lecture

2. Pneumonia
Schidlow DV, 1996

3. Child with Pneumonia

4. Introduction
Ostapchuck M et al, 2004;Greenberg D et al, 2005; McIntosh K, 2002

5. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

6. Introduction
Developing country 
± 60% pneumonia cases
caused by bacterial
 antibiotic.
In developed country
 mostly viral
Alberta Medical Association, 2001; Jadavji T et al,1997

7. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

8. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

9. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

10. Introduction
• Recent research showed
that antibiotic regimen
in WHO guidelines has
reduced 50% mortality
in developed country,
but there’s also excessive
use of antibiotics (75%)
Shann F et al, 1999
Need a guidelines for a
Rational use of antibiotics.

11. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

12. Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997

13. Antibiotics for Non Severe
Pneumonia
Ostapchuck M et al, 2004;Greenberg D et al, 2005

14. Antibiotics for Non
Severe Pneumonia
Ostapchuck M et al, 2004; McIntosh K, 2002

15. Antibiotics for Non Severe
Pneumonia
Alberta Medical Association, 2001

16. Antibiotics for Non
Severe Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT
2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007

17. Antibiotics for Non
Severe Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT
2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007

18. Antibiotics for Non Severe
Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP
study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007, CATCHUP study group
2002

19. Antibiotics for Non Severe
Pneumonia
Kabra SK et al. 2009

20. Antibiotics for Non Severe
Pneumonia
Kabra SK et al. 2009

21. Antibiotics for Non Severe
Pneumonia
Guidelines from The British Thoracic Society
(2002):
• For children < 5 years old: first line drugs is
amoxicillin (well tolerated, not expensive)
The British Thoracic Society, 2002
Alternative antibiotics:
co-amoxiclav, cephachlor,
eritromycin, Chlaritromycin,
and azitromycin

22. Antibiotics for Non Severe
Pneumonia
Guidelines , The British Thoracic Society, 2002:
• In children > 5 years old most common
organism is M. Pneumoniae
• First line drugs is macrolide
The British Thoracic Society, 2002
If S. pneumoniae suspected  amoxicillin
If S. aureus suspected  macrolide or
combination of flucloxacillin and amoxicillin

23. Antibiotics for Non Severe
Pneumonia
Monotherapy is
recommended.
National Guideline Clearinghouse, 2006

24. Antibiotics for Non Severe
Pneumonia
National Guideline Clearinghouse, 2006

25. Follow Up
• Evaluation performed after
24-72 hours of treatment, if
no improvement  change
antibiotics
National Guideline Clearinghouse, 2006
Signs of improvement:
Decrease respiratory rate
Lower fever
Appetite improvement

26. Indication for Admission
Alberta Medical Association, 2001; WHO , 2008

27. Indication for Admission
Alberta Medical Association, 2001; WHO , 2008

28. Antibiotic for Admitted
Pneumonia
Fonseca W, 2003; Pakistan MASCOT,
2002

29. WHO, 2005
Antibiotic for Admitted
Pneumonia

30. Antibiotic for Admitted
Pneumonia
Guideline for the Management of Community
Acquired Pneumonia in childhood:
The British Thoracic Society, 2002
As therapy begin, the organism
causing pneumonia is unknown.
Treatment based on age and specific
symptoms for specific pathogen.

31. 0-8 Weeks
Enarson PM, 2005

32. 2-59 Months
Enarson PM, 2005

33. Other Study

34. Macrolide

35. Cephalosporins and Non
Cephalosporins

36. Cephalosporins
• A randomized controlled trial compared
3rd generation of cephalosporins and
Cephachlor  no differences
(Paupe J, et all, 1992 )

37. Table 1. Therapeutic management of pneumonia
Patient age Outpatient Inpatient Critically ill
Birth to
20 days
Admit Ampicillin IV or IM:
Age <7 days:
Weight <2 kg (4.4 lb): 50 to
100 mg per kg per day in
divided doses every 12
hours
Weight ≥2 kg: 75 to 150 mg
per kg
per day in divided doses
every 8 hours
Ampicillin IV or
IM, in same
dosages as for
inpatients
plus
Gentamicin IV or
IM, with or
without cefotaxime
IV, in same
dosages as for
inpatients
Ostapachuk, M,.2004

38. Patient age Outpatient Inpatient Critically ill
Birth to
20 days
Admit Ampicillin IV or IM:
Age ≥7 days:
Weight <1.2 kg (2.6 lb): 50 to
100
mg per kg per day divided every
12 hours
Weight 1.2 to 2 kg: 75 to 150 mg
per
kg per day in divided doses every
8 hours
Weight >2 kg: 100 to 200 mg per
kg per day in divided doses every
6 hours
Table 1. Therapeutic management of pneumonia
Ostapachuk, M,.2004

39. Patient
age
Outpatient Inpatient Critically ill
Birth to
20 days
Admit plus
Gentamicin IV or IM:
≥37 weeks of gestation
And Age zero to 7 days: 2.5 mg per kg
every 12 hours
Age >7 days: 2.5 mg per kg every
8 hours
with or without
Cefotaxime (Claforan) IV:
Age ≤7 days: 100 mg per kg per day in
divided doses every 12 hours
Age >7 days:
150 mg per kg per day in divided doses
every 8 hours
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia

