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Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age

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Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD – PowerPoint PPT presentation

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Title: Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age


1
Management of Community Acquired Pneumonia in
Infants and Children Older than 3 Months of Age
  • Daniel Urschel, MD, Charles Pace, MD, Sherman
    Alter, MD
  • Department of Pediatrics, Boonshoft School of
    Medicine, Wright State University, The Childrens
    Medical Center of Dayton

2
Clin Infect Dis 2011 53 (7) 617-630
3
Objectives
  1. List common pathogens causing community-acquired
    pneumonia (CAP) in infants and children.
  2. Discuss appropriate use of diagnostic laboratory
    and imaging tests in a child with CAP in an
    outpatient or inpatient setting.
  3. Review choice of anti-infective therapy and
    duration of treatment provided to a child with
    suspected CAP in the outpatient or inpatient
    setting.

4
Teasers are docile male horses, usually old and
past prime with undesirable genes, who set up
aggressive just off-the-track mares to be bred
by the wild testosterone crazed prize stallions
whose only job is to deliver the goods, which
they do.
5
A 3yr old female presents to your office in
November with cough and tachypnea. You hear
crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had
good fluid intake. Previously healthy and
immunizations up to date. You believe patient
may be well enough to manage as an outpatient.
Which diagnostic tests should be performed on
this patient?
  1. Complete blood count
  2. Chest radiograph
  3. Pulse oximetry
  4. Blood culture
  5. All of the above

6
A 3yr old female presents to your office in
November with cough and tachypnea. You hear
crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had
good fluid intake. Previously healthy and
immunizations up to date. You believe patient
may be well enough to manage as an outpatient.
Which diagnostic tests should be performed on
this patient?
  1. Complete blood count
  2. Chest radiograph
  3. Pulse oximetry
  4. Blood culture
  5. All of the above

7
A school aged child hospitalized with
community-acquired pneumonia can be safely
discharged if he meets which of the following
criteria?
  1. Able to tolerate outpatient meds, greater level
    of activity, improving appetite.
  2. Afebrile for over 24 hours
  3. Pulse oximetry measurements gt90 in room air at
    least 12 hours
  4. A and C
  5. A, B, and C

8
Previously healthy 2 yr old diagnosed with
pneumonia (faint crackles in the right base) in
late October. Respiratory rate is 30
breaths/minute and temperature is 38.5 C. She
has received all recommended immunizations. She
attends a day care on daily basis. She is
interactive and drinking well. Which oral
anti-infective therapy should be provided to this
child managed as an outpatient?
  1. A second-or third-generation cephalosporin (e.g.,
    cefdinir, cefixime) for 10 days.
  2. Amoxicillin 90mg/kg/day divided 2 times a day for
    10 days
  3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days
    2-5
  4. Combined treatment with both amoxicilln and
    azithromycin as noted above
  5. No anti-infective therapy indicated

9
A fully-immunized 6 yr old boy is hospitalized at
Dayton Childrens. Radiography demonstrates left
lower lobe consolidation without an effusion. He
has a 92 SpO2 on 30 FiO2, some retractions and
poor oral fluid intake. A blood culture is
obtained. What first-line antibiotic therapy is
recommended?
  1. A third-generation parenteral cephalosporin
    (e.g., cefotaxime or ceftriaxone)
  2. Intravenous clindamycin
  3. A third-generation parenteral cephalosporin plus
    azithromycin
  4. Intravenous ampicillin
  5. Intravenous vancomycin

10
A 5 yr old is admitted with a right upper lobe
pneumonia. Child is not fully immunized. His
blood cultures yield Streptococcus pneumoniae.
Susceptibility testing on the blood isolate
demonstrates a penicillin MIC of gt 4 ug/mL.
Appropriate antibiotic therapy directed at this
pathogen consists of
  1. Ceftriaxone intravenously at 100mg/kg/day
  2. Levofloxacin intravenously at 20 mg/kg/day
  3. Ampicillin intravenously at 400 mg/kg/day
  4. A or C
  5. A, B, or C

11
Introduction
  • The Pediatric Infectious Diseases Society (PIDS)
    and the Infectious Diseases Society of America
    (IDSA) convened multiple subspecialists and
    expert consultants to create and review
    guidelines
  • Guidelines endorsed by AAP, American College of
    Emergency Physicians, Society of Critical Care
    Medicine.
  • The guidelines grade method of recommendation,
    low or very low evidence situations require
    clinical judgment

12
Strength of Recommendations
13
Strength of Recommendations
14
Inpatient Criteria
  • Age 3-6 months with a suspicion of bacterial
    pneumonia
  • Suspicion or documentation of methicillin-resistan
    t Staphylococcus aureus (MRSA) pneumonia
  • Concern for follow up or administration of home
    therapy

