CAP Flashcards
Risk factors for pediatric CAP
Recent history of URTI- viral respiratory prodrome
Lower socioeconomic status
Crowded living environment
Exposure to cigarette smoking
Comorbidities
Comorbidities for CAP
ASTHMA
Bronchopulmonary dysplasia
CF
Sickle cell disease
Congenital heart disease
Bacterial causes of CAP
Strep. pneumoniae- MOST COMMON PATHOGEN
H. influenzae
S. aureus
Group A Strep
Atypical (3-23%, mostly in older children):
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella (rare)
Viral causes of CAP
Influenza virus
RSV
PIV
Adenovirus
Rhinovirus
Viral agents are more common in what age group?
<2 years old, makes up ~80% of CAP cases in this population
Best predictor of cause via identification of likely pathogen and exposure
AGE
Suspected CAP pathogens: birth-20 days
GBS
Gram-negative enteric bacteria
L. monocytogenes
Suspected CAP pathogens: 3 weeks-3 months
S. pneumoniae
S. aureus
RSV
PIV
B. pertussis
C. trachomatis
Suspected CAP pathogens: 4 months-4 years
S. pneumoniae
H. influenzae
M. pneumoniae
Viruses
M. tuberculosis
Suspected pathogens: 5 years-15 years
S. pneumoniae
H. influenzae
M. pneumoniae
C. pneumoniae
Influenza A or B, adenovirus
M. tuberculosis
Outpatient CAP: <5 years old, presumed bacterial pneumonia, 1st-line option
Amoxicillin 90mg/kg/d PO div. BID or TID, MDD 3-4g/day
Reason a high dose of amoxicillin is used
Overcome S. pneumonia’s mechanism of resistance (production of PCN-binding protein)
Outpatient CAP: <5 years old, presumed bacterial pneumonia, alternative
Amox/clav 90mg/kg/day div. BID or TID, MDD= 875-1000mg/dose
What is the clavulanate there to do in amox/clav?
Cover the beta-lactamase producing organisms
ES formulations of amox/clav do what?
Increase the amoxicillin component without increasing the clav. component, which may increase diarrhea
Outpatient CAP: <5 years old, presumed atypical pneumonia, 1st-line option
Azithromycin 10mg/kg/day PO on day 1 (MDD=500mg), then Azithromycin 5mg/kg/day PO on days 2-5 (MDD=250mg)
Reason azithromycin course is only 5 days
Long half-life with post-ABX effect
Outpatient CAP: <5 years old, presumed atypical pneumonia, alternative
Clarithromycin 15mg/kg/day in 2 doses x7-14 days OR erythromycin 40mg/kg/day in 4 doses
Outpatient CAP: <5 years old, presumed influenza pneumonia, 1st-line option
oseltamivir x5 days, but only effective if initiated within 48 hours of symptoms
Outpatient CAP: ≥5 years old, presumed bacterial pneumonia, 1st-line option
Amoxicillin 90mg/kg/day (like in patients <5 years old)
Can add macrolide to beta-lactam ABX for empiric therapy if there’s not enough evidence to distinguish between this and atypical CAP
Outpatient CAP: ≥5 years old, presumed bacterial pneumonia, alternate
Amox/clav (like in patients <5 years old)
Outpatient CAP: ≥5 years old, presumed atypical pneumonia, 1st-line option
Amox/clav, like in patients <5
Outpatient CAP: ≥5 years old, presumed atypical pneumonia, alternates
erythromycin, doxycycline in kids >7
Outpatient CAP: ≥5 years old, presumed influenza pneumonia
oseltamivir or zanamivir for children ≥7
Inpatient CAP, fully immunized, MIC ≤2: presumed bacterial pneumonia
Ampicillin (or PCN G) 150-200mg/kg/day IV div. q6h, MDD=2g/dose
^empiric dose or S. pneumonia, H. influenzae
Group A Strep: 200mg/kg/day IV div. q6h
S. pneumoniae when PCN MIC is ≥4: 300-400mg/kg/day IV div q6h, MDD= 12g/day
Ampicillin ADEs
diarrhea, rash, eosinophilia
Ampicillin alternatives
ceftriaxone, cefotaxime, adding vanco or clindamycin for suspected CA-MRSA
Inpatient CAP, fully immunized, MIC ≤2: presumed atypical pneumonia
Azithromycin (in addition to beta-lactam if diagnosis of atypical pneumonia is in doubt)
Azithromycin alternatives
clarithromycin or erythromycin; doxycycline for children >7 years old; levofloxacin for children who have reached growth maturity or can’t tolerate macrolides
Inpatient CAP, fully immunized, MIC ≤2: presumed influenza pneumonia
oseltamivir or zanamivir for children ≥7 years old
Inpatient CAP: not fully immunized, MIC ≥2: presumed bacterial pneumonia
Ceftriaxone 50mg/kg/dose q24h, or cefotaxime; adding vanco or clindamycin for suspected CA-MRSA
CTX ADEs
diarrhea, rash, eosinophilia, pain at injection site with IM formulation
Reason CTX is used in un-immunized children
Concern for H. influenzae beta-lactamase producing
Alternatives to CTX/cefotaxime
levofloxacin, add vanco or clindamycin
Inpatient CAP: not fully immunized, MIC ≥2: presumed atypical pneumonia
Same treatment as fully immunized
Azithromycin
Inpatient CAP: not fully immunized, MIC ≥2: presumed influenza pneumonia
same as fully immunized
CAP treatment: what to do with a non-serious allergy
Trial under medical supervision
Use of cephalosporins: cefpodoxime, cefprozil, cefuroxime
CAP treatment: anaphylactic allergy
Respiratory fluoroquinolone
Linezolid
Macrolide
Clindamycin
Bactrim
Duration of CAP treatment
10 days total of treatment, but CA-MRSA may require more
5 days only for azithromycin and oseltamivir
When to discharge a patient with CAP
Clinical improvement, increased O2 sat, baseline mental status, can take PO meds
CAP: vaccine prevention
PCV13, Hib, DTaP, influenza, RSV in high-risk infants
Hallmark signs and symptoms of CAP
Fever, cough
Other signs/symptoms of CAP
Pleuritic chest pain d/t inflammation
Purulent expectorant
Tachypnea for age (Infants: >70 breaths/min, children: >50 breaths/min)
Respiratory distress- severe CAP, severity increases as disease progresses
Retractions (suprasternal, intercostal, subcostal)
Grunting
Nasal flaring
Apnea
Wheezing
Crackles/rales
Pulse ox <90% on room air
Altered mental status
Gold standard for diagnosing CAP
chest x-ray
How to distinguish viral vs. bacterial pneumonia
Viral on a chest-x-ray is general haziness
Bacterial on a chest x-ray is consolidated in a specific area
Who should be hospitalized for CAP?
Moderate-severe CAP
Significant respiratory distress: SPO2 <90%
All infants <3 months
Infants <6 months with suspected bacterial CAP
Suspicion/documentation of community-acquired MRSA infections
Concern for caretaker capabilities