40. Patient
age
Outpatient Inpatient Critically ill
3 weeks
to
3 months
If patient is afebrile:
Azithromycin
(Zithromax),
10 mg per kg orally
on day 1, then 5 mg
per kg per day on
days 2 through 5
or
Erythromycin, 30 to
40 mg per kg per day
orally in divided
doses every 6 hours
for 10 days
Admit if patient is
febrile or
hypoxic.
Erythromycin, 40 mg per
kg per day IV in
divided doses every 6
hours*
If patient is febrile, add
one of these agents:
Cefotaxime, 200 mg per
kg per day IV in divided
doses every 8 hours*
or
Cefuroxime (Ceftin), 150
mg per kg per day IV in
divided doses every
8 hours*
Cefotaxime, 200
mg per kg per day
IV in divided doses
every 8 hours
plus cloxacillin
(Tegopen), 150
to 200 mg per kg
per day IV in
divided doses every
6 hours*
or
Cefuroxime alone,
150 mg per kg
per day IV in
divided doses every
8 hours*
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia

41. Patient
age
Outpatient Inpatient Critically ill
4 mo to
5 years
Amoxicillin, 90 mg per
kg per day orally in
divided doses every 8
hours for 7 to 10 days
Consider initial dose of
ceftriaxone
(Rocephin),
50 mg per kg per day
IM, up to 1 g per day.
Follow with oral
therapy for full course.
Alternatives:
amoxicillin clavulanic
acid (Augmentin),
azithromycin, cefaclor
(Ceclor),
clarithromycin
(Biaxin),
erythromycin
Cefotaxime, 150
mg per kg per day
IV in divided doses
every 6 hours*
or
Cefuroxime, 150
mg per kg per day
IV in divided doses
every 8 hours*
If the patient has
pneumococcal
infection:
Ampicillin alone,
200 mg per kg per
day IV in divided
doses every 8
hours*
Cefuroxime, 150 mg per
kg per day IV in divided
doses every 8 hours,
plus erythromycin, 40
mg per kg per day IV or
orally in divided doses
every 6 hours for 10 to
14 days*
or
Cefotaxime, 200 mg per
kg per day IV in divided
doses every 8 hours,
plus cloxacillin, 150 to
200 mg per kg per day IV
in divided doses every 6
hours for 10 to 14 days
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia

42. Table 1. Therapeutic management of pneumonia
Patient
age
Outpatient Inpatient Critically ill
5 years
and older
Azithromycin, 10 mg per
kg (maximum of 500 mg)
orally on day 1, followed
by 5 mg per kg per day on
days 2 through 5
Or Clarithromycin, 15 mg
per kg per day orally in
divided doses every 12 hours
for 7 to 10 days
Or Erythromycin, 40 mg per
kg per day orally in divided
doses every 6 hours for 7 to
10 days
If the patient has
pneumococcal infection:
Amoxicillin alone, 90 mg
per kg per day orally in
divided doses every 8 hours
Cefuroxime, 150
mg per kg per day
IV in divided doses
every 8 hours
plus
Erythromycin, 40
mg per kg per day
IV or orally in
divided doses
every 6 hours for
10 to 14 days
If pneumococcal
infection is
confirmed:
Ampicillin alone,
200 mg per kg per
day IV in divided
doses every 8
hours
Cefuroxime, 150
mg per kg per day
IV in divided doses
every 8 hours
plus
Erythromycin, 40
mg per kg per day
IV or orally in
divided doses every
6 hours for 10 to 14
days
Ostapachuk, M,.2004

43. Follow Up
• Every 6 hours or at
least once a day
• Observations consist
of respiratory rate,
temperature, level of
consciousness and
feeding
National guidelines Clearinghouse, 2006
Amelioration signs :
•Decreasing of
respiratory rate
•No chest indrawing
•Lowering of fever
•Better appetite

44. Follow Up cont’
• Rules of hospital discharge :
– Adequately consumes oral antibiotics
– Antibiotic therapy can be done at home
– Family agree and understand the
management at home
– Support from environment for the therapy
– Family should take their child to the
clinician for next examination
Ostapachuk, M,.2004

45. Pitfalls Management of
Pneumonia in Children
• Chest x-ray should not routinelly done in
children with mild pneumonia. (A)
• Evaluation of chest x-ray only performed if
no improvement or there is worsening. (C)
Enarson M, 2006The British Thoracic Society,2002

46. Pitfalls Management of
Pneumonia in Children
• Antibiotics administration empirically
often inappropriate with the etiology 
overused antibiotics . Amoxycillin is the
first line antibiotic for pneumonia.
Alternatives  co-amoxyclav, cephachlor,
erytromycin clarytromycin and
azytromycin . (B)
Enarson M, 2006The British Thoracic Society,2002

