencia de las IVRI, que se correlaciona mejor con el tamao de la
familia, un reflejo de la apretadura ambiental. Nios en edad escolar a
menudo introducen a agentes virales respiratorios hogares, dando lugar a
infecciones secundarias en sus padres y hermanos [8].

Trastornos cardiopulmonares subyacentes y otras condiciones mdicas

predisponen a la neumona y contribuyan a aumentar la gravedad. stos
incluyen [5,9]:

Congenital cardiopata
Displasia de Bronchopulmonary
Fibrosis Cystic
Asthma
Enfermedad de clulas de Sickle
Neuromuscular trastornos, especialmente los asociados a una depresin
de la conciencia
Some trastornos gastrointestinales (por ejemplo, reflujo gastroesofgico,
fstula traqueoesofgica)
Congenital y trastornos de inmunodeficiencia adquirida

El humo del cigarrillo compromete mecanismos pulmonares naturales de

defensa interrumpiendo tanto mucociliar funcin y macrfagos actividad
[10]. Exposicin al humo del cigarrillo, sobre todo si la madre fuma,
aumenta el riesgo de neumona en bebs menores de un ao de edad. (Ver
"exposicin de humo de segunda mano: efectos en los nios".)

El uso de cigarrillos, alcohol y otras sustancias de abuso en adolescentes

puede aumentar el riesgo de neumona por aumentar el riesgo de aspiracin
a travs del deterioro de la tos y reflejos epiglottic. Adems, el consumo de
alcohol se ha asociado con la creciente colonizacin de la orofaringe con
bacilos Gram-negativos aerobios [11].

Efecto de las vacunas, la inmunizacin con el Haemophilus influenzae tipo b

(Hib) y las vacunas antineumoccicas conjugadas protege a los nios la
enfermedad invasiva causada por estos organismos. Hib era una vez una
causa comn de neumona en nios en los Estados Unidos. Sin embargo, ha
sido prcticamente eliminada como resultado de la inmunizacin con
vacunas conjugadas de Hib. (Vase "Prevencin de la infeccin por
Haemophilus influenzae", seccin en la 'Eficacia/efectividad').

La vacunacin universal de recin nacidos en los Estados Unidos con la

vacuna antineumoccica conjugada heptavalente con eficacia ha disminuido
la incidencia de neumona que requiere hospitalizacin y otras
Streptococcus pneumoniae las infecciones invasivas en nios menores de
dos aos (Figura 1) [12-15]. Las tasas de visitas ambulatorias por neumona
en nios menores de dos aos tambin disminuyeron despus de la
introduccin de la vacuna antineumoccica conjugada [16], pero las tarifas
para nios entre 1 y 18 aos se mantuvo estables [17]. (Consulte "Vacunas
conjugadas neumoccica (Streptococcus pneumoniae) en los nios", seccin
en 'Neumona').

Se prev que el 13-vacuna antineumoccica conjugada heptavalente que

sustituy a la heptavalente antineumoccica vacuna conjugada en 2010 y
ofrece cobertura adicional contra serotipos 1, 3, 5, 6A, 7F y 19A ms
disminuir la incidencia de neumona que requiere hospitalizacin, ya estos
serotipos son responsables de la mayora de los casos de neumona
neumoccica en nios en todo el mundo [18,19]. Primeros datos de los
Estados Unidos multicentro la vigilancia peditrica demuestran una
reduccin de 53 por ciento en los casos de neumona en comparacin con el
promedio de casos para 2007-2009 [20]. (Ver "Vacunas conjugadas
neumoccica (Streptococcus pneumoniae) en los nios", seccin en la
vacuna 13-Valente '.)

La vacunacin antineumoccica protege tambin contra la neumona

viral. Esto fue demostrado en un ensayo doble ciego, aleatorizado,
controlado con placebo en que completo de inmunizacin con una vacuna
de nueve se asoci con una reduccin de 31% (IC del 95%: 15-43) en la
incidencia de neumona asociada con siete virus respiratorios (influenza,

parainfluenza, respiratorio sincicial virus (VRS), adenovirus) en nios

hospitalizados [21] de cualquier vacuna antineumoccica conjugada. Esta
observacin sugiere que las neumonas asociadas con estos virus en nios
hospitalizados son a menudo debido a la infeccin neumoccica
concurrente.

