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Erich C. Maul, DO, FAAPPediatric Hospitalist

Assoc. Program Director, Pediatrics ResidencyA i t t P f f P di t iAssistant Professor of Pediatrics

University of Kentucky College of Medicine

Define Community Acquired Pneumonia (CAP) Discuss the epidemiology, diagnosis and scuss t e ep de o ogy, d ag os s a d

treatment of CAP across the age and patient care spectrum

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No financial backing from anyone No off label drugso o abe d ugs No conflicts of interest

Global distribution of cause-specific mortality among children d 5 i 2004 P i th l di kill funder age 5 years in 2004. Pneumonia was the leading killer of

children worldwide. From UNICEF/WHO. Pneumonia: the forgotten killer of children. New York and Geneva: The United Nations Children's Fund (UNICEF)/World Health Organization (WHO); 2006

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150 million cases world wide◦ 20 million severe◦ 1.9 million deaths worldwide 90% in developing countries 50% in Africa alone

North America◦ 40/1000 in kids <5 years◦ 15/1000 in kids 5-15 years15/1000 in kids 5 15 years◦ Mortality is <1/1000; much higher morbidity

Infection of the lung parenchyma◦ Lower Respiratory Tract Infection (LRTI)

Commonly accepted clinical definition◦ Fever◦ Lower respiratory signs◦ Radiologic evidence of LRTI

The proper diagnosis can be completely clinicalclinical

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It’s bug time

Birth-3 weeks◦ Group B streptococcus, Gram-negative enterics, g

Cytomegalovirus, Listeria monocytogenes, Herpes Simplex, Treponema pallidum, genital Mycoplasmaor Ureaplasma

3 weeks-3 months◦ Chlamydia trachomatis, Respiratory syncytial virus

(RSV), Parainfluenza (PIV), Streptococcus pneumoniae, Bordatella pertussis

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3 months-5 years◦ Viral (RSV, PIV, hMPV, AV, RV), Streptococcus

pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae, Mycobacterium tuberculosis

5 years-15 years◦ Mycoplasma pneumoniae, Chlamydophyla

pneumoniae, Streptococcus pneumoniae, Mycobacterium tuberculosis

Occasional pathogens◦ Histoplasma capsulatum, Coccidioides immitis,

Blastomyces dermatitidis, Legionella pneumophila, Francisella tularensis, Pseudomonas pseudomallei, Brucella abortus, Leptospira spp, Chlamydophilapsittaci, Coxiella burnetii, Yersinia pestis, Hantavirus, Varicella, Measles, Influenza, SARS, Bioterror agents, mouth flora after aspiration

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Age, time of year, local epidemiology, travel Fevere e Extra-respiratory symptoms◦ Headache, conjunctivitis, rash, lethargy, sore throat,

GI distress Underlying conditions Ill contacts/daycare Previous history of pneumonia Foreign body risk TB risk

Syndrome Typical Cause Age Group Features

Bacterial S pneumoniae All ages Abrupt onset high fever illBacterial S. pneumoniae All agesmost commonly <6 y/o

Abrupt onset, high fever, ill appearing, focal exam findings, pain, CXR infiltrate

Atypical-infant

C. trachomatis < 3 m/o Tachypnea, mild hypoxia, no fever, wheezing, interstitial CXR, “happyand tachypneic”

Atypical-older

M. pneumoniae >5 y/oMaybe younger

Gradual onset, low grade fever, diffuse findings on exam andolder Maybe younger

with appropriate contacts

diffuse findings on exam and CXR

Viral Take your pick All agesMost commonly3mo-5y

URI symptoms, +/- fever, diffuse findings, wheezes

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Tachypnea

Tachypnea as a sign of pneumonia◦ 50-85% sensitive◦ 70-97% specific

Yield of CXR is low if tachypnea is absent Grunting should also catch your attention◦ May signal impending respiratory failure

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Fever Cough

Fever Cough

T h Difficulty breathing Vomiting/poor feeding Irritability Lethargy Chest pain Abdominal pain

Tachypnea Dyspnea Retractions Nasal flaring Grunting Splinting Cyanosis

Symptoms Signs

Abdominal pain Shoulder pain

Cyanosis

Overall severity of illness Observe LOC of child or level of IrritabilityObse e OC o c d o e e o tab ty Observe work of breathing Listen first while quiet◦ Crackles◦ Decreased breath sounds◦ Dullness to percussion

E h ( )◦ Egophony (e→a)◦ Bronchial breath sounds

Generate a Bacterial Pneumonia Score

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Predictor Points

Ax Temp >39oC 3Ax. Temp >39 C 3

Age >9 mo 2

ANC>8,000 2

Bands>5% 1

CXR findings -3 to 7

Total -3 to 15

Moreno, L., J. A. Krishnan, et al. (2006). "Development and validation of a clinical prediction rule to distinguish bacterial from viral pneumonia in children." Pediatr Pulmonol41(4): 331-7.

