Uncomplicated Pneumonia in healthy Canadian children and youth: Practice points for management

Question 1

Why is the incidence of pneumonia more common in developing countries?

Answer 1

• Lower immunization coverage

Question 2

What effect does pneumococcal conjugate vaccine have on pneumonia admission rates for kids < 5 years?

Answer 2

Decreased by 27%

Question 3

Who is excluded from this CPS statement?

Answer 3

• Chronic pneumonia syndromes (symptoms > 2 weeks)
• Aspiration pneumonias
• Recurrent pneumonias
• Pneumonia d/t underlying medical dz (immunodeficiency)

Question 4

Define pneumonia

Answer 4

• 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

Question 5

What makes pneumonia complicated?

Answer 5

• Empyema
• Lung abscess
• Necrotic portion of lung patrenchyma

Question 6

What is the most common cause of pneumonia in infants and preschool kids?

Answer 6

• 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

Question 7

What is the most common cause of bacterial pneumonia in kids of all ages?

Answer 7

• 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

Question 8

How does pneumonia present?

Answer 8

• 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

Question 9

Describe normal RR for infants and kids

Answer 9

• < 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

Question 10

Who needs a CXR?

Answer 10

• 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

Question 11

What radiographic pattern is consistent with bacterial pneumonia?

Answer 11

• Alveolar/airspace disease seen as lobar consolidations with air bronchograms
• Can also be seen as subsegmental infiltrates or round pneumonias

Question 12

What radiographic pattern is consistent with viral infection?

Answer 12

• Poorly defined patched of infiltrates or atelectasis

Question 13

What are classical radiographic findings associated with atypical pathogens (mycoplasma, chlamydia)?

Answer 13

• Bilateral focal or interstitial infiltrates that appear to be more extensive relative to the milder but persistent symptoms

Question 14

What is the role of US/CT in managing pneumonia?

Answer 14

• Good for finding parapneumonic effusions and empyema (predominant symptom is persistent fever)

Question 15

How to determine the etiology of pneumonia?

Answer 15

• 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

Question 16

What bloodwork to order for pneumonia?

Answer 16

• 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

Question 17

List indications for admission in pneumonia

Answer 17

• 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

Question 18

When is Tamiflu indicated in management of pneumonia?

Answer 18

• If influenza is detected or suspected

Question 19

How to manage viral pneumonia?

Answer 19

• Suppotive care (O2, rehydration)

Question 20

How to manage pneumonia in outpatients?

Answer 20

• Amoxicillin 40-90mg/kg/day divided TID

Question 21

What is empiric therapy for inpatient pneumonia?

Answer 21

• Ampicillin 200mg/kg/day div Q6H

Question 22

How to manage pneumonia in kids with respiratory failure or shock?

Answer 22

• 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

Question 23

How to broaden antibiotic coverage if a child develops pneumatoceles or progressive multilobar disease?

Answer 23

• Add vancomycin to provide additional coverage for MRSA until cultures become available

Question 24

What to do if cultures are all negative?

Answer 24

• Step down to ampicillin followed by PO amox

Question 25

How would your management change if a patient developed an empyema?

Answer 25

• Antimicrobial choices would stay the same as most empyemas are caused by strep pneumoniae

Question 26

What is recommended therapy for strep pneumo that is susceptible to penicillin?

Answer 26

• Penicillin G 200,000-250,000U/day divided Q4-6h (max 24 million U/day)

Question 27

What is the rolf of antimicrobials in treating mycoplasma or chlamydophila?

Answer 27

• 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

Question 28

What to do if there is no improvement within 48-72h?

Answer 28

• Repeat imaging to rule out empyema or pleural effusion that has developed in the interim

Question 29

What is the duration of treatment for CAP?

Answer 29

• 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

Question 30

What to give if a patient previously developed a non urticarial rash with penicillin/amox?

Answer 30

• 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

Question 31

When do we expect pneumonia to improve?

Answer 31

48 hours after starting abx

If not find out why (CXR)