15
Patients Requiring Hospitalization
16
Diagnostic approach to the child with pneumonia
17
Outpatient Diagnostics
  • Chest radiography, blood culture, CBC, ESR/CRP
    not necessary
  • Pulse oximetry should be obtained in all patients
  • If available a rapid test for influenza and for
    other viral pathogens should be obtained
  • Testing for Mycoplasma pneumoniae should be
    obtained if suspicious
  • If no improvement on antibiotics for 48-72 hrs, a
    CXR and blood culture should be obtained

18
Inpatient Workup
  • All pts should have CXR
  • Blood culture
  • CBC
  • ESR/CRP
  • Urinary antigen for Pneumococcal infection is not
    recommended
  • Sputum samples if able (weak low evidence)
  • Rapid tests for Influenza and viruses should be
    used
  • Mycoplasma pneumoniae should be tested for if
    suspicious
  • No reliable test for Chlamydophila pneumoniae

19
Inpatient Diagnostics
  • A routine repeat CXR is not necessary
  • Repeat CXR should be obtained if no clinical
    improvement is demonstrated by 48-72 hrs
  • If blood culture yields MRSA, a repeat culture is
    mandatory todocument sterility of the blood.
  • If blood culture is positive for another
    organism, repeat culture of blood is not
    mandatory
  • Tracheal aspirate should be obtained in patient
    with endotracheal intubation

20
Criteria for admission to an ICU
21
Criteria for admission to an ICU
22
Criteria for admission to an ICU
  • Intubation, continuous CPAP or BIPAP
  • Sustained tachycardia or hypotension
  • lt92 SpO2 on gt50 FiO2
  • Altered mental status
  • Clinical judgment should be used regardless of
    scores

23
Discharge Criteria
  • Improved Clinical Status gt12 hrs
  • RA with Sp02 gt90 gt12 hrs
  • No increased work of breathing , tachypnea or
    tachycardia
  • Able to tolerate outpatient therapy
  • Chest tube out for gt12 hrs

24
Outpatient Treatment of Pneumonia
  • Antibiotics not routinely required for
    preschool-aged children
  • High-dose amoxicillin should be considered first
    line for presumed bacterial pneumonia in all ages
  • 90 mg/kg/day divided bid
  • TID dosing is required for Pen-resistant
    pneumococcus (MIC gt 2 µg/mL)
  • Macrolides (azithromycin) should be considered in
    school-aged and adolescents with illness
    consistent with atypical pneumonia

25
Atypical vs. Bacterial
  • Gradual onset
  • Malaise, headache, sore throat, ear infections
  • Lower fevers (101-102)
  • Usually nonproductive, persistent cough
  • May or may not have rales
  • Gradual or acute onset
  • Fatigue, dyspnea, chest pain
  • Fevers often higher (gt103)
  • Cough more often productive
  • Decreased or bronchial breath sounds, rales,
    dullness to percussion, egophony

26
Manifestations of Mycoplasma pneumonia
27
Outpatient Treatment of Pneumonia
  • For presumed atypical pneumonia, azithromycin is
    first-line
  • 10 mg/kg on day 1 5 mg/kg on days 2-5
  • In season, treat influenza presumptively until a
    sensitive test is negative
  • 10-day course of antibiotics is usually adequate
  • Azithromycin 5 day course
  • MRSA will require a longer course (and
    hospitalization!)

28
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29
Inpatient Treatment of Pneumonia
  • For the fully immunized child in regions that do
    not demonstrate high-level pneumococcal
    penicillin resistance
  • Ampicillin or Penicillin G are first-line
  • Azithromycin for suspected atypical pneumonia
    (with a beta-lactam if diagnosis is in question)
  • Vancomycin or clindamycin should be added when S.
    aureus is suspected by labs, clinical findings or
    imaging
  • Ceftriaxone or cefotaxime are alternatives

30
Inpatient Treatment of Pneumonia
  • For a not fully immunized child or in regions
    that demonstrate high-level pneumococcal
    penicillin resistance
  • Ceftriaxone or cefotaxime is preferred
  • Add azithromycin if considering atypical
    pneumonia
  • Add vancomycin or clindamycin for S. aureus
  • Ceftriaxone or cefotaxime also preferred for
    life-threatening infections and empyema

31
Empiric Inpatient Treatment of CAP
32
Pneumococcal Penicillin Resistance
  • MIC lt 0.06 µg/mL very susceptible
  • Standard-dose oral amoxicillin effective
  • MIC 0.12-1 µg/mL susceptible
  • High-dose oral amoxicillin effective
  • MIC 1-2 somewhat resistant
  • High-dose oral amoxicillin gt90 effective
  • MIC 2-4 resistant
  • Oral therapy likely to fail IV ampicillin or
    penicillin
  • MIC gt4 very resistant
  • Standard-dose ampicillin likely to fail
    ceftriaxone effective

33
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34
Specific Treatment for CAP
35
Specific Treatment of CAP
36
Specific Treatment of CAP
37
Specific Treatment of CAP
38
Specific Treatment of CAP
39
Viral Pneumonia in Children
  • Guidelines suggest not treating a preschool-aged
    child with suspected viral pneumonia (except
    influenza)
  • Hamano-Hasegawa, J Infect Chemother (2008)
  • Younger children more likely to have viral
    pneumonia
  • Evidence of bacterial co-infection in 33
  • Michelow, Pediatrics (2004)
  • Bacterial co-infections seen in 54 of viral
    pneumonias
  • 67 of influenza pneumonia
  • 55 of RSV pneumonia

