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Community acquired Pneumonia

       Dr Yog Raj Khinchi
Introduction
• Pneumonia, especially CAP has
  been a subject of challenge to the
  medical fraternity despite
  extensive research since
  ‘Antiquity’
Introduction – Contd..
• It is tragedy that in this era of easy
  vaccine availability millions of
  children die across the globe,
  particularly in developing countries
  due to vaccine preventable ‘Lower
  Respiratory Tract Infections’
Pneumonia

Congenital

             Acquired

                          Opportunistic
                                          Aspiration


Nosocomial     Community Acquired Pneumonia (CAP)
Definition - CAP

Pneumonia acquired outside the
hospital environment by an
immunocompetant healthy child
Disease Burden - CAP
• Global Scenario :

 - 100 million cases per year < 5 yrs
 - 80% OPD cases with 1% mortality
 - 20% IPD cases with 10 -12 % mortality
 - 2 – 2.3 million deaths / year, 90% in
   developing countries
Disease Burden – CAP Indian Scenario :

CAP contributes                                       13% of deaths


(< 5 years of age)                       24% National Burden of Disease (NBD)


                                 7.5 million total cases


                 .37 to .46 million deaths per year.


[Estimates on different studies done at Delhi – Pune – Kolkatta – Varanasi –

Rajasthan – Maharashtra - Haryana & Tripura [Source S.K.Kabra - National consensus

on child survival & development]
Risk Factors
                                Comorbid Pul. Illnesses
                                                                     Comorbid extra pul.
Rampant use of antibiotics                                              conditions
        particularly
 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

 [Study by Burman et al -Epidemiology of ARI in children of developing countries Rev.
                                  Inf. Dis. (1991)
Q : Do I need to chase an aetiological diagnosis
   in CAP before starting antimicrobial treatment??

                        A : NO !

                       Q : WHY ?

A : It is not only “difficult” but often “not possible” to
      document Aetiological factor by lab diagnostics
                            (> 60%)
                            THM:
    It is Prudent and Rational to start “Emperical
Antimicrobial” therapy before establishing microbial
                          aetiology
        Diagnosis per se is always - almost clinical
Diagnosis
   Q : Then how do I make the diagnosis ?

A : Clinically – Triad of fever, cough, tachyponea
                      With or without
               Chest pain, Sputum, Grunting,
              Crackles, Bronchial breathing,
            ↑ Vocal fremitus, Feeding difficulties,
                 Chest recession, Cyanosis.

   WHO ARI Control Program  Tachyponea most
                              sensitive sign
         New borns            > 70/min
         Infants (upto 2 yrs) > 50/min
           Children (> 2 yrs)  > 40/min
Diagnosis
Q : Does ancillary lab investigations support the
  diagnosis ?
A : Yes ! to some extent
 Non invasive & easily   Non invasive but not easily   Invasive & not cost
      accessible                accessible                  effective
         CBC                       X-rays                     BAL
         ESR                    Blood culture             Lung Biopsy
         CRP             Sputum and gastric aspirate        CT Scan
                                  culture
          Mx                      Serology                    PCR
Gram stain of sputum &           Pleural Tap             Rapid Antigen
   naso pharyngeal                                       detection test
      secretions

Less specific            Some what specific                    More
  specific
Q : How do I decide whether it is bacterial or
 viral ?

A : There are no definite markers to
   differentiate between bacterial or viral.
Features suggestive of bacterial pneumonia :
•   Fever > 38.5oC. Toxic look
•   Respiratory rate > 50 breaths / min
•   Chest recession (Respiratory distress)
•   Radiologically Lobar consolidation, Segmental consolidation
    and Round consolidation.
Features suggestive of viral
               pneumonia
•   Infants and young children
•   Fever < 38.5oC
•   Mucosal congestion
•   Wheeze
•   Hyperinflation
•   Marked recession
•   Respiratory rate normal or raised
•   Radiologically Hyperinflation, Diffuse
    infilterates & Segmental collapse.
Features suggestive of Pneumonia by
         Atypical organisms
•   School Age children
•   Cough
•   Wheeze
•   Chest pain
•   Respiratory distress
•   Anemia and reticulo cytosis
•   Radiologically Lobar consolidation and hilar
    adenopathy, Interstitial infiltrates
CAP
THM:
1. ‘S pneumoniae’ is the commonest causative
   organism of CAP in Infancy & childhood,
   accounting for 1 million deaths annually out of a
   total 1.9 million estimated deaths, particularly in
   developing countries.
2. Viruses are commonest cause in infants and young
   children (14-35% of CAP)
3. Significant proportion of CAP is due to mixed
   infections (8-40%)
4. In 20-60% cases pathogen is not identified.

 Source – British Thoracic Society guidelines for the diagnosis and management of
                    Community Acquired Pneumonia in children.
Q : What are other ‘Clues’ and ‘Parameters’ to
              catch aetiologocal diagnosis ?
‘CLUES’              Associated co-morbid conditions
      Otitis media              S pneumoniae
   Purulent sinusitis              S pneumoniae
     Pyoderma                         S aureus
     Empyema                          S aureus
     Measles                          S aureus
    Watery rhinorrhoea                         viral
 Meningitis                      S Pneumonia / HIB
Parameters : Age is a good predictor of the likely pathogens



          Pathogens in infants < 3 months

               . Group B Steptococcus

     Gram negative enterococci & klebseilla

                     Staph aureus

               Chlamydia trachomatis
Pathogens in Children 3 months to 5
             yrs of age

• More Common : - ‘S’ pneumoniae
              - Viruses (RSV, PIV3,
  Adenovirus)
              - H influenzae b

