What are the clinical manifestations and management of pneumonia in adolescents?

From the Guidelines

Pneumonia in adolescents should be treated with amoxicillin as the first-line therapy for mild to moderate community-acquired pneumonia (CAP) suspected to be of bacterial origin, particularly for Streptococcus pneumoniae, with consideration of atypical bacterial pathogens such as Mycoplasma pneumoniae. This recommendation is based on the clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1. The guidelines suggest that amoxicillin provides appropriate coverage for S. pneumoniae, the most prominent invasive bacterial pathogen, and that atypical bacterial pathogens should also be considered in management decisions.

For mild to moderate CAP in otherwise healthy adolescents, the dose of amoxicillin recommended is 45 mg/kg/day divided into three doses (maximum 1500 mg/day) for 5-7 days. For patients with penicillin allergy, azithromycin (10 mg/kg on day 1, maximum 500 mg, followed by 5 mg/kg daily for 4 days, maximum 250 mg) is an alternative 1. It's also important to consider the role of atypical pathogens, such as M. pneumoniae, which are common in this age group, and macrolide antibiotics like azithromycin may be prescribed for treatment of CAP caused by these pathogens.

Some key points to consider in the management of pneumonia in adolescents include:

• The importance of supportive care, including adequate hydration, rest, and fever control with acetaminophen or ibuprofen
• The need for parents to seek immediate medical attention if the adolescent experiences difficulty breathing, persistent high fever, or worsening symptoms despite treatment
• Prevention strategies, such as maintaining up-to-date vaccinations (including annual influenza vaccine), good hand hygiene, and avoiding tobacco smoke exposure
• The potential need for hospitalization for more severe cases or those with complicating factors, with intravenous antibiotics such as ceftriaxone (50-75 mg/kg/day) as a treatment option.

From the Research

Pneumonia in Adolescents

• Pneumonia is an acute infection of the pulmonary parenchyma that continues to have a significant impact on adolescent health, with significant morbidity and considerable cost to the healthcare system 2.
• The epidemiology, pathogenesis, etiology, clinical manifestations, radiography, laboratory evaluation, management, complications, and prevention of pneumonia in adolescents are important considerations in the diagnosis and treatment of the disease 2.

Etiology and Treatment

• Streptococcus pneumoniae is the primary bacterial cause of pneumonia in infants and children, while viral etiologies become less prevalent and mycoplasmal and chlamydial infections become more prevalent with increasing age 3.
• Treatment of pneumonia is often empiric, with antibiotic therapy withheld in mildly ill, ambulatory patients in whom viral infection is likely 3.
• Recommended treatment options include orally administered amoxicillin or amoxicillin/clavulanate, or intravenous cefuroxime for hospitalized patients 3.
• Combination antibiotic therapy, including a macrolide for wide coverage of atypical pneumonia, polymicrobial pneumonia, or resistant Streptococcus pneumoniae, may achieve a better outcome compared to monotherapy 4.

Antimicrobial Resistance

• The increasing resistance of Mycoplasma pneumoniae to macrolides is a concern, with point mutations in the 23S rRNA gene contributing to resistance 5.
• Inappropriate and overuse of macrolides for respiratory tract infections may induce resistance rapidly, highlighting the need for antibiotic stewardship 5.
• Alternative treatment options, such as tetracyclines and fluoroquinolones, may be effective for macrolide-resistant strains 5.