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

Question 1

By what percentage has the pneumococcal conjugate vaccine decreased radiologically proven pneumonia admission rates in children <5yo?

Answer 1

27%

Question 2

What is pneumonia?

Answer 2

An acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen.
Uncomplicated pneumonia maybe accompanied by small parapneumonia effusions but cannot have empyema, lung abscess or necrotic lung

Question 3

What is the etiology of pneumonia?

Answer 3

Viruses (e.g. RSV, influenza, parainflunza, HMPV) in infants and preschoolers

Streptococcus pneumoniae

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Haemophilus influenzae type b (rare since vaccine)

GAS (less common)

Staphylococcus aureus (less common)

Question 4

What are symptoms of pneumonia?

Answer 4

1. Fever
2. Cough
3. Difficulty breathing
4. Poor feeeding
5. Emesis
6. Decreased interest in normal activities
7. Chest or abdominal pain
8. Rigors
9. Malaise and headache 7-10d before fever and cough (Mycoplasma)
10. Diffuse myalgias, fever, cough, sore throat prior (influenza)

Question 5

What are signs of pneumonia?

Answer 5

1. Fever
2. Tachypnea (<2mo >60 2-12mo >50 1-5yo >40 >5yo >30)
3. Work of breathing
4. Hypoxemia
5. Cyanosis
6. Dullness to percussion
7. Increased tactile fremitus
8. Reduced normal vesicular breath sounds
9. Increased bronchial breath sounds
10. Dehydration
11. Sepsis

Question 6

What are the typical patterns of pneumonia on chest imaging?

Answer 6

Lobar consolidation with air bronchograms, nodular opacities = bacterial

Poorly defined patches of infiltrates or atelectasis = viral

Bilateral focal or interstitial infilitrates more extensive = atypical (Mycoplasma, Chlamydia)

Question 7

When is US useful?

Answer 7

Diagnosis of complicated pneumonia

Question 8

What investigations can be done to determine etiology?

Answer 8

1. Sputum C&S >10yo
2. Nasopharyngeal viral testing usu. not indicated
   3, NP specimen for mycoplasma

Question 9

What bloodwork is indicated for children who are hospitalized with pneumonia?

Answer 9

1. CBC + diff

2. Blood culture

Question 10

What are some general indications for pneumonia?

Answer 10

1. Inadequate oral intake
2. Intolerant of oral therapy
3. Severe illness
4. Respiratory compromise
5. Complicated pneumonia
6. Lower threshold for <6mo

Question 11

What is the treatment for pneumonia where influenza is detected?

Answer 11

Neuraminidase inhibitors e.g. oseltamivir, zanamivir

Question 12

What is the treatment for other viral pneumonias?

Answer 12

Manage with supportive care (O2, hydration)

No antibiotics

Question 13

What is the first line therapy for outpatient treatment of community acquired pneumonia?

Answer 13

Amoxicillin 40-90mg/kg/day PO TID (max 4000mg/day) x 5d

Question 14

What is the first line therapy for inpatient treatment of community acquired pneumonia?

Answer 14

Ampicillin 200mg/kg/day IV q6h (max 12g/day) x 7-10d

Question 15

What is the first line therapy for children presenting with respiratory failure or septic shock associated with pneumonia?

Answer 15

Third generation cephalosporin x 7-10d
Ceftriaxone 50-100mg/kg/day IV q12-24h (max 4g/day)
Cefotaxime

Question 16

What organisms do third generation cephalosporins provide better coverage for than ampicillin?

Answer 16

H influenza
High level penicillin resistant pneumococcas
MRSA

Question 17

What is the first line empiric coverage for children with rapidly progressing multilobar disease or pneumatoceles?

Answer 17

Ceftriaxone/Cefotaxime and Vancomycin IV x 7-10d

• discontinue vanco if culture negative

Question 18

What is the coverage for atypical pneumonia?

Answer 18

Azithromycin 10mg/kg on day 1, then 5mg/kg day 2-5 (max 500mg/day) PO/IV
Resistance consider Doxycycline in >8yo

Question 19

What is the recommended duration of therapy?

Answer 19

Hospitalized uncomplicated 7-10d
Outpatient 5d
Empyema or abscess 2-4w

Question 20

What is the recommended therapy for penicillin allergic patients?

Answer 20

If patient experienced non-urticarial rash then give ampicillin/amoxicillin

If patient mild reaction give third generation cephalosporin

If rapid onset of urticaria, angioedema, hypotension, bronchospasm then observe for 30min with accessible epinephrine after first dose of cephalosporin

Clarithromycin or azithromycin are alternative but high resistance rates

If SJS or TEN then give another class of drugs

Question 21

When should clinical improvement occur in uncomplicated pneumonia?

Answer 21

Within 48h of antibiotics

Question 22

What are some reasons for lack of clinical resolution?

Answer 22

1. Complications e.g. empyema, abscess
2. Foreign body aspiration
3. Reactive airway disease with atelectasis
4. Congenital pulmonary anomaly
5. TB
6. Unrecognized immunodeficiency

Question 23

When should radiographic resolution occur in uncomplicated pneumonia?

Answer 23

4-6 weeks