PATOGENESIA: Neumona ocurre debido a una debilitacin de las defensas

del anfitrin, invasin por un microorganismo virulento o invasin de un
gran inculo.

En el escenario tpico, la neumona sigue una enfermedad del tracto

respiratorio superior que permite la invasin de las vas respiratorias
inferiores por las bacterias, virus u otros patgenos que desencadenan la
respuesta inmune y producen inflamacin [3,22]. Los espacios de aire de las
vas respiratorias inferiores se llenan de clulas de sangre blancas (WBC), el
lquido y restos celulares. Este proceso disminuye la compliance pulmonar,
aumenta la resistencia, obstruye las vas areas ms pequeas y puede
resultar en el colapso de los espacios areos distales, aire captura y
alteradas relaciones ventilacin-perfusin [3]. Infeccin severa se asocia con
necrosis del epitelio bronquial o bronchiolar [23], o el parnquima pulmonar
[24].

Adquisicin Los agentes causantes de infeccin de vas respiratorias

inferiores (IVRI) ms a menudo se transmiten por gotitas separ resultando
de contacto con un caso de fuente. Contacto con fmites contaminados
tambin puede ser importante en la adquisicin de agentes virales,
especialmente virus sincitial respiratorio (VSR).

Neumonas bacterianas ms tpicas son el resultado de la colonizacin inicial

de la nasofaringe seguida por aspiracin o inhalacin de
microorganismos. La enfermedad invasiva ocurre ms comnmente sobre la
adquisicin de un nuevo serotipo del organismo con el cual el paciente no
ha tenido experiencia previa, normalmente despus de un perodo de
incubacin de uno a tres das. En ocasiones, una bacteriemia primaria
puede preceder a la neumona. Patgenos bacterianos atpicos colocar
membranas epiteliales respiratorias a travs del cual entran en las clulas
para la replicacin.

Los agentes virales que causan neumona proliferan y diseminarse por

contigidad a implican porciones menores y ms distales de las vas
respiratorias.

Defensa del husped normal, el sistema de defensa del husped pulmonar

es complejo y que incluye barreras anatmicas y mecnicas, inmunidad
humoral, actividad fagoctica y mediada por clulas inmunidad [25,26],
como se explica a continuacin, con un foco de infeccin bacteriana. La

respuesta del husped a la infeccin viral respiratoria est fuera del alcance
de esta revisin; puede obtener ms informacin de la referencia [27].

Anatomic y las barreras mecnicas, barreras anatmicas y mecnicas en

la va area superior forman una parte importante de la defensa del
husped. Partculas mayores de 10 micras son filtradas eficientemente por
los pelos en el anteriores nares o impacto sobre las superficies mucosas. La
mucosa nasal contiene epitelio ciliado y clulas productoras de moco. Los
cilios batir sincrnicamente, claro los organismos atrapados a travs de la
nasofaringe mediante expulsin o deglucin. En la orofaringe, flujo salival,
descamacin de clulas epiteliales, produccin local de IgA y complemento
de interferencia bacteriana de la flora residente sirven como factores
importantes en la defensa del husped local.

