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PEDIATRIC COMMUNITY

ACQUIRED PNEUMONIA
Epidemiology
Defined as inflammation of the
lung parenchyma

Leading cause of death globally


among
children >5 y/o

Incidence of pneumonia and number


of childhood related deaths from
pneumonia is higher in developing
than developed countries
Etiology
Most common cause: microorganisms
Other causes: Non-infectious including aspiration (food, gastric acid,
foreign bodies, etc.)
Etiology is hard to determine
Most common bacterial pathogens: Streptococcus pneumoniae (3
wk to 4 yr of age) & Chlamydophila pneumonia (5 y/o & up)
Major causes of hospitalization and death: S. pneumonia, H.
influenza and S. bureaus
Etiology
HIV-infected children: Mycobacterium tuberculosis, atypical
mycobacteria, Salmonella and E. coli
Decreased incidence of pneumonia caused by H. influenza and S.
pneumonia is due to routine immunisation
Viral pathogens
Common in >1 mo but < 5 yo
Detected in 40-80% of children using molecular dx methods
RSV and rhinoviruses esp <2 yo
Etiology
Age of patient may help identify possible pathogens
VIRAL PNEUMONIA
Pathogenesis
physiologic defense mechanisms (mucociliary clearance, IgA, coughing)

Immunologic defense mechanisms (macrophages, secretory IgA, other Igs)

Trauma, anaesthesia, and aspiration

↑ risk of pulmonary infection

viral infection

spread along airways direct injury of the respiratory epithelium

swelling, abnormal secretions and cellular debris

airway obstruction
BACTERIAL PNEUMONIA
Pathogenesis
viral infection

disturb normal host defense mechanisms

superimposed bacterial infection

colonize trachea

bacteremia

direct seeding of lung tissue

access to lungs

PNEUMONIA
Pathogenesis

When bacterial infection is established in the lung parenchyma, the


pathologic process varies according to the invading organism
Recurrent pneumonia

Is defined as 2 or more episodes in a single year or 3 or more


episodes ever, with radiographic clearing between occurences.
Clinical Manifestations
Preceded by several days of URTI (sx: rhinitis and cough)

In viral pneumonia fever is usually present but T is lower than in bacterial


pneumonia

Tachypnea is the most consistent clinical manifestation of pneumonia

Increased work of breathing by IC, SC and suprasternal retractions,


nasal flaring, and use of accessory muscles is common

Severe infection may be accompanies by cyanosis and lethargy, esp in


infants
Clinical Manifestations

Auscultation: crackles, wheezing (often difficult to localise


especially in infants with hyper resonant chest)

Often difficult to distinguish viral pneumonia clinically from


disease caused by Mycoplasma and other bacterial
pathogens.
Clinical Manifestations
BACTERIAL PNEUMONIA

Sudden onset of symptoms: high fever, cough and chest pain

Other symptoms: drowsiness with intermittent periods of


restlessness; rapid respirations; anxiety; and occasionally,
delirium.

In many children: splitting to affected side to minimise pleuritic


pain or knees drawn up to the chest
Clinical Manifestations

PHYSICAL FINDINGS

EARLY: diminished breath sounds, scattered crackles, and


rhonchi

LATE: dullness and diminished breath sounds, respiratory lag

lower lobe pneumonia: abdominal pain


Diagnosis
Chest radiograph
Peripheral WBC
Definitive diagnosis:
Viral: viral isolation
Bacterial: isolation of organism from blood, pleural fluid or lung
*However, culture of of sputum is of little value in the diagnosis of
pneumonia in young children
Treatment
MILD/NOT HOSPITALIZED: Amoxicillin high dose for penicillin-resistant
pneumococci (80-90 mg/kg/24 hr) or Azithromycin
HOSPITALIZED:
Fully immunized: Ampicillin or Penicillin G
Not immunized: Ceftriaxone or Cefotaxime
Staphylococcal pneumonia (pneumatocoeles, empyema): Vancomycin or
Clindamycin
Treatment
Antibiotics are generally continued until the patient has been afebrile for
72 hours

Total duration: should not be less than 10 days (or 5 if Azithromycin)

