Pneumonia in the developed world

In this paper, we review the literature on the management of pneumonia in the developed world setting. Pneumonia is usually diagnosed on the basis of a cough, respiratory distress, a fever, and chest X-ray changes. Pneumonia affects all paediatric age groups, though the highest incidence is in the under 5s. There is a significant burden of primary and secondary care illness, although mortality is low. Inpatient admission rates for pneumonia may have increased in recent years in some regions. Pneumonia is unlikely if a child presents with solely wheeze. In routine clinical practice, a microbiological diagnosis is often not made, because current tests are insensitive. Aetiology varies with geographical location, but approximately half of cases are viral. The mainstay of management of moderate pneumonia (the commonest group presenting to secondary care) is careful assessment, and oral antibiotics, followed by early discharge when the patient shows signs of improvement. We summarise the available clinical trial data from the developed world; most of these trials are not adequately powered. Patients with moderately severe pneumonia do not require invasive investigation, but clinical judgement should be used to identify and investigate more complex cases. We discuss several pathogens that have gained importance as causal agents, including non-vaccinated strains of S. pneumoniae, Panton Valentine leucocidin S. aureus, H1N1 Influenza A and Human Bocavirus. The importance of antimicrobial resistance is considered, and we review recent data on long term effects of pneumonia in childhood. By reviewing the available literature, we demonstrate that there are clear evidence gaps, and we suggest future areas for clinical research.