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Clinical PrACTICE GUIDANCE DEVELOPMENT 6-15-2014

JI RYDZ KITONGAN
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA
Pneumonia
Inflammation of lung tissue, caused by an infectious
agent that results in acute respiratory signs and
symptoms
Acquired out or in the hospital
3
rd
/10 Morbidity and mortality
Who shall be considered having it?
3-5 years old: Tachypnea & chest indrawing
5-12 years old: Fever, tachypnea & crackles
>12y/o: Fever, tachypnea and tachycardia
+ atlest 1 abnormal finding of
Diminished breath sounds
Rochi
Crackles
wheezes
Tachypnea and chest indrawing: reliable indicator of
pneumonia for a infants and preschool
Pneumonia patients mostlikely have the following:
nasal flaring, grunting, tachypnea, rales ad pallor
Which of the following, is the best predictor of
pneumonia?
A. Chest indrawing
B. Grunting
C. Tachypnea
D. Nasal flaring
Criteria for tachypnea(WHO)
2-12 mos: 50bpm
1-5 y/o: 40bpm
>5y/o: 30BPM
Diagnosis of adolescent suspected with CAP
Cough
Tachypnea (>20/min)
Tachycardia (>100/min)
Fever (>37.8c)
With atlest 1 abnormal finding
CXR: infiltrates



















Clinical PrACTICE GUIDANCE DEVELOPMENT 6-15-2014
JI RYDZ KITONGAN
Who are admitted?
Moderate to high risk of developing pneumonia
Variables PCAP A
minimal
PCAP B
Low
PCAP C
Moderate
PCAP D High risk
Co-morbid
illness
None Present Present Present
Compliant
caregiver
Yes Yes No No
Ability to
follow up
Possible Possible Not possible Not possible
Dehydration None Mild Moderate Severe
Ability to fed Able Able Unable Unable
Age >11mos >11mos <11mos <11mos
Respiratory
rate
2-12mos
1-5y/o
>5y/o
>/= 50/min
>/=40/min
>/=30/min
>50
>40
>30
>60
>50
>35
>70
>50
>35
Signs of
respiratory
failure
Retraction
Head bobbing
Cyanosis
Grunting
Apnea
sensorium
None
None
None
None
None
Awake
None
None
None
None
None
Awake
Intercostal/sub
Present
Present
None
None
Irritable
Supraclav/inter/sub
Present
Present
Present
Present
Lethargic/coma
compications none None Present present
Clinical PrACTICE GUIDANCE DEVELOPMENT 6-15-2014
JI RYDZ KITONGAN
Action plan OPD, FU
end of txt
OPD, FU
post
3days
Ward CCU
Complication(effusion, pneumothorax)
Overlap parameters: assume the next highest
Comorbid: malnutrition, asthma, CHD others
affecting respiration
Dehydration
MILD: thirsty, normal or increased PR, Dec UO,
Normal PE
Moderate: Tachycardia, little or no UO, Irritable,
Sunken eyes and fontanel, dec tears, dry mm, mild
skin tenting, delayed capillary refill, cool and pale
Severe: Rapid and weak pulse, decreased BP, No UO,
Very suken eyes and fontanel, no tears, parched
mm, tented skin, very delayed capillary refill time,
cool and mottled
The best single predictor of death for pneumonia on
admission?
A. Nasal flaring
B. Tachycardia
C. Retraction
D. Dehydration