Finding Description

Infiltrate Well defined, lobar, (sub)segmental 2Poorl defined patch 1Poorly defined, patchy 1Interstitial, peribronchial -1

Location Single lobe 2Multiple lobes, well defined 1Mult sites, perihilar, poorly defined -1

Pleural fluid Minimal angle blunting 1Obvious fluid 2Obvious fluid 2

Abscess, bullae,pneumatocele

Equivocal 1Obvious 2

Atelectasis Subsegmental (multiple sites) -1Lobar (RML or RUL) -1Lobar (any other) 0

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BPS>4◦ Sensitivity 100%

f◦ Specificity 94%◦ PPV 76%◦ NPV 100%

May not have captured all kids with pneumonia due to exclusion criteria, but the findings make sense.S h t b t i b Somewhat cumbersome to use in a busy hospital

Not validated in outpatient setting

NONE◦ If you think they can be

treated as an outpatient

CBC Blood culture

CXRtreated as an outpatient Viral tests? Challenge to you…◦ Skip the CXR if they are

well enough to be treated as an outpatient and your exam and history are

CXR Viral screening? ESR/CRP-not useful Urinary S. pneumoniae

antigen? Procalcitonin?

Outpatient Inpatient

consistent with pneumonia

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2 discussions◦ Outpatient◦ Inpatient

Reasons to admit◦ Hypoxemia <90-92% on room air◦ Respiratory distress◦ Dehydration◦ Other medical conditions◦ Outpatient failure◦ Altered mental status/toxic appearance◦ <60 days oldy◦ Lacking one of Dr Maul’s 3 C’s Car, Communication, Clue

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2mo to 2 yr◦ High dose amoxicillin

Amoxicillin Azithromycin

2 yr to 5 yr◦ High dose amoxicillin +

macrolide >5 yr◦ Amoxicillin + macrolide

Type I PCN allergy

y Clarithromycin Cefdinir Cefpodoxime Cefuroxime

axetilC ft iyp gy

◦ Macrolide + clindamycin Non-type I PCN allergy◦ Cephalosporin + macrolide

Ceftriaxone Clindamycin

Antipyretics prn Hydrationyd at o Diet as tolerated Avoid antitussive agents or decongestants Recheck them in 48 hours◦ Sooner if worsening

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<60 days old◦ Ampicillin + [gentamicin OR cefotaxime]g Add vancomycin if concerned for MRSA If Chlamydia is a concern, erythromycin or

azithromycin IV + cefotaxime◦ See Sanford guide for specifics

Fact or fiction◦ Hydration◦ Chest physiotherapy◦ Bronchodilators◦ Nutrition◦ Antibiotics

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PO, NGT, SQ, IV◦ Route doesn’t matter, safety does

“IV fluids are an actual therapeutic intervention, not a right of hospital admission.”

No good data to direct the use of this practice Data to suggest that it is not beneficialata to suggest t at t s ot be e c a◦ Fever lasts 1-3 days longer in CPT group◦ No improvement in LOS, improvement in cough,

FEV1, clinical resolution Sounds to me like it’s time to make this stop

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No published evidence about use in patients

h h i

Malnourished children with pneumonia do worsewho are not wheezing worse

Need early thoughts about restoring adequate nutrition when hospitalized

Skip BRAT diet◦ Use BREATH diet Baby Resumes Eating All

Bronchodilators Nutrition

Baby Resumes Eating All Things Healthy

Uncomplicated◦ <2 yr old Ampicillin OR cefotaxime

< 2 yr old◦ [Cefotaxime OR

ceftriaxone]Ampicillin OR cefotaxime◦ >2 yr old [Ampicillin OR cefotaxime

OR ceftriaxone] AND macrolide

Complicated◦ [Cefotaxime OR

ceftriaxone] AND

ceftriaxone] AND ◦ vancomycin

> 2 yr old◦ [Cefotaxime OR

ceftriaxone] AND

Floor PICU

◦ [vancomycin OR clindamycin]

◦ Vancomycin + macrolide

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Needs a more in depth discussion Has many controversiesas a y co t o e s es Will save it for another day, but let’s hit some

highlights

Major suppurative complications◦ Necrotizing pneumoniag Rare, very ill appearing, requires >4 wks of abx for

treatment◦ Lung abscess Pneumatocele, air-fluid level, generally after aspiration

in a child with seizure disorder or neuromuscular problem, polymicrobial, think about TB, +aspiration

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Very common Sterile

Becoming more commonF f i h Resolve without

intervention Fever, fatigue, chest

pain, respiratory distress

Imaging helps guide therapy

Need fluid to guide therapy and promote

Simple Empyema

therapy and promote recovery

Management is controversial◦ Drainage aloneg◦ Thoracostomy with fibrinolytics◦ VATS◦ Open thoracotomy

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If the child is getting better, don’t get them◦ CXRs can stay abnormal for 8 weeks or more

Repeat images may be of benefit for children not improving or not responding to therapy

Hand hygiene Cough hygieneCoug yg e e Avoiding tobacco smoke Breastfeeding Avoiding sick contacts Immunizations◦ Hib, PCV7 (PCV13), DTaP, Tdap, PPSV23, influenza, ( ), , p, ,

Asthma control

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