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    Pediatric Community Acquired Pneumonia

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    ggalicinao
    This document provides guidelines for the management of pediatric community acquired pneumonia (PCAP). It outlines criteria for classifying patients into risk groups (A minimal risk to D high risk) based on factors like age, symptoms, and comorbidities. Patients in groups A and B can often be managed as outpatients, while those in groups C and D typically require hospital admission. Diagnostic testing and empiric antibiotic treatment are recommended based on risk classification. Response to treatment and criteria for changing antibiotics are also discussed.

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    Pediatric Community Acquired Pneumonia

    Uploaded by

    ggalicinao
    69 views50 pages
    This document provides guidelines for the management of pediatric community acquired pneumonia (PCAP). It outlines criteria for classifying patients into risk groups (A minimal risk to D high risk) based on factors like age, symptoms, and comorbidities. Patients in groups A and B can often be managed as outpatients, while those in groups C and D typically require hospital admission. Diagnostic testing and empiric antibiotic treatment are recommended based on risk classification. Response to treatment and criteria for changing antibiotics are also discussed.

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    This document provides guidelines for the management of pediatric community acquired pneumonia (PCAP). It outlines criteria for classifying patients into risk groups (A minimal risk to D high risk) based on factors like age, symptoms, and comorbidities. Patients in groups A and B can often be managed as outpatients, while those in groups C and D typically require hospital admission. Diagnostic testing and empiric antibiotic treatment are recommended based on risk classification. Response to treatment and criteria for changing antibiotics are also discussed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    69 views50 pages

    Pediatric Community Acquired Pneumonia

    Uploaded by

    ggalicinao
    This document provides guidelines for the management of pediatric community acquired pneumonia (PCAP). It outlines criteria for classifying patients into risk groups (A minimal risk to D high risk) based on factors like age, symptoms, and comorbidities. Patients in groups A and B can often be managed as outpatients, while those in groups C and D typically require hospital admission. Diagnostic testing and empiric antibiotic treatment are recommended based on risk classification. Response to treatment and criteria for changing antibiotics are also discussed.

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    of 50

    PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

    PNEUMONIA

    Is an inflammation of the parenchyma of


    the lungs

    Most cases of pneumonia are caused by


    microorganism

    noninfectious causes- aspiration of food or


    gastric acid; foreign bodies; hydrocarbons; lipoid substances; hypersensitivity reactions and drug 0r radiation-induced pneumonitis

    Specific risk factors: 1. Lung disease 2. anatomic problems 3. Gastroesophageal reflux disease with
    aspiration

    4. Neurologic disorders that interfere with protection of the airway or compromise clearing of the airway

    5. Diseases that alter the immune system, such immunodeficiency diseases or hemoglobinopathies

    Etiology

    Viral - peak attack is between 2-3 y.o. S.pneumoniae, M.pneumoniae older


    than 5 y.o. other bacterial causes: group A strep, S.pyogenes, Staph aureus, H.influenzae type B

    Clinical manifestation

    Viral and bacterial pneumonias are most


    often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough Viral pneumonia, fever -temp.- is generally lower than bacterial.

    Tachypnea is the most consistent clinical


    manifestation

    Increased working breathing accompanied


    by intercostal retractions, nasal flaring and use accesory muscles

    Bacterial pneumonia in older children


    typically begins suddenly with shaking chill followed by high fever, cough and chest pain

    Predictors of CAP in a Patient with cough

    1. ages 3-5 y.o.- tachypnea and/or chest


    indrawing 2. ages 5-12 y.o. fever, tachypnea & crackles 3. > 12 y.o. fever, tachypnea, tachycardia at least 1 abnormal chest findings ronchi, crackles, wheezes, breath sounds

    Reliable indicators- either tachypnea and/or


    chest indrawing among infants and preschool children Tachypnea is still the best predictor Age specific criteria for tachypnea: 2-12 mos. 50 breaths/min. 1-5 years. 40 breaths/min. > 5 years 30 breaths/min.

