Uncomplicated Pneumonia in healthy Canadian children and youth: Practice points for management Flashcards
Why is the incidence of pneumonia more common in developing countries?
- Lower immunization coverage
What effect does pneumococcal conjugate vaccine have on pneumonia admission rates for kids < 5 years?
Decreased by 27%
Who is excluded from this CPS statement?
- Chronic pneumonia syndromes (symptoms > 2 weeks)
- Aspiration pneumonias
- Recurrent pneumonias
- Pneumonia d/t underlying medical dz (immunodeficiency)
Define pneumonia
- Acute inflammation of parenchyma of lower respiratory tract caused by a microbial pathogen
- Bacterial ifnections usually primary but sometimes secondary to infection with viral agent (influenza)
- May see small parapneumonic effusions with uncomplicated CAP
What makes pneumonia complicated?
- Empyema
- Lung abscess
- Necrotic portion of lung patrenchyma
What is the most common cause of pneumonia in infants and preschool kids?
- Viruses that usually circulate in the winter (RSV, influenza, parainfluenza, HMPV)
- Isolated viral infections (except influenza) a less common cause of pneumonia in older kids
What is the most common cause of bacterial pneumonia in kids of all ages?
- Strep pneumoniae
- Group A strep much less common
- Staph aureus increasingly prevalent in communities with high incidence of MRSA
- HIB pneumonia has almost disappeared due to vaccination
- Mycoplasma and chlamydophila pneumoniae more common causes of pneumonia among school aged kids but occasionally seen in younger kids
How does pneumonia present?
- Acute onset fever, cough, difficulty breathing, poor feeding, vomiting
- Chest pain, abdominal pain
- Mycoplasma: malaise and HA for 7-10d before onset of fever and cough
- Influenza suggested by sudden onset systemic symptoms (myalgias and fever) followed by sore throat, cough, resp symptoms
Describe normal RR for infants and kids
- < 2 mos 34-50, tachypnea at 60
- 2-12 mos 25-40, tachypnea at 50
- 1-5yrs 20-30, tachypnea at 40
- > 5 yrs 15-25, tachypnea at 30
Who needs a CXR?
- If suspecting bronchiolitis - NO!
- If highly suspicious for bacterial pneumonia and child not sick enough to warrant admission, no CXR required
- All hospitalized kids should have a CXR to document extent of pneumonia and r/o pleural effusion, abscess
What radiographic pattern is consistent with bacterial pneumonia?
- Alveolar/airspace disease seen as lobar consolidations with air bronchograms
- Can also be seen as subsegmental infiltrates or round pneumonias
What radiographic pattern is consistent with viral infection?
- Poorly defined patched of infiltrates or atelectasis
What are classical radiographic findings associated with atypical pathogens (mycoplasma, chlamydia)?
- Bilateral focal or interstitial infiltrates that appear to be more extensive relative to the milder but persistent symptoms
What is the role of US/CT in managing pneumonia?
- Good for finding parapneumonic effusions and empyema (predominant symptom is persistent fever)
How to determine the etiology of pneumonia?
- Difficult!
- Most kids not bacteremic at the time of presentation and sputum cultures with low yield
- Viral testing usually not indicated for outpatients but can be helpful for inpatients who could benefit from antivirals if they have influenza
- If kids have minimal leukocytosis and nonlobar infiltrates, consider testing for mycoplasma or chlamydia
What bloodwork to order for pneumonia?
- Higher WBC counts than atypical bacterial or viral pneumonia
- CBC and blood cultures indicated for all hospitalized patients
- Minimum volume required for culture is 1-2mL for infants, 4-5mL in kids < 10 and 10-20mL in kids > 10mL
List indications for admission in pneumonia
- Inadequate PO intake
- Intolerance to PO therapy
- Severe illness or respiratory compromise (grunting, nasal flaring, apnea, hypoxia)
- Complicated pneumonia
- Lower threshold for admitting infants < 6 months
When is Tamiflu indicated in management of pneumonia?
- If influenza is detected or suspected
How to manage viral pneumonia?
- Suppotive care (O2, rehydration)
How to manage pneumonia in outpatients?
- Amoxicillin 40-90mg/kg/day divided TID
What is empiric therapy for inpatient pneumonia?
- Ampicillin 200mg/kg/day div Q6H
How to manage pneumonia in kids with respiratory failure or shock?
- Use 3rd generation cephalosporin as it offers broader coverage than amp or amox for beta lactamase producing H flu, PCN resistant pneumococcus and MRSA
- Ceftriaxone 50-100mg/kg/day div BID
How to broaden antibiotic coverage if a child develops pneumatoceles or progressive multilobar disease?
- Add vancomycin to provide additional coverage for MRSA until cultures become available
What to do if cultures are all negative?
- Step down to ampicillin followed by PO amox
How would your management change if a patient developed an empyema?
- Antimicrobial choices would stay the same as most empyemas are caused by strep pneumoniae
What is recommended therapy for strep pneumo that is susceptible to penicillin?
- Penicillin G 200,000-250,000U/day divided Q4-6h (max 24 million U/day)
What is the rolf of antimicrobials in treating mycoplasma or chlamydophila?
- Unknown because most kids resolve spontaneously without antibiotics
- Azithromycin 10mg/kg PO OD on day one
- Azithromycin 5mg/kg PO OD on days 2-5
- Maximum 500mg/day
- Doxycycline would also work in kids > age 8 for strains that are resistant to macrolides
What to do if there is no improvement within 48-72h?
- Repeat imaging to rule out empyema or pleural effusion that has developed in the interim
What is the duration of treatment for CAP?
- 7-10 days
- Pneumonia complicated by empyeme usually needs 2-4 weeks of antibiotics - can step down to PO antibiotics once patients are improved, afebrile and otherwise ready for hospital discharge
What to give if a patient previously developed a non urticarial rash with penicillin/amox?
- Can safely be started on amox or amp
- Cross reactivity rate between penicillins and second/third gen cephalosporins extremely low
- Cefuroxime, cefprozil or ceftriaxone can be prescribed for PCN allergic patients
- If prev rxn was urticaria, angioedema, hypotension or bronchospasm, observe patient for 30 mins following first dose of cephalosporin in a setting
- Clarithro or axithro can also be used but there is increasing resistance
- SJS or TEN attributed to an antibiotic is an absolute contraindication
When do we expect pneumonia to improve?
48 hours after starting abx
If not find out why (CXR)
