Community acquired Pneumonia

Dr Yog Raj Khinchi

• Pneumonia, especially CAP has been a subject of challenge to the medical fraternity despite extensive research since ‘Antiquity’

Introduction

Introduction – Contd..

• It is tragedy that in this era of easy vaccine availability millions of children die across the globe, particularly in developing countries due to vaccine preventable ‘Lower Respiratory Tract Infections’

Pneumonia

Congenital

OpportunisticAspiration

Nosocomial

Acquired

Community Acquired Pneumonia (CAP)

Definition - CAP

Pneumonia acquired outside the hospital environment by an immunocompetant healthy child

Disease Burden - CAP

• Global Scenario :

- 100 million cases per year < 5 yrs- 80% OPD cases with 1% mortality- 20% IPD cases with 10 -12 % mortality- 2 – 2.3 million deaths / year, 90% in developing countries

Disease Burden – CAP Indian Scenario :

CAP contributes 13% of deaths

(< 5 years of age) 24% National Burden of Disease (NBD)

7.5 million total cases

.37 to .46 million deaths per year.

[Estimates on different studies done at Delhi – Pune – Kolkatta – Varanasi –

Rajasthan – Maharashtra - Haryana & Tripura [Source S.K.Kabra - National consensus

on child survival & development]

Risk FactorsComorbid Pul. Illnesses

Rampant use of antibiotics particularly

B-lactames in viral URTIs

Poor Socio Economic Status

Immunosuppressed conditions

Viral URTIsAir Pollution & Passive Smoking

Malnutrition, Vit A, D & Zinc def.

Lack of Breast Feeding

Low Birth Weight

Comorbid extra pul. conditions

CAP

[Study by Burman et al -Epidemiology of ARI in children of developing countries Rev. Inf. Dis. (1991)

Q : Do I need to chase an aetiological diagnosis in CAP before starting antimicrobial treatment??

A : NO !

Q : WHY ?

A : It is not only “difficult” but often “not possible” to document Aetiological factor by lab diagnostics

(> 60%) THM:

It is Prudent and Rational to start “Emperical Antimicrobial” therapy before establishing microbial

aetiologyDiagnosis per se is always - almost clinical

Q : Then how do I make the diagnosis ?

A : Clinically – Triad of fever, cough, tachyponeaWith or without

Chest pain, Sputum, Grunting, Crackles, Bronchial breathing,

↑ Vocal fremitus, Feeding difficulties, Chest recession, Cyanosis.

WHO ARI Control Program Tachyponea most sensitive sign

New borns > 70/minInfants (upto 2 yrs) > 50/minChildren (> 2 yrs) > 40/min

Diagnosis

Q : Does ancillary lab investigations support the diagnosis ?

A : Yes ! to some extentNon invasive & easily

accessibleNon invasive but not easily

accessibleInvasive & not cost

effective

CBC X-rays BAL

ESR Blood culture Lung Biopsy

CRP Sputum and gastric aspirate culture

CT Scan

Mx Serology PCR

Gram stain of sputum & naso pharyngeal

secretions

Pleural Tap Rapid Antigen detection test

Less specific Some what specific More specific

Diagnosis

Q : How do I decide whether it is bacterial or viral ?

A : There are no definite markers to differentiate between bacterial or viral.Features suggestive of bacterial pneumonia :• Fever > 38.5oC. Toxic look• Respiratory rate > 50 breaths / min• Chest recession (Respiratory distress)• Radiologically Lobar consolidation, Segmental consolidation

and Round consolidation.

Features suggestive of viral pneumonia

• Infants and young children• Fever < 38.5oC • Mucosal congestion• Wheeze• Hyperinflation• Marked recession• Respiratory rate normal or raised• Radiologically Hyperinflation, Diffuse

infilterates & Segmental collapse.

Features suggestive of Pneumonia by Atypical organisms

• School Age children• Cough• Wheeze• Chest pain• Respiratory distress• Anemia and reticulo cytosis• Radiologically Lobar consolidation and hilar

adenopathy, Interstitial infiltrates

Source – British Thoracic Society guidelines for the diagnosis and management of Community Acquired Pneumonia in children.