5-7 days may also be effective, particularly on outpatient basis

Oral Zinc: (10 mg/day for <12 mo, 20 mg/day for ≥12 mo) reduces
mortality among children with clinically defined severe pneumonia
2012 PAPP UPDATE IN THE
EVALUATION AND MGMT OF
PCAP
1. Who shall be considered as having community
acquired pneumonia?
WHO SHALL BE CONSIDERED AS
HAVING COMMUNITY ACQUIRED
PNEUMONIA?
• The presence of pneumonia may be considered even without a chest
radiograph in a patient presenting with cough and/or respiratory
difficulty [Recommendation Grade D] plus any of the following
predictors of radiographic pneumonia:
• tachypnea
• fever
• O2 sat < or = to 92% at room air at any age in the absence of any
coexisting illness
WHO SHALL BE CONSIDERED AS
HAVING COMMUNITY ACQUIRED
PNEUMONIA?
• the presence of pneumonia should be determined using a chest
radiograph in a patient presenting with
• cough or respiratory difficulty in the ff situations:
• presence of dehydration aged 3 months to 5 years
• presence of severe malnutrition aged less than 7 years
• high grade fever and leukocytosis aged 3 - 24 months without
respiratory symptoms
2. Who will require admission?
WHO WILL REQUIRE
ADMISSION?
3. What diagnostic aids are initially requested for
pCAP A or pCAP B?
3. What diagnostic aids are initially
requested for pCAP A or pCAP B?
1. CHEST X-RAY may be requested to rule out pneumonia-related
complications or pulmonary conditions simulating
pneumonia [Recommendation Grade D]
1.1. It should NOT be routinely requested to predict end-of-
treatment clinical outcome [Recommendation Grade A].
2. Chest x-ray, complete blood count, C-reactive protein, erythrocyte
sedimentation rate, procalcitonin, or blood culture should NOT be
routinely requested to determine appropriateness of antibiotic usage
[Recommendation Grade D]
4. What diagnostic aids are initially requested for
pCAP C or pCAP D?
4. What diagnostic aids are initially
requested for pCAP C or pCAP D?
1. For pCAP C
• The following ancillary/diagnostic procedures should be done
to determine etiology:
• Gram stain and/or culture and sensitivity of pleural fluid when available
to assess gas exchange:
• Oxygen saturation using pulse oximetry
• Arterial blood gas [Recommendation Grade D]
4. What diagnostic aids are initially
requested for pCAP C or pCAP D?

1. For pCAP C
• The following ancillary/diagnostic procedures may be done
• to determine etiology
• Sputum culture and sensitivity [Recommendation Grade C]
• Blood culture and sensitivity [Recommendation Grade C]
• to predict clinical outcome:
• Chest x-ray PA-lateral [Recommendation Grade B]
• Pulse oximetry [Recommendation Grade B]
4. What diagnostic aids are initially
requested for pCAP C or pCAP D?
1. For pCAP C
• The following ancillary/diagnostic procedures may be done
• to determine the presence of tuberculosis if clinically suspected:
• Mantoux test (PPD 5-TU) [Recommendation Grade D]
• Sputum smear for aid fast bacilli
• to determine metabolic derangement:
• Serum electrolytes [Recommendation Grade C]
• Serum glucose [Recommendation Grade C]
2. For pCAP D, a referral to a specialist should be done [Recommendation
Grade D].
5. When is antibiotic recommended?
5. When is antibiotic
recommended?

• For pCAP A or B, an antibiotic may be administered if a patient is


• beyond 2 years of age; OR
• with high grade fever without wheeze
5. When is antibiotic
recommended?
• For pCAP C, an antibiotic
• should be administered if alveolar consolidation on chest x-ray is present
• may be administered if a patient is with any of the following:
• Elevated serum C-reactive protein [CRP]
• Elevated serum procalcitonin level [PCT]
• Elevated white cell count
• High grade fever without wheeze
• Beyond 2 years of age

• For pCAP D, a specialist should be consulted.


6. What empiric treatment should be administered if
a bacterial ethology is strongly considered?
5. When is antibiotic
recommended?
1. For a pt who has been classified as pCAP A or B without previous antibiotic,
• amoxicillin [40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided
doses for at most 7 days] is the drug of choice
• may be given for a minimum of 3 days
• may be given in 2 divided doses for a minimum of 5 days

• azithromycin [10 mg/kg/day OD for 3 days or 10mg/kg/day at day 1 then


5 mg/kg/day for days 2 to 5, max dose of 500mg/day]
• OR clarithromycin [15 mg/kg/day, maximum dose of 1000 mg/day in 2
divided doses for 7 days] may be given to those patients with known
hypersensitivity to amoxicillin on an outpatient basis
5. When is antibiotic
recommended?
2.For PCAP C without previous antibiotic,
A. requiring hospitalization and
• has completed the primary immunization against Haemophilus influenza
type b,
penicillin G [100,000 units/kg/day in 4 divided doses] administered as
monotherapy is the drug of choice
• has not completed the primary immunization or immunization status
unknown
against Haemophilus influenza type b, ampicillin [100 mg/kg/day in 4
divided doses] administered as monotherapy is the drug of choice.
5. When is antibiotic
recommended?
• above15 years of age:
• a parenteral non-antipseudomonal β-lactam [β-lactam/β-
lactamase inhibitor combination (BLIC), cephalosporin or
carbapenem]
• + extended macrolide [azithromycin or chlarithromycin], OR a
parenteral non-antipseudomonal β-lactam [β-lactam/ β-lactamase
inhibitor combination (BLIC], cephalosporin or carbapenem]
• + respiratory fluoroquinolones [levofloxacin or moxifloxacin]
administered as combination therapy may be given
5. When is antibiotic
recommended?
2.For PCAP C without previous antibiotic,
B. and who can tolerate oral feeding and does not require oxygen
support, amoxicillin [40-50 mg/kg/day, maximum dose of 1500 mg/day in
3 divided doses for at most 7 days] may be given on an outpatient basis.
5. When is antibiotic
recommended?
3. For a patient classified as pCAP C who is severely malnourished or
suspected to have methicillin-resistant Staphylococcus aureus, or classified
as pCAP D, referral to a specialist is highly recommended.

