COMMUNITY ACQUIRED PNEUMONIA

DR MANDAR HAVALMBBS DCH DNB

FELLOW IN NEONATOLOGY

MAGNITUDE OF THE PROBLEM

• Acute respiratory Infections (ARI) in children less than 5 years old are the leading cause of childhood morbidity and mortality in the world.

• Recent WHO estimates suggest the median incidence of clinical pneumonia is 0.28 episodes per child per year.

• More than 95% of all episodes of clinical pneumonia in young children worldwide occur in developing countries.

RECENT ESTIMATES FROM INDIA

• ARI in children under 5 years of age constitutes 24% of the National Burden of disease and 13% of deaths

• Mortality estimates suggest that 2.3 million children less than 5 years of age die every year in India and 20% of these deaths are due to ARI.

IDENTIFICATION OF ETIOLOGICAL AGENTS

• The Identification of the etiological agent / agents responsible for pneumonia remains a challenge. This is primarily because of difficulty in obtaining adequate samples for culture, differentiating infection from colonization and lack of reliable diagnostic tests.

• The gold standard would be lung puncture samples taken directly from the infected area of the lungg. However this is an invasive test and not routinely preferred

WHAT IS COMMUNITY ACQUIRED PNEUMONIA?

• Community acquired pneumonia is an acute infection of the pulmonary parenchyma in a previously healthy child, acquired outside of a hospital setting.

• The patient should not have been hospitalized within 14 days prior to the onset of symptoms

or• Has been hospitalized less than 4 days prior to

onset of symptoms.

WHAT ARE THE COMMON PATHOGENS INVOLVED?

• Age is a good predictor of the likely pathogen of pneumonia and can help narrow the list of etiological agents.

• While Gram negative agents are common under 3 months of age.

• S. pneumoniae is common at all ages thereafter • H. influenzae is a common organism upto 2 years of

age.• Staphylococcus though not very common is an

important formidable enemy

HOW DOES ONE DIAGNOSE PNEUMONIA IN A CHILD?

A. Children with suspected pneumonia can present with symptoms like

1. Fever2. Cough, may or may not be productive3. Chest pain and/or abdominal pain4. Difficulty in breathing (dyspnea) / rapid

breathing (tachypnoea)5. Constitutional symptoms: malaise, lethargy,

headache, nausea / vomiting

2. Signs that suggest a high probability of pneumonia and need for antibiotic treatment

• Rapid respiration identifies children who have a very high probability of having pneumonia and are therefore candidates for antibiotic therapy

• Age< 2 months - 60 or more 2 months upto 12 months- 50 or more 12 months upto 5 years - 40 or more

breaths/min.

Continue

• The presence of grunt, crackles, bronchial breathing is suggestive of pneumonia but are not so common

• Often there may be presence of signs of the complications of pneumonia like para-pneumonic effusions/ empyema, pneumothorax

HOW DOES ONE ESTABLISH THE DIAGNOSIS?

• Diagnosis of CAP can be established with a fair degree of accuracy by judicious use of the clinical signs detailed above.

• There are few clinical features to suggest probable etiology yet some clues like presence of skin boils, rapid progression / deterioration, empyema or pneumothorax or radiological evidence of pneumatocele strongly incriminate Staphylococcus

Clinical differentiation of viral and bacterial pneumonias is difficult

DIAGNOSING PNEUMONIA AIMED AT

• Recognizing signs that suggest a high probability of Pneumonia and need for antibiotic treatment

• Assess severity of pneumonia to identify patients requiring hospital care

STUDY

DIFFERENTIAL DIAGNOSIS

CONSIDER BRONCHIOLITIS-WALRI

• Age 1month-1year• Presence of upper respiratory catarrh• Progressive increase in resp distress

(tachypnea, retractions)• Wheeze ± crackles• Clinical and radiological evidence of

hyperinflation

CONSIDER LTB-CROUP

• Hoarseness of voice and barking/brassy cough • Stridor• Mild to marked respiratory distress• Sonorous rhonchi• Fever usually mild (or spiking as in tracheitis,

however this disease entity is rare)

CONSIDER ASTHMA

• Recurrent afebrile episodes, 3 or more• Wheeze• Good response to bronchodilator• Hyperinflation• Family/personal history of atopy

INVESTIGATION

RADIOLOGY

• Not a very reliable diagnostic tool due to wide inter- and intra-observer error in reading radiographs

• Those needing domiciliary care usually do not benefit from radiographs

• Those sick enough to need hospitalization may benefit

INDICATIONS FOR CXR IN EITHER PRIMARY CARE OR HOSPITAL CARE

• For diagnosis of child under 5 years with fever of 39 C of unknown origin,If complications suspected, (for example, pleural effusion as suggested by diminished air entry),

• Ambiguous features, Unresponsive to treatment after 48 hrs of treatment / deteriorates

MICROBIOLOGICAL TESTS ARE OF NO USE ROUTINELY

ACUTE PHASE REACTANTS

• TLC, DLC, CRP are not diagnostic but may be useful to monitor the response to treatment.

