Pneumonia

PNEUMONIA IN CHILDREN
IAP UG Teaching slides 2015-16 1

INTRODUCTION
• 156 million new episodes / yr. - worldwide
• 151 million episodes - developing world
• 95% in developing countries
• 19% of all deaths in children <5 years
• 4 million worldwide death

TYPES
•Community acquired (CAP)
•Hospital acquired (Nosocomial)
•Aspiration
•Opportunistic
•Ventilator associated

PROTECTIVE MECHANISMS AGAINST PNEUMONI
• Nasopharyngeal anatomy
• Bronchial division (dichotomous)
• Reflex bronchoconstriction
• Coughing, sneezing
• Mucociliary escalator
• Innate immunity
• Adaptive immunity (humoral, cell-mediated)

COMMUNITY ACQUIRED PNEUMONIA
• Community acquired pneumonia is an acute

infection of the pulmonary parenchyma in a
previously healthy child, acquired outside of a
hospital setting
• The patient should not have been hospitalized

within 14 days prior to the onset of symptoms

RISK FACTORS
Rampant use of Comorbid Pulm. Illnesses

antibiotics Comorbid extra pulm.
Particularly conditions
B-lactames in viral URTIs
Low Birth Weight

Poor Socio Economic
Status
CAP
Lack of Breast Feeding
Immunosuppressed
conditions
Malnutrition, Vit A, D &

Zinc def.
Viral URTIs
Air Pollution & Passive Smoking
HISTORY
• cough (nature )
• Fever, coryza
• Difficulty in breathing
• Feeding
• Activity
• h/o immunization
• h/o antibiotic use
• h/o hospitalization
• h/o pyoderma/ measles
• Recurrent episodes of breathlessness
• Family h/o asthma

CLI
NICAL FEATURES
• Tachypnea
Chest retractions
o• cough (nature )
• IC, SC, sternal
• Poor feeding,
• Pleural /abdominal pain
• Rales, wheeze, grunt
• Thoracoabdominal asynchrony
• Irritability drowsy, cyanosis

DIAGNOSIS
o • Tachypnea( fast breathing) is the simplest
tool to diagnose pneumonia
• Tachypnea with accessory muscles

working = severe pneumonia
sensitivity and specificity (74% and 67% respectively)

o cough (nature )
Age Respiratory rate
< 2 months 60 or more
2 mo up to 12 mo 50 or more
12 mo up to 5 yrs. 40 or more
Tachypnea is the simplest tool to diagnose Community acquired

pneumonia than chest radiography

•Chest radiography
oc •WBC count
•Acute phase reactants
•Sputum
•Blood culture
•Pleural fluid analysis
•Serology/PCR
•Antigen detection
•Broncho alveolar lavage (BAL)
•Transthoracic puncture

DIFFERENTI
AL DIAGNOSIS
•Bronchiolitis
o cough (nature )
•WALRI
•Asthma
•Metabolic acidosis (DKA, CRF)
•Congestive heart failure

CHEST RADIOGRAPHY
• Symptoms are present before radiographic findings
• Poor indicators of aetiology
• Too insensitive to differentiate - bacterial and non-

bacterial
• Inter observer variation
• Useful in exclusion of other diagnoses, complications
• Follow up chest radiography - persistent pneumonia

o cough (nature )
Consolidation- right upper

zone

o cough (nature )
Staphylococcal
Pneumonia

HEMATOLOGICAL TESTS
• Complete blood count -information about the

current infection.
• Leukocytosis (WBC above 16000/ µL) and

leucopenia (WBC below 4000/ µL) - acute
infection.
• CRP - do not help in the diagnosis; useful in

monitoring the disease

NEWER MICROBIOLOGICAL
INVESTIGATIONS
o cough (nature )
•Acute and convalescent sample - where a
microbiological diagnosis was not reached
•Nasopharyngeal aspirates <18 mo for viral antigen

detection in nasopharyngeal aspirates
•Viral antigen detection by immunofluorescence is

highly specific for respiratory syncytial virus,
parainfluenza virus, influenza virus, and adenovirus.

CLUES TO ETIOLOGY OF PNEUMONIA
o cough P redisposing Organism

Factor
Pyoderma, Measles Staphylococcus
HIV Pneumocystis,
Tuberculosis
Neutropenia Gram Negative,
Aspergillus
Cystic Fibrosis Pseudomonas,

Staphylococcus

CLINICAL/INVESTIGATION CLUES
FOR ETIOLOGY
 Preceding coryza- ? Viral
oe)
 Young infant with neonatal conjunctivitis- ?
Chlamydia
 Multisystem involvement (rash, anemia, hepatitis, CNS)

- ? Mycoplasma
 No leukocytosis - viral/ mycoplasma
 Pneumatoceles - Staphylococcus 19
PLEURAL FLUID ANALYSIS
o cough (natur
o Exudative fluid will be :
Purulent
pH <7.1
Glucose<40
Proteins >3g/dl,
LDH >1000 IU/L

COMMON ETIOLOGICAL AGENTS
• Viruses- 35%
• Bacteria- 60% (H influenzae, S pneumonia, Staph)
• Mycoplasma - 24-30% ( more in above 5 years)
• Chlamydia- 6-11%
• Mixed infections- 9%

