PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

PNEUMONIA

Is an inflammation of the parenchyma of

the lungs

Most cases of pneumonia are caused by

microorganism

 noninfectious causes- aspiration of food or

gastric acid; foreign bodies; hydrocarbons; lipoid substances; hypersensitivity reactions and drug 0r radiation-induced pneumonitis

 Specific risk factors: 1. Lung disease 2. anatomic problems 3. Gastroesophageal reflux disease with
aspiration

4. Neurologic disorders that interfere with protection of the airway or compromise clearing of the airway

5. Diseases that alter the immune system, such immunodeficiency diseases or hemoglobinopathies

Etiology

Viral - peak attack is between 2-3 y.o. S.pneumoniae, M.pneumoniae older

than 5 y.o. other bacterial causes: group A strep, S.pyogenes, Staph aureus, H.influenzae type B

Clinical manifestation

Viral and bacterial pneumonias are most

often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough Viral pneumonia, fever -temp.- is generally lower than bacterial.

 Tachypnea is the most consistent clinical

manifestation

Increased working breathing accompanied

by intercostal retractions, nasal flaring and use accesory muscles

 Bacterial pneumonia in older children

typically begins suddenly with shaking chill followed by high fever, cough and chest pain

Predictors of CAP in a Patient with cough

1. ages 3-5 y.o.- tachypnea and/or chest

indrawing 2. ages 5-12 y.o. fever, tachypnea & crackles 3. > 12 y.o. fever, tachypnea, tachycardia at least 1 abnormal chest findings ronchi, crackles, wheezes, breath sounds

 Reliable indicators- either tachypnea and/or

chest indrawing among infants and preschool children Tachypnea is still the best predictor Age specific criteria for tachypnea: 2-12 mos. 50 breaths/min. 1-5 years. 40 breaths/min. > 5 years 30 breaths/min.

 Patients with CAP are 2-3 times more

likely to have the following signs and symptoms: nasal flaring, grunting, tachypnea, rales and pallor

 Diagnosis of an adolescent suspected to

have CAP: cough tachypnea (RR .20 breaths/min.) tachycardia (HR .100bpm) fever (temp > 37.8C) at least 1 abnormal chest findings CXR with infiltrates

Criteria for admission

A patient who is moderate to high risk to

develop pneumonia-related mortality should be admitted

A patient who is at minimal to low risk can

be managed on OPD basis

RISK CLASSIFICATION FOR PNEUMONIA-RELATED MORTALITY

VARIABLES PCAP A Minimal risk
co-morbid illness
Compliant care giver Ability to ff-up Presence of dehydration Ability to feed

PCAP B Low risk

present
yes possible mild able

PCAP C Moderate risk

present
no Not possible moderate unable

PCAP D High risk

Present
no Not possible severe unable

none
Yes possible none able

age

>11 mo.

>11 mo.

<11 mo.

<11 mo.

VARIABLES PCAP A Minimal risk

resp rate 2-12mo. 1-5 yrs. >5 yrs. Signs of resp failure a.Retraction b. Head bobbing c. Cyanosis d. Grunting

PCAP B Low risk

PCAP C Moderate risk

>60/min >50/min >35/min

PCAP D High risk

>50/min >40/min >30/min

>50/min >40/min >30/min

>70/min >50/min >35/min

none

none

Intercostal/su bcostal Present present none

Supraclavicular/ intercostal/subc ostal

present

VARIABLES PCAP A Minimal risk

Signs of resp failure e. apnea f. sensorium

PCAP B Low risk

PCAP C Moderate risk

PCAP D High risk

None awake

None awake none

None irritable present

Present Lethargic,stupor ous/comtose

Complications none

present

Action plan

OPD

OPD

Admit to regular ward

Admit to ICU

 Parameters to be evaluated when

considering admission: 1. Host factors a. ability to feed b. age c. signs of resp failure d. pulmonary complications

e. respiratory rate f. state of dehydration g. presence of comorbid factors 2. External factors a. compliant caregiver b. ability to ff-up

Grunting and apnea are manifestations

of acute respiratory failure requiring admission to critical care unit

compared with older children, an infant

younger than one year has higher risk of contracting sever pneumonia

 Age from 2-11 mos. was associated with

death

Presence of retraction on admission was

the best single predictor of death Subcostal, intercostal, supraclavicular retractions were associated with mortality

 Chest retraction has been considered to

be an excellent sign for selecting children needing admission for more intensive treatment. Tachypnea, chest retraction, somnolence and young age, chronic illness & malnutrition were independently associated with hospitalization

 Cyanosis and head bobbing corelates well

with hypoxemia

Inability to cry, head nodding and a resp

rate of >60/min. were best predictors of hypoxemia.

DIAGNOSTICS

No diagnostic aids are initially requested

for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D).