4. For a patient who has been established to have Mycobacterium


tuberculosis infection or disease, antituberculous drugs should be
started
7. What treatment should be initially given if a viral
ethology is strongly considered?
7. What treatment should be initially
given if a viral ethology is strongly
considered?
1. Oseltamivir
• (30 mg twice a day for ≤15 kg body weight, 45 mg twice a day for >15-23 kg,
60 mg twice a day for >23-40 kg, and 75 mg twice a day for >40 kg) remains to
be the drug of choice for laboratory confirmed, or clinically suspected cases of
influenza.

2. The use of immunomodulators for the treatment of viral pneumonia is NOT


recommended

3. Ancillary treatment as provided in Clinical Question 11 may be given


8. When can a patient be considered as responding
to the current antibiotic?
8. When is antibiotic
recommended?
1. Decrease in respiratory signs and/or defervescense within 72 hours
after initiation of antibiotic are predictors of favorable response.

2. If clinically responding, further diagnostic aids to assess response such


as chest x-ray, C-reactive protein and complete blood count should not be
routinely requested
9. What should be done if a patient is not
responding to current antibiotic therapy
9. What should be done if a patient is
not responding to current antibiotic
therapy
1. If an outpatient with pCAP A or pCAP B is not responding to the
current antibiotic within 72 hours, consider any of the ff:
• Other diagnosis.
• Coexisting illness.
• Conditions simulating pneumonia.
• Other etiologic agents for which C-reactive protein, chest x-ray or
complete blood count may be used to determine the nature of the
pathogen.
• May add an oral macrolide if atypical organism is highly
considered.
• May change to another antibiotic if microbial resistance is highly
considered.
9. What should be done if a patient is
not responding to current antibiotic
therapy
2. If an inpatient with pCAP C is not responding to the current antibiotic
within 72 hours, consider any of the following:
• Other diagnosis:
• Coexisting illness.
• Conditions simulating pneumonia.
• Consider other etiologic agents for which C-reactive protein, chest x-ray
or complete blood count may be used to determine the nature of the
pathogen.
• May add an oral macrolide if atypical organism is highly considered.
• May change to another antibiotic if microbial resistance is highly
considered.
• May refer to a specialist.
9. What should be done if a patient is
not responding to current antibiotic
therapy
3. If an inpatient classified as pCAP D is not responding to the current
antibiotic within 72 hours, immediate consultation with a specialist should
be done.
10. When can switch therapy in bacterial pneumonia
be started?
10. When can switch therapy in
bacterial pneumonia be started?
1. For pCAP C,
• switch from IV antibiotic administration to oral form 3 days after initiation
of current antibiotic is recommended in a patient who should fulfill all of
the following:
1. Responsive to current antibiotic therapy
2. Tolerance to feeding and without vomiting or diarrhea.
3. Without any current pulmonary (effusion/empyema; abscess; air
leak, lobar consolidation, necrotizing pneumonia) or extrapulmonary
complications; and
4. Without oxygen support.
• switch therapy from three [3] days of parenteral ampicillin to amoxicillin
[40-50 mg/kg/day for 4 days].
10. When can switch therapy in
bacterial pneumonia be started?
2. For pCAP D, referral to a specialist should be considered
11. What ancillary treatment can be given?
11. What ancillary treatment can be
given?

1. For pCAP A or B
• cough preparation, elemental zinc , vitamin A, vitamin D, probiotic
and chest physiotherapy should not be routinely given during the
course of illness.
• a bronchodilator may be administered in the presence of
wheezing.
11. What ancillary treatment can be given?
2. For pCAP C,
• oxygen and hydration should be administered whenever applicable.
• Oxygen delivery through nasal catheter is as effective as using nasal
prong.
• a bronchodilator may be administered only in the presence of wheezing.
• Steroid may be added to a bronchodilator.
• a probiotic may be administered.
• cough preparation, elemental zinc, vitamin A, vitamin D and chest
physiotherapy should not be routinely given during the course of illness

3. For pCAP D, referal to a specialist should be considered.


12. How can pneumonia be prevented?
12. How can pneumonia be
prevented?
1. The following should be given to prevent pneumonia:
• Vaccine against
• Streptococcus pneumonia (conjugate type)
• Influenza
• Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus Influenzae type b

• Micronutrient
• Elemental zinc for ages 2 to 59 months to be given for 4 to 6 months
12. How can pneumonia be
prevented?
2. The following may be given to prevent pneumonia:
• Micronutrient.
• Vitamin D3 supplementation

3. The following should not be given to prevent pneumonia:


• Micronutrient
• Vitamin A