Un reflejo intacto de epiglottic ayuda a prevenir la aspiracin de secreciones

infectadas, y el reflejo de la tos ayuda a expulsar materiales que pueden ser
aspirados. Los ngulos en que la rama central airways causa partculas de 5
a 10 micrones al impacto en las superficies mucosas, donde son atrapadas
en el moco endobronquial. Una vez atrapado, el sistema ciliar mueve las
partculas hacia arriba fuera de las vas respiratorias en la garganta, donde
normalmente se ingieren.
Humoral inmunidad IgA secretoria es la principal inmunoglobulina
producida en las vas areas superiores y representa el 10 por ciento de la
concentracin de protena total de las secreciones nasales. Aunque no es un
muy buen agente opsonizantes, posee actividad antibacteriana y
antiviral. IgG y IgM entrar en las vas respiratorias y espacios alveolares
predominante por trasudacin de la sangre y actuar para opsonize
bacterias, activar el complemento y neutraliza la toxina. Inmunoglobulinas,
surfactante, fibronectina y complemento actan como opsoninas eficaces
para ayudar a eliminar los microorganismos (partculas de 0.5 a 1 micrn)
que alcanzan las vas areas terminales y alvolos. cidos grasos libres,
lisozima y protenas hierro-que atan tambin estn presentes y pueden ser
microbicidas.
Las clulas del Phagocytic, all son dos poblaciones de clulas fagocticas
en el pulmn: leucocitos polimorfonucleares (PMNs) de la sangre y los
macrfagos. Hay varias poblaciones distintas de los macrfagos, que
pueden variar en su ubicacin y funcin:
Macrfagos alveolares el se encuentra en el lquido alveolar y es el primer
fagocito encontrado por partculas inertes y patgenos potenciales entrar en
el pulmn. Si esta clula est abrumada, tiene la capacidad de convertirse
en un mediador de la inflamacin y producen citocinas que reclutan
neutrfilos.
Interstitial los macrfagos se encuentran en el tejido conectivo del pulmn
y sirven como clulas fagocticas y clulas de antgeno-procesamiento.
Los macrfagos intravasculares se encuentra en las clulas endoteliales
capilares y phagocytizes y elimina el material extrao entrar en los
pulmones por el torrente sanguneo.

La inmunidad mediada por Cell-Inmunidad mediada por clulas es

especialmente importante frente a ciertos patgenos, incluyendo virus y
microorganismos intracelulares que pueden sobrevivir dentro de macrfagos
pulmonares. Aunque relativamente pocos en nmero (5 a 10 por ciento de
la poblacin de clulas de parnquima pulmonar total), linfocitos juegan tres
roles fundamentales: la produccin de anticuerpos, actividad citotxica y la
produccin de citocinas.
Patrones de neumona hay cinco patrones de neumona bacteriana [22]:

Lobar neumona participacin de un solo lbulo o segmento de un

lbulo; Este es el clsico patrn de neumona de S. pneumoniae
Bronchopneumonia participacin primaria de vas respiratorias y el
intersticio circundante; Este patrn se observa a veces en Streptococcus
pyogenes y Staphylococcus aureus neumona
Necrotizing neumona (asociada con neumona por aspiracin y neumona
por S. pneumoniae, S. pyogenes y S. aureus) (imagen 1)
Granuloma caseating (como en la neumona por tuberculosis)
interstitial y peribronchiolar con infiltracin parenquimatosa secundaria
este patrn ocurre tpicamente cuando una neumona viral grave es
complicada por neumona bacteriana
Existen dos patrones de neumona viral [22]:

interstitial neumonitis (imagen 2)

Infeccin parenchymal con inclusiones virales
Resultados de la examinacin, los resultados de la examinacin varan
dependiendo del sitio de la infeccin como sigue [3]:

Inspiratory crepitantes, que tambin se llama estertores crepitantes [28],

son ms comunes en la neumona lobar y la bronquiolitis, neumona
Decreased sonidos de la respiracin pueden ser observados en reas de
consolidacin
Coarse, sonidos de la respiracin continua grave (roncuses) son ms
comunes en bronconeumona
Exp14<<iratory sibilancia, los ruidos respiratorios agudos, son causadas
por la oscilacin del aire a travs de una va area estrechada; son ms
comunes en la bronquiolitis y neumonitis intersticial
AGENTES etiolgicos Un gran nmero de microorganismos se han
implicado como agentes etiolgicos de la neumona en nios (tabla 1AB). Los agentes comnmente responsables varan segn la edad del nio y
el entorno en que se adquiere la infeccin.