    Patients with CAP are 2-3 times more


    likely to have the following signs and symptoms: nasal flaring, grunting, tachypnea, rales and pallor

    Diagnosis of an adolescent suspected to


    have CAP: cough tachypnea (RR .20 breaths/min.) tachycardia (HR .100bpm) fever (temp > 37.8C) at least 1 abnormal chest findings CXR with infiltrates

    Criteria for admission

    A patient who is moderate to high risk to


    develop pneumonia-related mortality should be admitted

    A patient who is at minimal to low risk can


    be managed on OPD basis

    RISK CLASSIFICATION FOR PNEUMONIA-RELATED MORTALITY


    VARIABLES PCAP A Minimal risk
    co-morbid illness
    Compliant care giver Ability to ff-up Presence of dehydration Ability to feed

    PCAP B Low risk


    present
    yes possible mild able

    PCAP C Moderate risk


    present
    no Not possible moderate unable

    PCAP D High risk


    Present
    no Not possible severe unable

    none
    Yes possible none able

    age

    >11 mo.

    >11 mo.

    <11 mo.

    <11 mo.

    VARIABLES PCAP A Minimal risk


    resp rate 2-12mo. 1-5 yrs. >5 yrs. Signs of resp failure a.Retraction b. Head bobbing c. Cyanosis d. Grunting

    PCAP B Low risk

    PCAP C Moderate risk


    >60/min >50/min >35/min

    PCAP D High risk

    >50/min >40/min >30/min

    >50/min >40/min >30/min

    >70/min >50/min >35/min

    none

    none

    Intercostal/su bcostal Present present none

    Supraclavicular/ intercostal/subc ostal

    present

    VARIABLES PCAP A Minimal risk


    Signs of resp failure e. apnea f. sensorium

    PCAP B Low risk

    PCAP C Moderate risk

    PCAP D High risk

    None awake

    None awake none

    None irritable present

    Present Lethargic,stupor ous/comtose

    Complications none

    present

    Action plan

    OPD

    OPD

    Admit to regular ward

    Admit to ICU

    Parameters to be evaluated when


    considering admission: 1. Host factors a. ability to feed b. age c. signs of resp failure d. pulmonary complications

    e. respiratory rate f. state of dehydration g. presence of comorbid factors 2. External factors a. compliant caregiver b. ability to ff-up

    Grunting and apnea are manifestations


    of acute respiratory failure requiring admission to critical care unit

    compared with older children, an infant


    younger than one year has higher risk of contracting sever pneumonia

    Age from 2-11 mos. was associated with


    death

    Presence of retraction on admission was


    the best single predictor of death Subcostal, intercostal, supraclavicular retractions were associated with mortality

    Chest retraction has been considered to


    be an excellent sign for selecting children needing admission for more intensive treatment. Tachypnea, chest retraction, somnolence and young age, chronic illness & malnutrition were independently associated with hospitalization

    Cyanosis and head bobbing corelates well


    with hypoxemia

    Inability to cry, head nodding and a resp


    rate of >60/min. were best predictors of hypoxemia.

    DIAGNOSTICS

    No diagnostic aids are initially requested


    for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D).

    Recommendations for PCAP C & D:


    Routine exams: a. CXR-PA Lateral b. WBC count c. Culture and sensitivity of: blood,pleural fluid, & tracheal aspirate for PCAP D, sputum for older children

    The following should not be requested: 1. ESR 2. C-reactive protein

    ANTIBIOTIC RECOMMENDATION

    1. for patient classified as either PCAP A or B and is a. beyond 2 years of age b. having high grade fever without wheeze 2. For a patient classified as PCAP C and is a. beyond 2 years of age

    b. having high grade fever without wheeze c. having alveolar consolidation in the CXR d. having WBC count > 15,000 3. For a patient classified as PCAP D

    Practice guidelines cited as AGE as the


    best predictor of underlying etiology of pediatric pneumonia

    First 2 years of life VIRUSES are most


    frequently implicated As age increases, bacterial pathogens become more prevalent