 Recommendations for PCAP C & D:

Routine exams: a. CXR-PA Lateral b. WBC count c. Culture and sensitivity of: blood,pleural fluid, & tracheal aspirate for PCAP D, sputum for older children

 The following should not be requested: 1. ESR 2. C-reactive protein

ANTIBIOTIC RECOMMENDATION

1. for patient classified as either PCAP A or B and is a. beyond 2 years of age b. having high grade fever without wheeze 2. For a patient classified as PCAP C and is a. beyond 2 years of age

b. having high grade fever without wheeze c. having alveolar consolidation in the CXR d. having WBC count > 15,000 3. For a patient classified as PCAP D

Practice guidelines cited as AGE as the

best predictor of underlying etiology of pediatric pneumonia

First 2 years of life VIRUSES are most

frequently implicated As age increases, bacterial pathogens become more prevalent

 Literature review showed the following

pattern of microbial etiology: 1. PCAP managed as an outpatient a. bacterial pathogen is more common than a viral pathogen b. Streptococcus pneumoniae is the pathogen in more than half of the patients

Less common pathogens include M.

pneumoniae and C. pneumoniae
2. PCAP managed as an in patient a. bacterial pathogen is more common than a viral pathogen b. S.pneumoniae is the pathogen in little more than half of the patients

 H. influenzae type B should be

considered in a patient below 5 y.o. who has not completed the primary series of Hib immunization

 certain features that suggest the presence of a bacterial

and viral pathogen Demonstration of either alveolar infiltrates in CXR or elevated WBC favors bacterial pathogen

FEATURES
Fever Wheeze

Bacterial
>38.5C absent

Viral
<38.5C present

EMPIRIC TREATMENT

1. for patient classified as PCAP A or B without

previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses

2. for a patient classified as PCAP C w/o

previous antibiotic & who has completed the primary immunization against H. influenzae type B, Pen G 100,000 u/kg/day in 4 divided doses.

if a primary immunization against Hib has

not been completed,and below 5 y.o., IV ampicillin (100mg/kg/day in 4 divided doses

3. for a patient classified as PCAP D, a

specialist should be consulted

INITIAL TREATMENT GIVEN WITH VIRAL ETIOLOGY

Antiviral agents such as amantadine and

the newer neuraminidase inhibitors zanamivir and oseltamivir -reduces the duration of illness by 1-1.5 days -to reduce the duration of viral shedding among patients with influenza

For influenza A infection amantadine

(4.4-4.8 mg/kg/day) can be given for 3-5 days
- Discontinue the drug within 24-48 hrs. after resolution of symptoms

 For influenza A or B infection oseltamivir

(2mg/kg/dose BID) can be given for 5 days

In case proven epidemics of influenza,

oseltamivir may be given Its use for treatment & prophylaxis of household contacts has been effective for >12 y.o.

RESPONSE TO CURRENT ANTIBIOTICS

1. decrease in respiratory signs

(tachypnea) & defervescence within 72 hrs. after initiation of antibiotic 2. persistence of symptoms beyond 72 hrs after initiation of antibiotics requires reevaluation

3. end of treatment CXR, WBC, ESR or

CRP should not be done to assess therapeutic response to antibiotic

1. if an out patient classified as either

PCAP A or PCAP B is not responding to the current antibiotic within 72 hrs. - change the initial antibiotic - start oral macrolide - reevaluate diagnosis

possibility of penicillin resistant

S.pneumoniae
Course of action: change amoxicillin to any of the ff.: cefuroxime, co-amoxiclav, sultamicillin or cepfodoxime

Possibility of Mycoplasma sp or
Chlamydia sp.
Course of action: start an oral macrolide, such as erythromycin

2. if an inpatient classified as PCAP C is

not responding to the current antibiotic within 72 hrs. consider consultation with a specialist following possibilities: - penicillin resistant S.pneumoniae - presence of complications

If an inpatient classified as PCAP D is not

responding within 72 hrs., consider immediate re-consultation with a specialist

WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA

Switch from IV antibiotics to oral form 2-3 days

after initiation of antibiotic is recommended in patients: a. responding to initial antibiotic therapy b. able to feed with intact GI absorption c. does not have any pulmonary or extrapulmonary complications

ANCILLARY TREATMENT

1. cough preparations, chest

physiotherapy, bronchial hygiene, nebulization using NSS, steam inhalation, topical solution, bronchodilators and herbal medicine are not routinely given

 2. among patients, oxygen and hydration

should be given if needed

3. in the presence of wheezing, a

bronchodilator may be given

PREVENTION

1. vaccines recommended by the Phil.

Pediatric Society should be routinely administered 2. Zinc supplementation

3. Vitamin A, immunomodulators and

Vitamin C should not be routinely given