Neumona adquirida en la comunidad

Resumen La verdadera prevalencia de los diferentes agentes etiolgicos

en pulmona comunidad-adquirida (casquillo) en nios es incierto
[29]. Estudios que investigaron la etiologa de la neumona en la niez se
han realizado en poblaciones de diferentes edades, en diversas
configuraciones y utilizando una variedad de tcnicas microbiolgicas [6,3041]. Porque cultura directa del tejido pulmonar infectado requiere de
tcnicas invasivas, estudios publicados usan principalmente pruebas de
laboratorio que proporcionan pruebas indirectas de la etiologa. Estos
mtodos indirectos incluyen serologa, Hemocultivo, reaccin en cadena de
polimerasa y cultivo nasofarngeo. Adems del uso de mtodos indirectos,
interpretacin de los resultados se ve obstaculizada por la falta de
identificar un organismo en 15 a 35 por ciento de los casos y la frecuencia
de infecciones mixtas (de 23 a 33 por ciento de los casos) [2,6]. La mayora
de estos estudios se realizaron antes de la licencia de la vacuna
antineumoccica conjugada [42].

A pesar de estos problemas, las revisiones sistemticas han identificado

algunas tendencias consistentes y conclusiones con respecto a la etiologa
de la tapa en los nios, que se enumeran a continuacin [2,29]:

S TOMA CON. pneumoniae es la causa bacteriana ms comn de

neumona en nios [9.43]
Viruses solos cuenta 14 a 35 por ciento de los casos y hasta el 50 por
ciento de casos en nios pequeos
Viruses se identifican ms comnmente en nios menores de cinco aos
en los nios mayores de cinco aos, Mycoplasma pneumoniae y
Chlamydia pneumoniae son ms comunes [6,44,45]
En algunas zonas que estafilococo meticilina-resistente comunidad-asociado
aureus (CA-MRSA) es un asunto importante, CA-MRSA se est convirtiendo
en una causa importante de CAP complicada por empiema y necrosis
[46,47]. Cuando se asocia con gripe, MRSA CAP puede ser particularmente
severa [48,49]. (Ver "Epidemiologa; presentacin clnica; y la evaluacin de
derrame paraneumnico y empiema en los nios"y" gripe estacional en
nios: caractersticas clnicas y diagnstico ", seccin 'Coinfeccin
bacteriana' y" las infecciones meticilina-resistente del estafilococo ureo en
nios: Epidemiologa y espectro clnico ", seccin de epidemiologa y
factores de riesgo.)

En los recin nacidos, la etiologa de la neumona en recin nacidos

(neonatos < 28 das de edad) se discute por separado. (Vase "Neumona
Neonatal", seccin de 'Microbiologa'.)

En los bebs, como se describe a continuacin, los virus son la etiologa ms

comn de PAC en nios menores de cinco aos, incluyendo lactantes. Sin
embargo, los bebs menores de un ao tambin pueden desarrollar

"neumona afebril de la infancia". Neumona afebril de la infancia es un

sndrome generalmente visto entre dos semanas y tres meses de vida. Es
clsicamente causada por Chlamydia trachomatis, pero otros agentes, como
el citomegalovirus (CMV), Mycoplasma hominis y Ureaplasma urealyticum,
tambin estn implicados. (Consulte "Trachomatis infecciones por clamidia
en el recin nacido", seccin en 'Neumona').

Neonatos con infeccin severa de Bordetella pertussis tambin pueden

desarrollar neumona. (Vea "infeccin por Bordetella pertussis en lactantes y
nios: caractersticas clnicas y diagnstico", seccin en 'Complicaciones'.)

En los nios < 5 aos

Viruses virus son la etiologa ms comn de PAC en lactantes mayores y

nios menores de cinco aos de edad [2,6,29]. Sin embargo, bacterias
patgenas, incluyendo S. pneumoniae, S. aureus y S. pyogenes, tambin
son importantes porque se asocian con mayor morbilidad y mortalidad
[47,48,50].

Virus sincitial respiratorio (VSR), un miembro de la familia de virus

Paramyxoviridae, es el patgeno viral ms comn responsable de la
neumona en nios menores de cinco aos [6.36]. Neumona de RSV con
frecuencia representa una extensin de la bronquiolitis. (Ver bronquiolitis
en bebs y nios: caractersticas clnicas y diagnstico ", seccin en
caractersticas clnicas y" infeccin por virus sincicial respiratorio:
caractersticas clnicas y diagnstico ", seccin en Manifestaciones
clnicas.)