    Literature review showed the following


    pattern of microbial etiology: 1. PCAP managed as an outpatient a. bacterial pathogen is more common than a viral pathogen b. Streptococcus pneumoniae is the pathogen in more than half of the patients

    Less common pathogens include M.


    pneumoniae and C. pneumoniae
    2. PCAP managed as an in patient a. bacterial pathogen is more common than a viral pathogen b. S.pneumoniae is the pathogen in little more than half of the patients

    H. influenzae type B should be


    considered in a patient below 5 y.o. who has not completed the primary series of Hib immunization

    certain features that suggest the presence of a bacterial


    and viral pathogen Demonstration of either alveolar infiltrates in CXR or elevated WBC favors bacterial pathogen

    FEATURES
    Fever Wheeze

    Bacterial
    >38.5C absent

    Viral
    <38.5C present

    EMPIRIC TREATMENT

    1. for patient classified as PCAP A or B without


    previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses

    2. for a patient classified as PCAP C w/o


    previous antibiotic & who has completed the primary immunization against H. influenzae type B, Pen G 100,000 u/kg/day in 4 divided doses.

    if a primary immunization against Hib has


    not been completed,and below 5 y.o., IV ampicillin (100mg/kg/day in 4 divided doses

    3. for a patient classified as PCAP D, a


    specialist should be consulted

    INITIAL TREATMENT GIVEN WITH VIRAL ETIOLOGY

    Antiviral agents such as amantadine and


    the newer neuraminidase inhibitors zanamivir and oseltamivir -reduces the duration of illness by 1-1.5 days -to reduce the duration of viral shedding among patients with influenza

    For influenza A infection amantadine


    (4.4-4.8 mg/kg/day) can be given for 3-5 days
    - Discontinue the drug within 24-48 hrs. after resolution of symptoms

    For influenza A or B infection oseltamivir


    (2mg/kg/dose BID) can be given for 5 days

    In case proven epidemics of influenza,


    oseltamivir may be given Its use for treatment & prophylaxis of household contacts has been effective for >12 y.o.

    RESPONSE TO CURRENT ANTIBIOTICS

    1. decrease in respiratory signs


    (tachypnea) & defervescence within 72 hrs. after initiation of antibiotic 2. persistence of symptoms beyond 72 hrs after initiation of antibiotics requires reevaluation

    3. end of treatment CXR, WBC, ESR or


    CRP should not be done to assess therapeutic response to antibiotic

    1. if an out patient classified as either


    PCAP A or PCAP B is not responding to the current antibiotic within 72 hrs. - change the initial antibiotic - start oral macrolide - reevaluate diagnosis

    possibility of penicillin resistant


    S.pneumoniae
    Course of action: change amoxicillin to any of the ff.: cefuroxime, co-amoxiclav, sultamicillin or cepfodoxime

    Possibility of Mycoplasma sp or
    Chlamydia sp.
    Course of action: start an oral macrolide, such as erythromycin

    2. if an inpatient classified as PCAP C is


    not responding to the current antibiotic within 72 hrs. consider consultation with a specialist following possibilities: - penicillin resistant S.pneumoniae - presence of complications

    If an inpatient classified as PCAP D is not


    responding within 72 hrs., consider immediate re-consultation with a specialist

    WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA

    Switch from IV antibiotics to oral form 2-3 days


    after initiation of antibiotic is recommended in patients: a. responding to initial antibiotic therapy b. able to feed with intact GI absorption c. does not have any pulmonary or extrapulmonary complications

    ANCILLARY TREATMENT

    1. cough preparations, chest


    physiotherapy, bronchial hygiene, nebulization using NSS, steam inhalation, topical solution, bronchodilators and herbal medicine are not routinely given

    2. among patients, oxygen and hydration


    should be given if needed

    3. in the presence of wheezing, a


    bronchodilator may be given

    PREVENTION

    1. vaccines recommended by the Phil.


    Pediatric Society should be routinely administered 2. Zinc supplementation

    3. Vitamin A, immunomodulators and


    Vitamin C should not be routinely given

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