47. Pitfalls Management of
Pneumonia in Children
• Nasogastric tube should not be applied in
severe pneumonia (D)
• Every pneumonia patient has to be
monitored for oxygen saturation. (A)
• Children with oxygen saturation below
92% must given oxygen therapy with
nasal canule, head box, or facial mask, to
keep the saturation above 92%. (A)
The British Thoracic Society,2002

48. Pitfalls Management of
Pneumonia in Children
• Intravenous fluid administered for 80%
from daily requirement and electrolyte
examination must be done in severe
pneumonia. (C)
• Chest physiotherapy is not always useful
(B)
The British Thoracic Society,2002

49. Study design Evidence
level
Recomendation
Advance systematic study Ia A+
One or more good study Ib A-
One or more prospective study II B+
One or more retrospective
study
III B-
Experts’ assumption formally Iva C
Experts’ assumption informally
or other information
IVb D
Table 2 . Evidence Level and Recommendation
The British Thoracic Society, 2002

50. CONCLUSION
• Antibiotic administration is a challenge for clinician in the
management of pneumonia
• Some pneumonia caused by viral infection
• As we decide to give antibiotic, we must consider which
antibiotic should be used (broad spectrum or narrow
spectrum)
• First  give antibiotic empirically based on children age
• Second  observe within 24-72 hours
• All of the steps above are useful to prevet pittfalls in the
management of pneumonia

51. Cochrane Database of
Systematic Review 2008
To determine the equivalence in effectiveness and safety
of oral antibiotics compared to parenteral antibiotics
Oral Antibiotics vs Parenteral Antibiotics for
Severe Pneumonia
Rojas-Reyes MX, Rugeles CG, 2006

52. Cochrane Database of
Systematic Review 2008
Published or unpublished randomized controlled trials
(RCTs) comparing any oral and parenteral antibiotic
 children 3 months to 5 years
Oral therapy  effective and safe alternative to
parenteral antibiotics in hospitalized children
Rojas-Reyes MX, Rugeles CG, 2006

53. Cochrane Database of
Systematic Review 2008
Short –course vs Long-course antibiotic therapy
for non-severe community-acquired
pneumonia
Results:
Analysis of three days of treatment with the same
antibiotic non significant differences in clinical
cure, treatment failure, and relapse rate after
seven days of clinical cure
Haider BA, Saeed MA, Bhutta ZA, 2007

54. Cochrane Database of
Systematic Review 2008
Conclusion
A short course (3 days) of antibiotic
therapy is as effective as a longer
treatment (5 days) for non severe
pneumonia in children under five years
of age.
Haider BA, Saeed MA, Bhutta ZA, 2007

55. Cochrane Database of
Intervention Review
To identify effective antibiotic drug therapy
for community acquired pneumonia in
children by comparing various
antibiotics.
Antibiotics for CAP in Children
Kabra SK, Lodha R, Pandey RM, 2009

56. Cochrane Database of
Intervention Review
• Cotrimoxazole is inferior to amoxycillin and
prokain penicillin
• Penicillin in conjunction with gentamycin
better than chloramphenicol alone.
• Co-amoxyclavulanic acid was better than
amoxycillin alone
• No difference between injectable penicillin and
oral amoxycillin
Kabra SK, Lodha R, Pandey RM, 2009

57. Cochrane Database of
Intervention Review
No differences between
• Injectable penicillin and oral amoxycillin
• Azithromycin and erythromycin
• Cefpodoxime and amoxycillin
• Azithromycin and co-amoxyclavulanic
acid.
Kabra SK, Lodha R, Pandey RM, 2009

58. Conclusion
Ambulatory patients
• Amoxycillin was better than co-trimoxazole
• No difference between azithromycin and
erythromycin
• No difference between cefpodoxime and co-
amoxyclavulanic
Cochrane Database of
Intervention Review
Kabra SK, Lodha R, Pandey RM, 2009

59. Cochrane Database of
Intervention Review
• Hospitalized patients
• Procain penicillin was better than
cotrimoxazole
• Penicillin + gentamycin better than
chloramphenicol alone
• Injectable penicillin and oral amoxycillin
similar failure rates
Kabra SK, Lodha R, Pandey RM, 2009

60. Cochrane Database of
Intervention Review
Over-the-counter (OTC) medications to reduce
cough as an adjunct to antibiotics for acute
pneumonia in children and adults
To evaluate the efficacy of OTC cough
medications as an adjunct to antibiotics in
children and adults with pneumonia
Chang CC, Cheng AC, Chang AB, 2009

61. Cochrane Database of
Intervention Review
• Insufficient evidence to decide whether
OTC medications for cough associated with
acute pneumonia are beneficial.
• Mucolytics may be beneficialinsufficient
evidence
• Codeine and antihistamines should not be
used in young children
Chang CC, Cheng AC, Chang AB, 2009

62. Buku saku pelayanan
kesehatan anak di
rumah sakit rujukan
tingkat pertama di
kabupaten/kota

63. Technical updates
of the guidelines on
the Integrated
Management of
Childhood Illness
(IMCI)