Otras causas virales de la neumona en nios menores de cinco aos

incluyen [6]:
Influenza virus A y B. (Ver "gripe estacional en nios: caractersticas
clnicas y diagnstico", seccin 'Pulmona'.)
Parainfluenza virus, generalmente de tipo 3. (Ver "Virus de la Parainfluenza
en los nios", seccin en la presentacin clnica).
Un nmero de serotipos de adenovirus (1, 2, 3, 4, 5, 7, 14, 21 y 35) se han
divulgado para causar neumona; serotipos 3, 7 y 21 han sido asociados con
neumona severa y complicada [51]. (Ver seccin "Epidemiologa y
manifestaciones clnicas de la infeccin por adenovirus, en la presentacin
clnica).
RRHH metapneumovirus, identificado en el ao 2001, es una causa comn
de infecciones del tracto respiratorio inferior en nios; mayora de los nios
se han infectado por cinco aos de edad. (Vea "Infecciones por adenovirus").
Rhinovirus se ha implicado como causa de la pulmona usando anlisis PCR
[52], pero su papel etiolgico es cuestionada [53].

Coronaviruses, incluyendo el sndrome respiratorio agudo severo (SARS), el

sndrome respiratorio de Medio Oriente y el coronavirus de New Haven,
causa tambin infecciones del tracto respiratorio en nios menores de cinco
aos [54,55]. Sin embargo, su impacto clnico todava tiene que ser
completamente determinado [56]. (Ver "Coronavirus", seccin 'Respiratorio'
y "Sndrome respiratorio agudo severo (SARS)", seccin en la ' clnica ' y
"Coronavirus del sndrome respiratorio medio Oriente", seccin en
Manifestaciones clnicas).
Calvo de RRHH y parechovirus humano tipos 1, 2 y 3 tambin han sido
implicados como causa de infecciones del tracto respiratorio inferior en
nios [57-59].
Bacteria-causas bacterianas importantes de neumona en nios en edad
preescolar incluyen S. pneumoniae, H. influenzae tipo b, H. influenzae no
tipificable, Moraxella catarrhalis, S. aureus, S. pyogenes y bacterias atpicas.
S. pneumoniae es el patgeno bacteriano ms comn solo que causa
neumona en todos los pacientes ms all de las primeras semanas de vida
[9.43]. (Consulte "Neumona neumoccica en los nios", seccin en
'Epidemiology').
Cuadrados. influenzae tipo b es una causa rara de neumona en pases con
vacunacin infantil universal.
S. aureus (particularmente asociada a la comunidad MRSA, CA-MRSA) y S.
pyogenes se estn volviendo cada vez ms frecuentes causas de PAC,
particularmente sos complicada por la necrosis y empiema
[47,60]. Adems, estos organismos en ocasiones causar neumona y con
frecuencia se observan tras influenza y varicela, respectivamente
[48,49]. (Ver "caractersticas clnicas de la infeccin por virus varicelazoster: varicela" y "gripe estacional en nios: caractersticas clnicas y
diagnstico", seccin 'Pulmona'.)
La prevalencia de M. pneumoniae y C. pneumoniae puede aumentar en
nios preescolares con tapa [29,61]. (Ver "Neumona causada por especies
de Chlamydia en nios" y "Infeccin por Mycoplasma pneumoniae en nios",
seccin en 'Epidemiology'.)
En nios 5 aos

S TOMA CON. pneumoniae es la causa bacteriana ms comn tpica de

neumona en nios mayores de cinco aos (ver "Neumona neumoccica en
los nios", seccin en 'Epidemiology')
M. pneumoniae es ms comn entre nios 5 aos que entre los nios
ms pequeos (vea "Infeccin por Mycoplasma pneumoniae en nios",
seccin en 'Epidemiology')
C. pneumoniae tambin est emergiendo como una causa frecuente de
neumona en adultos mayores de los nios y jvenes (vase "Causada por
especies de Chlamydia en nios con neumona")
Neumona por aspiracin, cuando hay una predisposicin a la aspiracin, la
neumona puede ser causada por flora anaerobia oral, incluyendo:

Anaerobic estreptococos (por ejemplo, Peptostreptococcus)

Fusobacterium spp
Bacteroides spp
Prevotella melaninogenica
Factores de riesgo para la aspiracin incluyen un historial de convulsiones,
anestesia u otro episodio de disminucin del nivel de conciencia,
enfermedad neurolgica, disfagia, reflujo gastroesofgico, alcohol o abuso
de sustancias, uso de una sonda nasogstrica, o aspiracin de cuerpo
extrao.

Neumona nosocomial: Neumona bacteriana Nosocomial generalmente es

causada por bacilos gramnegativos o Staphylococcus aureus. La neumona
nosocomial ocurre con frecuencia en unidades de cuidados intensivos donde
la ventilacin mecnica, catteres permanentes y administracin de
antibiticos de amplio espectro son comunes. (Ver "la neumona en nios:
tratamiento hospitalario", seccin de 'Neumonia Nosocomial'.)

Adems, durante el invierno respiratoria viral, todos los pacientes en un

entorno de atencin mdica corren el riesgo de neumona nosocomial
causada por RSV, parainfluenza y virus de la gripe. (Ver "gripe estacional en
nios: caractersticas clnicas y diagnstico" y "Virus Parainfluenza en los
nios", seccin en la presentacin clnica y "infeccin por virus sincicial
respiratorio: caractersticas clnicas y diagnstico", seccin en la
'Transmisin'.)

Poblaciones especiales

Inmunocomprometidos, Las causas de la pulmona en anfitriones

immunocompromised incluyen todos los patgenos antes mencionados, as
como una variedad de otros organismos, como se explica a continuacin.

Bacilos Gram-negativos y S. aureus son las etiologas comunes en pacientes

neutropnicos o en aquellos con defectos del glbulo blanco
(WBC). Legionelosis clnicamente significativas generalmente se ven
solamente en anfitriones immunocompromised con una exposicin a un
reservorio acutico de Legionella pneumophila, como un ro, lago, torre de
enfriamiento de aire acondicionado o sistemas de distribucin de agua
[62]. Sin embargo, estudios seroepidemiolgico sugieren que las infecciones
subclnicas o leves ocurren en nios [63,64]. (Vase "Epidemiologa y
patogenia de la infeccin por Legionella").

Hongos oportunistas como Aspergillus y Fusarium spp, tambin son una

preocupacin en pacientes neutropnicos y en los que reciben terapias
inmunosupresoras que afectar la respuesta mediada por clulas. Uno de los

patgenos ms comunes de neumona diagnosticados en pacientes

infectados por el VIH es la neumona por Pneumocystis jirovecii, que
anteriormente fue llamada carinii de Pneumocystis [65]. (Ver "Epidemiologa
y manifestaciones clnicas de la aspergilosis invasora" y "Micologa,
patognesis y epidemiologa de la infeccin de Fusarium" y la "Historia
Natural y clasificacin de la infeccin VIH peditrica, seccin sobre
'Neumona por Pneumocystis jirovecii'.)

Causas virales de la neumona, que puede ser peligrosa para la vida en el

anfitrin immunocompromised, incluyendo la posterior slida del rgano y
clula de vstago trasplante de poblaciones incluyen:

