Pneumonia

Question 1

How would you define a complicated pneumonia?

Answer 1

Evidence of abscess, empyema or necrotic parenchyma

Question 2

Is there an age when Viral pneumonia are more common?

Answer 2

Yes. Infants and preschool children

Question 3

What are the pathogens responsible for pneumonia?

Answer 3

Strep pneumonia - most common
GAS
MSSA and MRSA
Haemophilus Influenza B - if unimmunized

Atypical: mycoplasma and chlamydia pneumonia (school aged)

Question 4

What are the symptoms Of mycoplasma?

What does the CXR show?

Answer 4

Malaise and HA X 7-10 days then onset of fever and cough which then predominate.

Symptoms tend to be milder

CXR: bilateral focal or interstitial infiltrates

Question 5

What are the symptoms of influenza?

Answer 5

1st = sudden onset systemic symptoms with diffuse myalgia and fever
2nd = cough, sore throat or resp symptoms

Question 6

Can you use ultrasound instead of CXR?

Answer 6

US appears to be sensitive and specific for detecting infiltrates but requires further validation

Question 7

How would you investigate a complicated pneumonia (based on CXR)?
(2)

Answer 7

Ultrasound or CT

Question 8

What is the predominant symptom for an empyema?

Answer 8

Persistent fever

Question 9

In addition to imagine what investigations should kids get and why?

Answer 9

Viral swab - antivirals will be of benefit for moderate to severe influenza pneumonia (quicker recovery and prevent secondary bacterial infection)
CBC - atypical pneumonias have lower WBC
BCx - rarely positive but important surveillance post PCV13 vaccine
+/- mycoplasma PCR

Question 10

What should outpatient bronchopneumonia or lobar pneumonia be treated with? Inpatient?

Answer 10

Amoxicillin to cover strep pneuma

Ampicillin

Question 11

What anti microbial would you use for kids with respiratory failure or septic shock?
Why? (3)

Answer 11

Third generation cephalosporin - ceftriaxone or cefotaxime

1. Offers better coverage for beta lactamase producing H influenza
2. May be more efficacious against high level penicillin resistant pneumococcus
3. Coverage of rare MSSA

Question 12

What antimicrobial would you add if there was rapidly progressing multi lobar disease or pneumatocele?

Answer 12

Vancomycin to cover MRSA, until cultures are available

Question 13

Would your antimicrobial choice change if there was an empyema?

Answer 13

No. Still use something to cover strep pneuma and GAS.

If the empyema is Staph Aureus - the cultures are likely to grow if drawn within 48 hours of ABx.

Question 14

What is the role of antimicrobials for treating Mycoplasma and Chlamydia pneumonia?

Answer 14

Unclear. Many infections resolve without macrolide. Treatment may be appropriate to hasten recovery in children who are more seriously ill or have a persistent cough.

Question 15

When do you expect improvement?

If you’re not seeing improvement, what should you do and what should you consider?

Answer 15

48-72 hours for bacterial. Viral pneumonia can take longer.

CXR

Consider:

1. Alternate infection: TB
2. Complication: empyema, immunodeficiency with opportunistic infection
3. Alternate non-infection aetiology: Collagen vascular disease, asthma, congenital lung anomaly, CCF
4. FB

Question 16

Which antibiotic would you give a penicillin allergic kid?

Any extra precautions?

Answer 16

Third generation cephalosporin cefuroxime, cefpozil, ceftriaxone

If truly anaphylactic, you should observe for 30 min after does

Alternatives: azithro and clarithro however resistance is increasing so follow up is essential

Question 17

When do the CXR changes disappear?

Do you need to document that?

Answer 17

4-6 weeks.

Not in an otherwise healthy child. I’m

Question 18

When would you do a blood culture?

Answer 18

Any kid hospitalised.

The yield is low but it’s important surveillance and is helpful if positive especially if the kid has a complicated course.