40
Michelow IC, et al. Epidemiology and clinical
characteristics of community-acquired pneumonia
in hospitalized children. Pediatrics. 2004
Apr113(4)701-7.
41
Michelow IC, et al. Epidemiology and clinical
characteristics of community-acquired pneumonia
in hospitalized children. Pediatrics. 2004
Apr113(4)701-7.
42
Viral Pneumonia in Children
  • A 2010 retrospective cohort study of 4015
    pediatric patients hospitalized with pneumonia
  • 27 developed influenza-associated pneumonia
  • Of these, 2 had a bacterial co-infection
  • 18 identified by blood cultures 3 by pleural
    fluid
  • The actual incidence of secondary bacterial
    pneumonia with influenza is likely much higher

Dagwood FS et al. Influenza-Associated Pneumonia
in Children Hospitalized With Laboratory-Confirmed
Influenza, 2003-2008. Pediatr Infect Dis J.
2010 Jul29(7)585-90.
43
Adjunctive Therapy
  • CXR should be obtained if suspicious for effusion
  • US or CT if CXR is inconclusive
  • Size of effusion and respiratory compromise will
    determine treatment

44
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45
Pleural Fluid Tests
  • Gram stain (25-50)
  • Antigen or PCR if available (S. pneumoniae,
    S.aureus)
  • Pleural fluid analysis rarely changes management
    and is not recommended
  • WBC count with differntial helps differentiate
    source
  • Majority of cultures will be negative

46
Effusion/Empyema
  • Total antibiotic therapy 2-4 weeks or 10 days
    after resolution of fever
  • If abscess or necrosis is identified tx should
    begin with IV antibiotics
  • If abscess is peripheral may attempt to drain,
    most will resolve spontaneously with IV
    antibiotics
  • Abscess secondary to congenital malformation
    requires surgery consultation
  • Necrosis should not routinely be managed
    surgically given high rates of broncho-pleural
    fistulas

47
A 3yr old female presents to your office in
November with cough and tachypnea. You hear
crackles in left lower lobe and minimal
retractions. She is alert, talkative, has had
good fluid intake. Previously healthy and
immunizations up to date. You believe patient
may be well enough to manage as an outpatient.
Which diagnostic tests should be performed on
this patient?
  1. Complete blood count
  2. Chest radiograph
  3. Pulse oximetry
  4. Blood culture
  5. All of the above

48
A school aged child hospitalized with
community-acquired pneumonia can be safely
discharged if he meets which of the following
criteria?
  1. Able to tolerate outpatient meds, greater level
    of activity, improving appetite.
  2. Afebrile for over 24 hours
  3. Pulse oximetry measurements gt90 in room air at
    least 12 hours
  4. A and C
  5. A, B, and C

49
Previously healthy 2 yr old diagnosed with
pneumonia (faint crackles in the right base) in
late October. Respiratory rate is 30
breaths/minute and temperature is 38.5 C. She
has received all recommended immunizations. She
attends a day care on daily basis. She is
interactive and drinking well. Which oral
anti-infective therapy should be provided to this
child managed as an outpatient?
  1. A second-or third-generation cephalosporin (e.g.,
    cefdinir, cefixime) for 10 days.
  2. Amoxicillin 90mg/kg/day divided 2 times a day for
    10 days
  3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days
    2-5
  4. Combined treatment with both amoxicilln and
    azithromycin as noted above
  5. No anti-infective therapy indicated

50
Previously healthy 2 yr old diagnosed with
pneumonia (faint crackles in the right base) in
late October. Respiratory rate is 30
breaths/minute and temperature is 38.5 C. She
has received all recommended immunizations. She
attends a day care on daily basis. She is
interactive and drinking well. Which oral
anti-infective therapy should be provided to this
child managed as an outpatient?
  1. A second-or third-generation cephalosporin (e.g.,
    cefdinir, cefixime) for 10 days.
  2. Amoxicillin 90mg/kg/day divided 2 times a day for
    10 days
  3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days
    2-5
  4. Combined treatment with both amoxicilln and
    azithromycin as noted above
  5. No anti-infective therapy indicated

51
A 5 yr old is admitted with a right upper lobe
pneumonia. Child is not fully immunized. His
blood cultures yield Streptococcus pneumoniae.
Susceptibility testing on the blood isolate
demonstrates a penicillin MIC of gt 4 ug/mL.
Appropriate antibiotic therapy directed at this
pathogen consists of
  1. Ceftriaxone intravenously at 100mg/kg/day
  2. Levofloxacin intravenously at 20 mg/kg/day
  3. Ampicillin intravenously at 400 mg/kg/day
  4. A or C
  5. A, B, or C

52
BMJ 2003 3271459-1461
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