• A normal test may be more useful in EXCLUDING the diagnosis as compared to confirmation on the basis of a positive test

ASSESSING PNEMONIA

ASSESSING SEVERITY OF PNEUMONIA

• WHO criteria of assessment of severity is simpler and useful at all levels of care

WHY AND HOW DOES ONE ASSESS SEVERITY?

• Assess for severity to decide the level of facility at which to treat and also to determine the choice of treatment including antibiotics.

Note..

• Hypoxaemia is a good indicator of the severity of Pneumonia, and pulse oxymetry should therefore be performed on every child deemed ill enough to be admitted.

Indications For Admission To Hospital In Pneumonia Among Children?

1. Mild to moderate cases do not need admission (refer to ‘FACTS’)

2. Infants less than 3 months of age are best treated as inpatients.

THE INDICATIONS FOR TRANSFER TO PEDIATRIC INTENSIVE CARE UNIT (PICU)

• There is failure to maintain SaO2 >92% in FiO2 >0.6

• The patient is in peripheral circulatory failure• There are rising respiratory and pulse rates

with clinical evidence of severe respiratory distress and exhaustion with or without raised PaCO2

• There is recurrent apnoea or slow irregular breathing.

HOW DOES ONE TREAT SUCH CASES?

• The components of management are (a) Oxygen as indicated by pulse

oxymetry and/ or clinical signs of hypoxia

(b) Supportive therapy

(c) Antibiotic

USING ANTIBIOTICS FOR CAP - GENERAL PRINCIPLES

• Empiric therapy should be based on knowing the most likely pathogen in each community. S. pneumoniae is an important causative agent for Community Acquired Pneumonia at all ages.

• Because it is difficult to distinguish between bacterial, viral, and mixed infections, most children with Community Acquired Pneumonia are treated with antibiotics.

• Selection of antibiotic is dictated by the age of the child and epidemiological factors and sometimes the results of the chest radiography.

SIMPLE WAY OF APPROACH

When to start second line of drug?

• Deterioration of clinical condition at anytime on first line antibiotics

OR

• No response even on DAY 4 of antibiotic therapy

QUINOLONES

SELECTION OF ANTIBIOTICS

UNDERLYING DISEASE

• Children with hemoglobinopathy or nephrotic syndrome are more susesptible to Pneumococcal

• Cystic fibrosis – Staphylococcus, H influenza, Pseudomonas

• Immunodeficiency – opportunistic infection

• HIV – Gram negative bacilli, P.jiroveci and Fungal

NOTE – PROGRESSION IN IMMUNODEFICIENCY IS RAPID HENCE MORE EFFICIENT ANTIBIOTIC COMBINATION USED AS A FIRST LINE

• Neutropenia – Gram Negative bacilli, Staphylococcus along with common pathogen like S.pneumoniae and H. influenzae

• Drug of choice – CEFTAZIDIME with AMINOGLYCOSIDE

• If no response then add ANTIFUNGAL or SEPTRAN

• History of Hospitalization – Gram Negative bacilli.

• NOTE – STAPHYLOCOCCAL infection in hospital setting is Resistance to PENICILLIN and need VANCOMYCIN or LINIZOLID

History of previous antibiotics

• Current episode OR recent past (2-4 week) should be consider

• Idea of possible RESISTANT ORGANISMS. So change antibiotic accordingly.

NUTRITIONAL STATUS

• The symptoms of pneumonia may be MASKED in severe malnutrition

• Added predisposition to GRAM NEGATIVE organisms

DURATION OF ILLNESS

• Short duration – possible BACTERIAL etiology

• Prolonged duration – M. TUBERCULOSIS, ATYPICAL ORGANISM, ADENOVIRUS

INDICATION FOR IV ANTIBIOTICS

• SEVERE PNEUMONIA • DISTURBED CONSCIOUSNESS• IMPROPER SWALLOWLING • FREQUENT VOMITING• MALABSORPTION

• Note – switch to ORAL when child start accepting orally or clinically improving

SUPPORTIVE THERAPY FOR CAP

• Oxygen as indicated by pulse oxymetry and/ or clinical signs of hypoxia

• IV fluids : If dehydrated,If tachypnoea is severe enough to make the child unable to drink, or Impending respiratory failure.

• Fever management

• Bronchodilators, indicated only in the presence of wheeze, should be used to decrease the work of breathing.

HOW LONG DOES ONE CONTINUE TREATMENT?

• Domiciliary cases: Total of 5-7 days• Admitted cases: Switch to oral as soon as patient

can accept orally. Total 5-7 days. • However, if on second line therapy, then use IV

antibiotics for 7-10 days.• If suspected or confirmed Staphylococcal based

disease, treat for 2 weeks at least in uncomplicated cases and for 4-6 weeks for those with complications like empyema, metastatic abscesses etc.

HOW DOES ONE MONITOR RESPONSE?

• Clinical response in the form of absence of fever, improvement in breathing is a useful method.

The end of treatment X-ray is not needed in every case except when:

1. The response is delayed or incomplete, or 2. There were any ambiguous signs in initial

film, or 3. There are any associated complications, or 4. Children with lobar collapse or ongoing

symptoms.

PREVENTION OF PNEUMONIA

• ROUTEIN IMMUNIZATION against PERTUSSIS, MEASLES, H.influenzae type B

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