THM:1. ‘S pneumoniae’ is the commonest causative

organism of CAP in Infancy & childhood, accounting for 1 million deaths annually out of a total 1.9 million estimated deaths, particularly in developing countries.

2. Viruses are commonest cause in infants and young children (14-35% of CAP)

3. Significant proportion of CAP is due to mixed infections (8-40%)

4. In 20-60% cases pathogen is not identified.

CAP

Q : What are other ‘Clues’ and ‘Parameters’ to

catch aetiologocal diagnosis ?

‘CLUES’ Associated co-morbid conditions

Otitis media S pneumoniae

Purulent sinusitis S pneumoniae

Pyoderma S aureus

Empyema S aureus

Measles S aureus

Watery rhinorrhoea viral

Meningitis S Pneumonia / HIB

Pathogens in infants < 3 months

. Group B Steptococcus

Gram negative enterococci & klebseilla

Staph aureus

Chlamydia trachomatis

Parameters : Age is a good predictor of the likely pathogens

Pathogens in Children 3 months to 5 yrs of age

• More Common : - ‘S’ pneumoniae- Viruses (RSV, PIV3,

Adenovirus)- H influenzae b

Less Common : - M.catarrhalis- Staph aureus- Group A streptococci

Pathogens in Children > 5 yrs of age

• Mycoplasma pneumoniae• Chlamydia pneumoniae• Streptococcus pneumoniae• Leigonella species

Diagnostic Difficulties1. No specific markers to differentiate viral from

bacterial.2. Sputum samples are not often obtainable3. Nasopharyngeal secretions are unreliable due to

high asymptomatic carriage rates.4. Some common organisms like M pneumoniae, C

pneumoniae & H influenzae cannot be cultured easily.

5. Bactec culture facilities are not available everywhere

6. Invasive tests which are more specific are not practical in practice and are not cost effective.

7. Infection may be polymicrobial

a) Evaluation Diagnosis

Grading of severity

Mode of management

b) Stabilization Supportive treatment

ICU Management

c) Specific Agents Antimicrobials

Q : How do I manage a case of CAP ?

Principles of Management

Mild OPD Management

Moderate IPD Management

Severe ICU Management

Indicators Indicators IndicatorsFever < 38.5oc, Mild cough R.R< 50 / minNo dehydration,Adequate intake

Fever > 38.5oc on two occ. at 8 hrs apartModerate to severe coughTachyponeaR.R.> 50 / minResp. distressPso2 92% GruntingRefusal of feeds & dehyderation

Altered sensoriumCyanosis / Pso2 < 92Pao2 < 60% Pco2 > 40%pH > 7.3Systolic BP<60 mmHgBUN > 20 mg% Exp. GruntSevere Resp. Distress

As per BTS & ATS guidelines on CAP management

Severity Assessment

Mode of Management

A) OPD - Appropriate oral Antibiotics for 3-5 days- Analgesics & Antipyretics- Symptomatic

B) IPD - IV antibiotics for 3 - 5 days – switch to oral

- IV fluid therapy & Electrolyte maintenance

- Pulse oxymetry monitoring- Maintenance of Nutrition- Oxygen if required

C) ICU - All of the above + ABG monitoring + Ventilatory life support if required

Specific Antimicrobials

Which antibiotic ? Which Route ?Duration ? When to switch to oral?

“Age is a good predictor of the likely

pathogen & choice of antibiotic is

based on suspected pathogen”

AGE OPD IPD ICU

Birth to 3 months

IV Ampicillin / Amoxycillin 100-200 mg / kg / day + IV Aminoglycoside with or without

3rd Generation Cefalosporin100-150 mg / kg / day

IV Ampicillin / Amoxycillin +IV Aminoglycoside

with or without

IV Ceftazidime 50-100 mg / kg / day or Vancomycin / Teicoplanin 10- 15 mg / kg / day orImipenem / Meropenem orPipracillin / Tazobactum

CAP Treatment

AGE OPD IPD ICU3 months to 5 yrs

Oral Amoxycillin50-100 mg/kg/day orCo-amoxiclav50-100 mg/kg/day orCefaclor25-30 mg/kg/day orCefuroxime15-25 mg/kg/day And / OrMacrolidea)Azithromycin10mg/kg/dayb) Clarithromycin15mg/kg/day