Common adquirida en la comunidad agentes virales tales como RSV,

adenovirus, influenza, parainfluenza, rinovirus y adenovirus [66,67] (Ver
tema correspondiente comentarios)
Rubeola (neumona de clulas gigantes de Hecht) (ver seccin
"manifestaciones clnicas y diagnstico de sarampin, en 'Pacientes
inmunocomprometidos')
Varicella-zster (VZV) (ver "caractersticas clnicas de la infeccin por virus
varicela-zoster: varicela", seccin 'Neumona')
CMV (vase "Adquirido infeccin por citomegalovirus en recin nacidos,
nios y adolescentes", seccin en la 'Infeccin por CMV en anfitriones
immunocompromised')
Epstein-Barr virus (EBV), que puede ser el detonante de la neumonitis
intersticial linfoctica, un indolente pero progresivo proceso que ocurre en
nios infectados por el VIH (vea "manifestaciones clnicas y tratamiento de
la infeccin por virus Epstein - Barr" y "Neumona intersticial linfoctica en
nios", seccin 'Patogenia')
La fibrosis qustica, nios con fibrosis qustica con frecuencia estn
infectados con p. aeruginosa y S. aureus y H. influenzae (en su mayora no
tipificable cepas). Ms adelante en el curso de la enfermedad, mltiples
organismos gram-negativos resistentes a los medicamentos, como
Burkholderia cepacia y Stenotrophomonas maltophilia, Achromobacter
xylosoxidans, pueden ser recuperados. Aspergillus spp y micobacterias no
tuberculosas tambin pueden causar enfermedad en esta
poblacin. Enfermedad pulmonar de la fibrosis qustica se discute en detalle
por separado. (Ver "fibrosis qustica: manifestaciones clnicas de la
enfermedad pulmonar" y "fibrosis qustica: Resumen del tratamiento de la
enfermedad pulmonar" y "fibrosis qustica: terapia con antibiticos para la
enfermedad pulmonar".)

Anemia de clulas falciformes, se incrementa la prevalencia de neumona en

nios con anemia drepanoctica [68]. Patgenos bacterianos atpicos
parecen ser ms frecuentes y son ms comnmente asociados con el
sndrome torcico agudo. Otras causas bacterianas de la neumona en nios
con anemia de clulas falciformes incluyen S. pneumoniae, S. aureus y H.

influenzae [9]. (Vase "El sndrome torcico agudo en nios y adolescentes

con enfermedad de clulas falciformes", seccin en la 'Infeccin').

Consideraciones ambientales

Geografa, Residencia o viajes a reas geogrficas especficas deben sugerir

patgenos endmicos:

Tuberculosis es ms comn en los inmigrantes procedentes de pases con

alta prevalencia de infeccin (por ejemplo, pases en Asia, frica, Amrica
Latina y Europa del este) (Figura 2). (Vea "Epidemiologa de la
tuberculosis").
Measles neumona es comn en el mundo en desarrollo. (Vase
"manifestaciones clnicas y diagnstico de sarampin").
Coccidioides immitis es endmico en el sudoeste Estados Unidos, norte de
Mxico y partes de Amrica Central y del sur. (Vea "infeccin coccidioidal
primaria").
Blastomyces dermatitidis, que causa la Blastomicosis, es endmica en los
Estados del sudeste y centrales y los Estados del medio oeste que bordea
los grandes lagos. (Ver "Micologa, patognesis y epidemiologa de la
blastomicosis" y "Tratamiento de la blastomicosis".)
Histoplasma capsulatum es endmico en los valles de Ohio, Mississippi y
Ro de Missouri en los Estados Unidos; en 2013 se inform por primera vez
en Montana [69]. Tambin se produce en Canad, Amrica Central, Europa
oriental y meridional, partes de frica, Asia oriental y Australia. Actividades
que potencialmente conduzcan a la exposicin a excrementos de aves y
guano de murcilago pueden ser sugestivas. Estos incluyen jardinera,
construccin, limpieza de establos y dependencias y espeleologa. (Ver
"Patognesis y caractersticas clnicas de la histoplasmosis pulmonar" y
"diagnstico y tratamiento de la histoplasmosis pulmonar".)
en los Estados Unidos, sndrome cardiopulmonar por hantavirus
(enfermedad febril aguda asociada a insuficiencia respiratoria, shock y alta
mortalidad) ocurre predominantemente al oeste del ro Mississippi (en la
regin de "cuatro esquinas" donde se encuentran las fronteras de Colorado,
Nuevo Mxico, Arizona y Utah) despus de la exposicin ambiental a heces,
orina o saliva infectada ratn ciervo (Peromyscus maniculatus). Las
actividades relacionadas con la exposicin incluyen limpieza de graneros y
dependencias, reventado roedores, animales de pastoreo y agrcolas con
herramientas de mano. (Ver "Epidemiologa y diagnstico de infecciones por
hantavirus" y "Sndrome cardiopulmonar por Hantavirus".)
Exposiciones de animales, es asociado con la exposicin a excrementos de
aves y guano de murcilago, y la infeccin del hantavirus est asociada con
la exposicin a un ratn infectado. Otras causas de neumona asociados con
la exposicin animal incluyen:

