Respiratory: CAP Flashcards
In what percentage of cases is no causative organism found?
Over 50%
Are viruses or bacteria the most common cause in young children?
Viruses
Are viruses or bacteria the most common cause in older children?
Bacteria
Mixed bacterial-viral infections are found in up to what fraction of cases?
1/3
In clinical practice, is it difficult to distinguish from viral or bacterial cause?
Yes but organisms vary with age and some clinical features make either more likely
What are the most common causative organisms in newborns?
Group B streptococcus
Gram negative enterococci and bacilli
(Organisms from mothers genital tract)
What are the most common causative organisms in infants and young children?
Respiratory viruses - RSV most common
Bacterial: streptococcus pneumoniae, haemophilius influenzae
Also pertussis and chlamydia
Uncommon: staph aureus
What are the most common causative organisms in children over 5?
Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydia pneumoniae
What causative organism should be considered at all ages?
Mycobacterium tuberculosis
What causative organism has there been a marked reduction of since the introduction of a vaccine for it?
Haemophilius influenzae
Also there is a vaccine for 13 of the most common serotypes of streptococcus pneumoniae responsible for invasive disease (part of routine immunisation in UK)
Viral pneumonia is most common below what age?
2 years old
Describe the onset of viral pneumonia
Gradual over 24-48 hours Coryzal prodrome (runny nose, cough)
What clinical findings are seen with viral pneumonia?
Myalgia, rash, mucous membrane signs Temperature <38.5 Cough usually dry Bilateral, diffuse chest signs Associated wheeze No pleuritic pain
In suspected viral pneumonia, will other family members be unwell?
Most likely - concurrent RTI, rash, conjunctivitis
In bacterial pneumonia, what age is typically affected?
Over 2 years
Describe the typical onset of bacterial pneumonia
Abrupt (often appearing toxic)
No prodrome, no runny nose
What clinical findings are seen with bacterial pneumonia?
Appears toxic Temperature > 38.5 Cough can be wet and productive Pleuritic pain: chest, abdomen or neck Unilateral clinical signs No wheeze on auscultation
Will other members of the family be unwell (in suspected bacterial pneumonia)?
No usually not
What clinical findings are there on chest examination?
Bronchial breathing (indicates patent airway surrounded by consolidated lung tissue) Reduced expansion on inspiration Increased vocal fremitus Increased vocal resonance Diminished air entry Possible crackles Pleural rub Dullness to percuss
What is the most sensitive clinical sign of pneumonia in children?
Increased RR - may be the only respiratory sign
Can a child have no abnormal signs on auscultation and have pneumonia?
Yes
What are the characteristics of mild CAP in infants?
RR <50/min
CRT <2 sec
Mild recessions
Taking full feeds
What are the characteristics of mild CAP in older children?
RR<35/min
CRT <2 sec
Mild breathlessness
Taking full feeds
What are the characteristics of moderate CAP in infants?
RR 50-70/min
CRT about 2 sec
Moderate recessions
Reduced feeds
What are the characteristics of moderate CAP in older children?
RR 35-50
CRT about 2 sec
Moderate recessions
Reduced feeds
What are the characteristics of severe CAP in infants?
RR>70/min CRT>2 sec Nasal flaring Intermittent apnoea Grunting Unable to feed
What are the characteristics for severe CAP in older children?
RR>50 CRT>2 Unable to complete sentences Severe recessions Nasal flaring Signs of dehydration
What indicates increased work of breathing?
Nasal flaring
Expiratory grunting - increased PEEP
Use of accessory muscles
Retractions - suprasternal, SC and IC
When deciding whether to treat child in the community or admit for hospital based care, what factors should be considered?
Assessment of severity
Underlying risk factors
Ability of carers to manage the illness in the community
Can children with mild symptoms be managed in the community?
Yes
As long as they are able to tolerate fluids and medications, do not need additional oxygen to maintain sats over 92%.
Providing parents are adequately supported, reassured and informed
Do children with moderate CAP need admission?
Yes will likely need admission
Can usually be managed on oral antibiotics
Should children with severe CAP be admitted?
Yes - need IV antibiotics
Are blood tests and CXRs routinely needed in children admitted with moderate CAP?
No
When should CXR be done?
Diagnosis unclear
Complicated pneumonia suspected
Severe pneumonia
What bloods should be done in children with severe CAP?
FBC, CRP, U&E
Blood culture
Mycoplasma serology
Ideally before antibiotics commenced
Children on IV fluids will need what done daily?
U&Es to check for evidence of hyponatraemia secondary to SIADH
When should microbiology testing be done?
All children with severe pneumonia and those with complicated pneumonia
Includes:
Point of care testing for respiratory viruses during flu season
Blood culture
Nasopharyngeal secretions and/or nasal swabs - viral detection by PCR and bacterial culture
Mycoplasma serology
If present, pleural fluid sent
Who should receive antibiotics?
All children with suspected bacterial CAP
In Children less than 2 admitted with moderate features of CAP, wheeze, temp less than 38.5 a viral cause is more likely. Can registrar / consultant decide to withhold antibiotics?
Yes but child should be monitored closely for signs of deterioration
What antibiotics should be given to children with moderate CAP?
Oral amoxicillin
If allergy to penicillin: clarithromycin
What antibiotics should be given in severe CAP?
IV co-amoxiclav and clarithromycin
Allergy to penicillin: cefuroxime and clarithromycin
Is there an advantage of giving IV rather than oral treatment in mild/moderate pneumonia?
No
What antibiotic class should be used if mycoplasma or chlamydia suspected?
Macrolides e.g erythromycin
Is sputum often produced by children?
No rarely produced as they swallow it - main exception is purulent lung disease e.g from CF
