Pneumonia in a child Flashcards
Which antibtiotic covers for strep pneumoniae infection in a child allergic to penicillin? What is the ROA?
clarithromycin intravenously
What antibiotic has the best coverage for pneumonia?
Amoxicillin
What % of pneumonias have no cause identified?
50%
Which types of pathogens most commonly cause pneumonia in younger vs older children?
Young - viruses
Older - bacteria
BUT in practice it is difficult to distinguish between viral and bacterial pneumonia
What are the most common pathogens causing pneumonia in childhood?
Newborn - organisms from mother’s genital tract
- GBS
- Gram negative enterococci
- Gram negative bacilli
Infants and young children
- Respiratory viruses e.g. RSV
- Streptococcus pneumoniae
- H. influenzae
- Bordatella pertussis
- Chlamydia trichomatis
- Staphylococcus aureus (infrequent but serious at this age)
Children >5yrs
- Mycoplasma pneumoniae
- Streptococcus pneumoniae
- Chlamydia pneumoniae
Consider TB at all ages.
Which types of pneumonia have been reduced due to vaccination?
H. infleunzae - Hib immunisation which is a polysaccharide conjugate vaccine (Prevenar 13) and protects against 13 of the most common serotypes.
S. pneumoniae - responsible for invasive disease is now included in routine immunisation. This has led to a decrease in septicaemia, meningitis and severe rhinosinusitis but not bacteraemic pneumonia.
What are the clinical features of pnemonia in children?
Usually preceded by URTI
- Fever
- Cough
- Tachypnoea
- Nasal flaring
- Chest indrawing
- Lethargy, poor feeding
- Decreased oxygen saturation
- Examination:
- End-respiratory coarse crackles
- Dullness on percussion
- Decreased breath sounds
- Bronchial breathing over affected area are often absent in young children
What are some unusual symptoms with which pneumonia can present in children?
Neck stiffness
Acute abdominal pain
How is pneumonia diagnosed?
- CXR - may confirm diagnosis but cannot differentiate viral/bacterial; done in those with signs of severe pneumonia especially hypoxaemia and significant respiratory distress and complicated pneumonia (absent breath sounds, dull to percussion, decreased chest expansion)
- Nasopharyngeal aspirate
Other for severe pneumonia/complicated pneumonia (with absent breath sounds, dull to percussion and decreased chest expansion):
- Blood culture
- FBC/U&E/CRP/creatinine
But children with uncomplicated CAP should not undergo these tests.
What are the complications of pneumonia in children? What is their management?
Effusions +/- septations -
Seen as blunting of the costophrenic angle. May develop into empyema and fibrin strands may form leading to septations. PC chest drain with regular instillation of fibrinolytic agent to break down fibrin may be effective or video-assisted thoracoscopic surgery or thoracotomy may be required in severe cases.
Occur in up to a third of children with pneumonia and may resolve with antibiotics BUT persistent fever beyond 48 hours of antibiotics suggests pleural collection which requires drainage under US guidance.
What is the management of pneumonia in children? (BTS)
BTS guidelines appendix 3
Basics - yes or no –>
- If moderate-high risk of sepsis then treat using NICE sepsis guidelines
- If signs of severe pneumonia then perform AP CXR (especially in hypoxaemia, significant respiratory distress)
- If clinical suspicion of complicated pneumonia (absent breath sounds, dull to percussion, decreased chest expansion) then
- Obtain CXR
- Bloods:
- Blood culture
- FBC
- CRP
- U&Es
- Creatinine
- Commence IV Abx
- If able to tolerate oral fluids
- Commence oral amoxicillin (or macrolide if mycoplasma or chlamydia)
- CXR and bloods not indicated
- If unable to tolerate oral fluids
- IV antibiotics - consult local guidelines
- CXR not routinely indicated
- If no improvement after 48hrs then consider complicated pneumonia
What are the features of severe pneumonia? (BTS)
If <5 years old:
- Tachypnoea (>70 bpm under 12 months age, >50bpm over 12 months)
- Moderate/severe recession (12 months)
- Grunting
- Nasal Flaring
- Apnoea
- Cyanosis
- Tachycardia (170 bpm under 6 months, >160 bpm 6-12 months, >150 bpm 1-3 years, >140 3-5 years)
- Capillary Refill Time ≥ 2 secs
- Hypoxaemia (sustained oxygen saturation <92% in room air)
- Not feeding (<12 months)
- Signs of dehydration (>12 months)
If 5-17 years old:
- Tachypnoea (RR >50 bpm)
- Severe difficulty breathing
- Grunting
- Nasal Flaring
- Cyanosis
- Tachycardia (>120 bpm 5-14, >100bpm 15-17)
- Capillary Refill Time ≥ 2 secs
- Hypoxaemia (sustained oxygen saturation <92% in room air)
- Signs of dehydration
What are the indications for admission with pneumonia?
- Sats <92%
- Recurrent apnoea
- Grunting and/or
- Inability to maintain adequate fluid/feed intake
When is amoxicillin vs coamoxiclav used for pneumonia? When are oral vs IV antibiotics used?
Older oral; infants IV. No advantage in giving IV over oral antibiotics in mild/moderate pneumonia.
- Amoxicicllin for uncomplicated
- Coamoxiclav for complicated or unresponsive pneumonia
- Amoxicillin or oral macrolide (e.g. erythromycin) are used for children >5yrs
Which lobes are affected in these pneumonias?
A - right upper lobe with loss of volume of this lobe. Horizontal fissure has been shifted upwards
B - left upper lobe consolidation
Which lobes have been affected in these pneumonias?
C - right lower lobe consolidation with volume loss on the right. Heart silhouette is clearly seen but the right hemidiaphragm is raised and partially obscured
D - normal right hemidiaphragm but partial loss of the right heart border typical of right middle lobe consolidaion
Which lobes have been affected in these pneumonias?
E - left lower lobe consolidation; diaphragm is not clearly seen behind the cardiac silhouette
F - lingular consolidation with obvious loss of the left heart border