IV Amoxycillin 100-200 mg / kg / day

with or without

a) Cefotaxime 100-150 mg/kg/day b) Ceftriaxone100-150 mg/kg/day orB-Lactamesa) Co-amoxiclav100-150 mg/kg/dayb) Cefuroxime50-100 mg/kg/day with or withoutOral Macrolide

IV Ampicillin + Cloxacillin200 mg/kg/day orIV B-Lactamesa) co-amoxiclavb) Cefuroximec) Ceftriaxone

with or without

Aminoglycoside or Vancomycin / Teicoplanin

CAP Treatment

AGE OPD IPD ICU> 5 yrs Oral Amoxycillin

60-90 mg/kg/day

and / or

Macrolide a) Azithromycin10mg/kg/dayb) Clarithromycin15 mg/kg/day orc) Doxycycline (> 8 yrs) 5 mg / kg / day

IV Co-amoxiclav 100 mg / kg / day

and / or

IV Cefuroxime100-150 mg/kg/day

with or without

IV Cefotaxime100 mg/kg/day

with or without

Oral macrolide

IV Co-amoxiclav100-150 mg/kg/day +IV Ceftriaxone100-200 mg/kg/day + IV Macrolide or IV Fluroquinolone(Newer anti Pneumococcal)

CAP Treatment

Failure of clinical response !!What should I Do ?

A) Check the diagnosis May be wrong diagnosis - Aspiration Pneumonia

- Interstitial Lung Disease - Tuberculous Pneumonia - Foreign body Aspiration

B) Look for underlying cardio pulmonary conditions like : - Lung Abscess

- Empyema - Cystic Fibrosis - Bronchiectasis - L-R shunt - GERD - Asthma

Failure of clinical response !!What should I Do ?

C) Immunosupression in host - PCP Pneumonia - Fungal Pneumonia - Pseudomonal Pneumonia

D) Think for drug resistance - Child from day care centre (DRSP/ B-Lactamase producing - Use of corticosteroids &

organisms) - B-Lactames in previous 1 month

E) Possibility of Viral + Bacterial Polymicrobial Aetiology or

Bacterial + atypical Bacterial

Cont’d…..

• Empyema• Pneumothorax• Lobar Atelectesis• Septicemia• Bronchogenic dissemination• Osteomylitis• Septic Arthritis• Multiple Systemic Abscesses• Meningitis etc…

Q : What complications can I expect if not treated properly ?

Q : How should I follow up & should I chase for follow up x-rays ?

- Follow up should be clinical for 3-4 weeks- No chase for follow up x-rays except in case of -

Lobar collapse- Round Pneumonia- Symptomatic child

Radiographic resolution56% - 2 weeks74% - 4 weeks98% - 6 weeks

“NO”

Q : How can I contribute in prevention of CAP in community ?

i) Promotion of Immunisation – Measles, Influenza, HIB & Pneumococus vaccines

ii) Prevention of passive smoking & air pollutioniii) Judicious use of corticosteroids & antibiotics

particularly B-Lactams)iv) Supplementation of Vit A, Vit D & Zincv) Promotion of Breastfeeding & demotion of bottle

feedingvi) Treatment of malnutrition

1. Aetiological diagnosis in CAP is not only difficult but not always possible (>60%)

2. Emperical Antimicrobial therapy is ‘Rational’ & ‘Prudent’

3. Age is a good predictor of likely pathogens4. Streptococcus pneumoniae is the most common

cause of CAP in childhood followed by viruses5. Chest radiography though supports the diagnosis

– is poor indicator of aetiology.6. Followup x-rays are not required unless in special

circumstances

Key points

Key Points – Contd..7. Acute phase reactants do not distinguish between viral &

bacterial infections8. Pulse oxymetery monitoring should be performed in every

admitted child with CAP.9. Blood cultures though desirable yields only 10-20%

positivity.10. Amoxycillin is the drug of choice for CAP from infancy to

adolescent alternatives are co-amoxiclav, cefuroxime or macrolide

11. Child remaining febrile & symptomatic for more than 48-72 hrs after hospitalization should be re-evaluated for complications, underlying comorbid conditions, co-mimics, immunosuppression or drug resistance.