VIRUSES BACTERIA
Respiratory Syncytial
Influenza Streptococcus Pneumonia
Parainfluenza Haemophilus Influenza
Adenovirus
Group A Streptococcus
Rhinovirus
Corona Virus Staphylococcus Aureus
Human Metapneumovirus

COMMON AGE RELATED PATHOGENS IN CAP
Gram Negative (E coli, Klebsiella)
0 - 3 months Chlamydia trachomatis
Viruses
S. Pneumoniae
Viruses
S. pneumoniae
3 months- 5 years H. influenzae
Staphylococcus
Mycoplasma pneumoniae
S. pneumoniae
Mycoplasma pneumoniae
> 5 years Staphylococcus
Viruses
S. pyogenes
ANTIBIOTICS
• All pneumonias deserve antibiotics
• Differentiation between viral & bacterial difficult
• Identification of causative organism usually not
possible
• Choice of antibiotics is empirical
• Antibiotics depends on -
• Age, Severity, Predisposing conditions
IAP UG Teaching slides 2015-16 24 24

ANTIBIOTICS FOR OUTPATIENTS
Age First Line Second line
3 mo- 5 yrs. Amoxicillin Coamoxiclav/

(30-50 mg/kg/day) Chloramphenicol
> 5 years Amoxicillin Macrolide/

coamoxyclav/
chloramphenicol
< 3 months tr
eat as inpatients
ANTIBIOTICS FOR INPATIENTS(IM/IV)
Age First Line Second line
< 3 months Cefotaxime/ Ceftriaxone +/- aminogly
3 months- 5 Coamoxyclav OR Coamoxyclav/

years Amp + Chloro Ceftriax/ Cefotax
> 5 years Ampicillin/ Coamoxiclav/
Chloramphenicol/ Ceftriaxone/ Cefotax
Coamoxyclav/ AND
Macrolide (if Macrolides
mycoplasma suspected)
26
SUSPECTED STAPHYLOCOCCAL
PNEUMONIA
• Inj 3rd Gen Cephalosporins: Cefotaxime/Ceftriaxone
• + Cloxacillin
• OR
• Inj Cefuroxime
• OR
• Inj Co-amoxyclavulinic acid
• Second line: Vancomycin/ Teicoplanin

• +
• Inj 3rd Gen Cephalosporins
2016-4-7 27 27
Thank You

Pneumonia

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PNEUMONIA IN CHILDREN

IAP UG Teaching slides 2015-16 1

• 156 million new episodes / yr. - worldwide

• 151 million episodes - developing world

• 95% in developing countries

• 19% of all deaths in children <5 years

• 4 million worldwide death

IAP UG Teaching slides 2015-16 2

•Community acquired (CAP)

•Hospital acquired (Nosocomial)

IAP UG Teaching slides 2015-16 3

IAP UG Teaching slides 2015-16 4

• Community acquired pneumonia is an acute

• The patient should not have been hospitalized

IAP UG Teaching slides 2015-16 5

Rampant use of Comorbid Pulm. Illnesses

Low Birth Weight

Malnutrition, Vit A, D &

IAP UG Teaching slides 2015-16 7

IAP UG Teaching slides 2015-16 8

• Tachypnea with accessory muscles

IAP UG Teaching slides 2015-16 9

Tachypnea is the simplest tool to diagnose Community acquired

IAP UG Teaching slides 2015-16 10

IAP UG Teaching slides 2015-16 11

•Metabolic acidosis (DKA, CRF)

•Congestive heart failure

IAP UG Teaching slides 2015-16 12

• Symptoms are present before radiographic findings

• Poor indicators of aetiology

• Too insensitive to differentiate - bacterial and non-

• Useful in exclusion of other diagnoses, complications

• Follow up chest radiography - persistent pneumonia

Consolidation- right upper

IAP UG Teaching slides 2015-16 14

IAP UG Teaching slides 2015-16 15

• Complete blood count -information about the

• Leukocytosis (WBC above 16000/ µL) and

• CRP - do not help in the diagnosis; useful in

IAP UG Teaching slides 2015-16 16

•Nasopharyngeal aspirates <18 mo for viral antigen

•Viral antigen detection by immunofluorescence is

IAP UG Teaching slides 2015-16 17

o cough P redisposing Organism

Cystic Fibrosis Pseudomonas,

IAP UG Teaching slides 2015-16 18

 Multisystem involvement (rash, anemia, hepatitis, CNS)

 No leukocytosis - viral/ mycoplasma

LDH >1000 IU/L

IAP UG Teaching slides 2015-16 20

• Bacteria- 60% (H influenzae, S pneumonia, Staph)

• Mycoplasma - 24-30% ( more in above 5 years)

IAP UG Teaching slides 2015-16 21

IAP UG Teaching slides 2015-16 22

IAP UG Teaching slides 2015-16 24 24

Age First Line Second line

3 mo- 5 yrs. Amoxicillin Coamoxiclav/

> 5 years Amoxicillin Macrolide/

< 3 months Cefotaxime/ Ceftriaxone +/- aminogly

3 months- 5 Coamoxyclav OR Coamoxyclav/