Which of the following is the best predictor of
hypoxemia
A. Inability to cry
B. Head nodding
C. Respiratory rate of >60/min
D. All of the above
Diagnostics for pcap a and b managed as ambulatory
None
Diagnostic aids for pcap c &d managed in the hospital
1. Routinely requested
a. chest xrap PAL
b. WBC count
c. culture and sensitivity: blood for PCAP D, pleural
fluid, tracheal aspirate, blood gas
2. Maybe requested
a. C/S of sputum for older children
3. Not routinely requested: ESR & CRP
Xray: adv: when to start an antibiotics,
consolidation = infection
confirm presence of pulmonary
complications detected on hx and PE
basis for risk of pneumonia related
mortality and therapeutic infection
Children >5y/o with fever >39c with no
know origin
WBC count: increased in bacterial infection. Vs
viral, not yet adequately demonstrated
Microbio: Blood culture for PCAP D routine.
taken from 2 diff sites
not done when antibiotics were
given first
pleural culture for thoracenthecis
tracheal aspirate c/s upon intubation
sputum c/s for patients whoc can
expectorate
O2 sat: aid in deciding appropriate therapeutic
interventions
When is antibiotics recommended?
1. PCAP A OR B
a. beyond 2 years of age
Clinical PrACTICE GUIDANCE DEVELOPMENT 6-15-2014
JI RYDZ KITONGAN
b. high grade fever without wheeze
2. PCAP C
a. beyond 2 years of age
b. high grade fever without wheeze
c. alveolar consolidation on cxr
d. WBC count > 15,000
3. PCAP D
In and out px: bacterial pathogen, strep pneumonia,
mycoplasma, chlamydia, - HiB for in px
Bacterial VS viral pathogen
Bacterial: Fever > 38.5c with the absece of wheeze
Viral: Fever <38.5c with wheeze
Empiric therapy if a bacterial etiology is strongly considered
PCAP A or B without previous antibiotic: Amoxicillin
at 40-50MKD in 3 divided doses
PCAP C without previous antibiotic, complete
immunization with HiB: Pen G 100,000MKD in 4
divided doses
No primary immunization: Ampicillin
100MKD in 4 divided doses
PCAP D
Refer
Amox: high dose not reco: weak resistance patern
for s. pneumonia
Basis for reco: efficacy to patho
low resistance patern of strep and
haemophilis
affordability
minimal adverse reaction
Duration of AB: 7 days for out patient
hospitalized: depends cant tolerate oral, poor
compliance
alt ab: chloramphenicaol, cefuroxime, sultamicillin
What treatment should be given for viral etiology
Ancillary treatment should be given
Lab confirmed
Influenza a: amantadine 4.4-8.8mkd max
150MKD x 3-5days
Influenza A or B: Oseltamivir 2MKD BID
Epidemics
Oseltamivir treatment and prophylaxis
>12years old
Used to reduce the duration of illness,
Reduce duration of viral shedding
When can a patient be considered responding to current
antibiotics
Decreased respiratory signs within 72hrs
Persistence of symptoms >72hrs requires
revaluation
End of treatment CXR, WBC, ESR or CRP not done
What should be done if patient is not responding
PCAP A or B
Change initial antibiotics
Start on oral macrolide
Reevaluate diagnosis
PCAP C
Pen resistant S. Pneumoniae
Complications are present
Other diagnosis
PCAP D
Immidiate reconsultation
Out patient as PCAP A or B
Resistant S. Pnuemoniae: AMOX to Cefu, Coamox,
Sultamicillin, cefodoxime
Mycoplasma and Chlamydia: Macrolides
Wrong diagnosis or complication: refer
PCAP C not responding
Resistant strep Pneumoniae
Other etiologic agents
Clinical PrACTICE GUIDANCE DEVELOPMENT 6-15-2014
JI RYDZ KITONGAN
Other complications or wrong Dx
PCAP D
When can switch therapy be started?
Switch is recommended from 2-3 days after
initiation of antibiotic
Responding to initial antibiotic thereapy
Able to fed with good GI absorption
No pulmo and extra pulmo complication
Ancillary treatments?
For in-patients, o2 and hydration should be given if
needed
Cough prep, chest physiotherapy, bronchial hygiene,
nss neb, steam inhalation, topical solution, herbal
meds are not routinely given
Wheezing? bronchodilator maybe given
How can it be prevented
Vaccines
Zinc supplement (10-20mg for 4-6mos)
Vitamin A, Vit c and Immunomodulators not
routinely given
Special considerations
Malnutrition
PTB
CHD obstruction RSV mc
Asthma Chlamydia
Early antibiotics = asthma and allergic DO

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