Chlamydia psittaci (psitacosis), que es transmitida al hombre

predominante de domsticos y silvestres de aves (vase "Psitacosis")
Coxiella burnetii (fiebre Q), que se asocia con la exposicin a la
parturientas ovejas, cabras, ganado y los gatos (o la exposicin a polvo,
suelo contaminado por estos animales) (ver "Microbiologa y epidemiologa
de Q fiebre" y "manifestaciones clnicas y diagnstico de la fiebre de Q")
Otros riesgos: exposicin a individuos con alto riesgo para la tuberculosis es
un factor de riesgo para el desarrollo de la tuberculosis en los
nios. Individuos de alto riesgo incluyen a los inmigrantes sin techo,
recientes de regiones endmicas (Figura 2), personas encarceladas y
pacientes VIH-infectados. (Vea "Epidemiologa de la tuberculosis").

INFORMACIN para pacientes: UpToDate ofrece dos tipos de materiales

educativos para pacientes, "The Basics" y "ms all de lo bsico." Las piezas
de la educacin del paciente aspectos bsicos estn escritas en lenguaje
llano, en el grado 5 a 6 nivel, de lectura y responder a las cuatro o cinco
preguntas claves que un paciente pueda tener sobre una condicin
determinada. Estos artculos son los mejores para los pacientes que desean
una visin general y que prefieren materiales cortos, fcil de leer. Ms all
de los conceptos bsicos piezas educacin del paciente son ms largas, ms
sofisticado y ms detallada. Estos artculos estn escritos en el grado de 10
a 12 nivel de lectura y son los mejores para los pacientes que desean
obtener informacin detallada y con cierta jerga mdica.

Aqu estn los artculos de la educacin del paciente que son pertinentes a
este tema. Le recomendamos que imprima o por correo electrnico estos
temas a sus pacientes. (Tambin puede localizar artculos de la educacin
del paciente sobre una variedad de temas mediante la bsqueda en
"paciente info" y las palabras claves de inters.)

Basics temas (ver "informacin para el paciente: la neumona en nios

(conceptos bsicos)")
Extracto: La neumona es ms comn en nios menores de cinco aos de
edad que en nios mayores y adolescentes. Factores de riesgo para
neumona incluyen apiamiento ambiental, tener hermanos de edad escolar
y cardiopulmonares y otros trastornos mdicos subyacentes. (Ver
'Epidemiology' arriba).

Neumona puede ser causada por un gran nmero de microorganismos

(tabla 1A-B). Los agentes comnmente responsables varan segn la edad
del nio y el entorno en que se adquiere la infeccin. (Ver a agentes
etiolgicos anteriormente).

en los nios menores de cinco aos, los virus son ms comunes. Sin
embargo, bacterias patgenas, incluyendo S. pneumoniae, S. aureus y S.
pyogenes, tambin son importantes. (Ver ' en nios < 5 aos arriba.)

en otra manera saludable para nios mayores de cinco aos, S.

pneumoniae, M. pneumoniae y Chlamydia pneumoniae son ms
comunes. (Vase 'en nios 5 aos' arriba).
Community-associated methicillin-resistente S. aureus (CA-MRSA) es un
patgeno cada vez ms importante en los nios de todas las edades,
particularmente en sos con pulmona de necrotizacin. S. pneumoniae es
otra causa frecuente de pulmona de necrotizacin. (Ver 'Resumen' arriba).
Aspiration neumona es causada generalmente por flora oral
anaerobia. (Vase Neumona por aspiracin arriba).
Nosocomial la neumona es causada generalmente por bacilos
gramnegativos o Staphylococcus aureus. (Vase 'Neumona Nosocomial'
arriba).