Treatment of Viral Pneumonia in Pediatrics
Antimicrobial therapy is not routinely required for preschool-aged children with viral pneumonia, as viral pathogens are responsible for the great majority of clinical disease. 1
Diagnostic Approach
- Viral pneumonia should be suspected in children with respiratory symptoms, especially those under 5 years of age 2
- Rapid antigen testing and PCR have the advantage of rapid turnaround times and should be used when available to confirm viral etiology 1
- For children requiring mechanical ventilation, obtain tracheal aspirates for testing of viral pathogens, including influenza virus, at the time of initial endotracheal tube placement 1
- Bronchoscopic sampling, bronchoalveolar lavage, or other invasive procedures should be reserved for immunocompetent children with severe pneumonia if initial diagnostic tests are not positive 1
Treatment Algorithm for Viral Pneumonia
Supportive Care (Primary Treatment)
- Ensure adequate hydration and nutrition 3
- Provide supplemental oxygen for hypoxemic patients (oxygen saturation <90%) 3
- Monitor for clinical improvement, which should occur within 48-72 hours 4
Specific Antiviral Treatment
Influenza Virus
- Administer antiviral therapy as soon as possible to children with moderate to severe pneumonia consistent with influenza virus infection 1
- Preferred agent: Oseltamivir at age-appropriate dosing 1
- For oseltamivir-resistant strains, consider zanamivir or investigational antiviral agents 1
- Testing for oseltamivir resistance should be pursued through public health laboratories when resistance is suspected 1
Other Viral Pathogens
- Most other viral pneumonias (RSV, rhinovirus, adenovirus, etc.) have no specific approved antiviral therapy and require supportive care 2, 5
- For adenovirus pneumonia, which can be severe in children, supportive care with respiratory support is the mainstay of treatment 5
Management of Secondary Bacterial Infection
- Monitor for clinical deterioration supported by laboratory evidence of increased systemic inflammation, which may indicate secondary bacterial infection 1
- If secondary bacterial infection is suspected, particularly in hospitalized children with influenza or RSV, initiate antibacterial therapy 1
- For empiric coverage of common bacterial pathogens:
- Amoxicillin as first-line therapy for mild to moderate suspected bacterial co-infection (50-75 mg/kg/day in 2 doses) 1
- For hospitalized patients: ampicillin, ceftriaxone, or cefotaxime 1
- Consider coverage for atypical pathogens (Mycoplasma, Chlamydophila) in children 3-5 years old with macrolides if perihilar/bilateral infiltrates and wheezing are present 1
Special Considerations
- Children with viral pneumonia who develop respiratory failure may require intensive care management with mechanical ventilation 1
- For children requiring significant intervention to maintain adequate oxygenation or perfusion, transfer to a unit capable of providing intensive care 1
- Children with severe adenovirus pneumonia may be at risk for post-infectious bronchiolitis obliterans and should be monitored closely 5
Follow-up and Return to School
- Children with viral pneumonia can return to school when fever-free for 24 hours without antipyretics and symptoms have significantly improved 4
- Repeated chest radiographs are not routinely required in children who recover uneventfully 1
- Obtain follow-up chest radiographs in children who fail to demonstrate clinical improvement or have progressive symptoms within 48-72 hours 1
Prevention
- Ensure appropriate immunization, including annual influenza vaccination 4
- Implement infection control measures to prevent transmission in healthcare and school settings 4
By following this evidence-based approach to the management of viral pneumonia in pediatric patients, clinicians can optimize outcomes while avoiding unnecessary antibiotic use.