 Less Common :     - M.catarrhalis
             - Staph aureus
             - Group A streptococci
Pathogens in Children > 5 yrs of age
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Streptococcus pneumoniae
• Leigonella species
Diagnostic Difficulties
1. No specific markers to differentiate viral from
   bacterial.
2. Sputum samples are not often obtainable
3. Nasopharyngeal secretions are unreliable due to
   high asymptomatic carriage rates.
4. Some common organisms like M pneumoniae, C
   pneumoniae & H influenzae cannot be cultured
   easily.
5. Bactec culture facilities are not available
   everywhere
6. Invasive tests which are more specific are not
   practical in practice and are not cost effective.
7. Infection may be polymicrobial
Q : How do I manage a case of CAP ?
             Principles of Management

   a) Evaluation                    Diagnosis

                   Grading of severity

                    Mode of management

b) Stabilization          Supportive treatment

                         ICU Management

   c) Specific Agents         Antimicrobials
Severity Assessment
        Mild                              Moderate              Severe
   OPD Management                     IPD Management       ICU Management

            Indicators                    Indicators       Indicators
Fever < 38.5oc,                 Fever > 38.5oc on two   Altered sensorium
Mild cough                      occ. at 8 hrs apart     Cyanosis / Pso2 < 92
R.R< 50 / min                   Moderate to severe      Pao2 < 60%
No dehydration,                 cough                   Pco2 > 40%
Adequate intake                 Tachyponea              pH > 7.3
                                R.R.> 50 / min          Systolic BP<60 mmHg
                                Resp. distress          BUN > 20 mg%
                                Pso2 92%                Exp. Grunt
                                Grunting                Severe Resp. Distress
                                Refusal of feeds &
                                dehyderation


     As per BTS & ATS guidelines on CAP management
Mode of Management
A) OPD       - Appropriate oral Antibiotics for 3-5 days
             - Analgesics & Antipyretics
             - Symptomatic
B) IPD       - IV antibiotics for 3 - 5 days – switch to oral
             - IV fluid therapy & Electrolyte maintenance
             - Pulse oxymetry monitoring
             - Maintenance of Nutrition
             - Oxygen if required
C) ICU       - All of the above + ABG monitoring +
     Ventilatory life support if required
Specific Antimicrobials


Which antibiotic ? Which Route ?
Duration ? When to switch to oral?


 “Age is a good predictor of the likely

  pathogen & choice of antibiotic is

  based on suspected pathogen”
CAP Treatment
   AGE       OPD                 IPD                          ICU
Birth to 3         IV Ampicillin / Amoxycillin   IV Ampicillin / Amoxycillin
months             100-200 mg / kg / day                    +
                                                 IV Aminoglycoside
                            +
                   IV Aminoglycoside
                                                    with or without
                       with or without
                                                 IV Ceftazidime
                   3rd Generation Cefalosporin   50-100 mg / kg / day
                   100-150 mg / kg / day                 or
                                                 Vancomycin / Teicoplanin
                                                    10- 15 mg / kg / day
                                                            or
                                                 Imipenem / Meropenem
                                                            or
                                                 Pipracillin / Tazobactum
CAP Treatment
  AGE            OPD                      IPD                      ICU
3 months Oral Amoxycillin     IV Amoxycillin          IV Ampicillin + Cloxacillin
to 5 yrs 50-100 mg/kg/day     100-200 mg / kg / day   200 mg/kg/day
                or                                          or
          Co-amoxiclav           with or without      IV B-Lactames
          50-100 mg/kg/day                            a) co-amoxiclav
                or            a) Cefotaxime           b) Cefuroxime
          Cefaclor            100-150 mg/kg/day       c) Ceftriaxone
          25-30 mg/kg/day     b) Ceftriaxone
                or            100-150 mg/kg/day           with or without
          Cefuroxime                 or
          15-25 mg/kg/day     B-Lactames              Aminoglycoside
            And / Or          a) Co-amoxiclav              or
          Macrolide           100-150 mg/kg/day       Vancomycin / Teicoplanin
          a)Azithromycin      b) Cefuroxime
          10mg/kg/day         50-100 mg/kg/day
          b) Clarithromycin   with or without
          15mg/kg/day         Oral Macrolide
CAP Treatment
  AGE            OPD                        IPD               ICU
> 5 yrs   Oral Amoxycillin    IV Co-amoxiclav     IV Co-amoxiclav
          60-90 mg/kg/day     100 mg / kg / day   100-150 mg/kg/day
                                                             +
               and / or          and / or         IV Ceftriaxone
                                                  100-200 mg/kg/day
          Macrolide           IV Cefuroxime                  +
          a) Azithromycin     100-150 mg/kg/day   IV Macrolide
          10mg/kg/day                                        or
          b) Clarithromycin   with or without     IV Fluroquinolone
          15 mg/kg/day                            (Newer anti Pneumococcal)
                or            IV Cefotaxime
          c) Doxycycline      100 mg/kg/day
          (> 8 yrs)
          5 mg / kg / day     with or without

                              Oral macrolide
Failure of clinical response !!
                What should I Do ?
A) Check the diagnosis
   May be wrong diagnosis       - Aspiration Pneumonia
                                   - Interstitial Lung Disease
                                   - Tuberculous Pneumonia
                                   - Foreign body Aspiration
B) Look for underlying
cardio pulmonary conditions like : - Lung Abscess
                                     - Empyema
                                     - Cystic Fibrosis
                                     - Bronchiectasis
                                     - L-R shunt
                                     - GERD
                                     - Asthma
Failure of clinical response !!               Cont’d…..
                   What should I Do ?
C) Immunosupression in host       - PCP Pneumonia
                                   - Fungal Pneumonia
                                   - Pseudomonal Pneumonia

D) Think for drug resistance       - Child from day care centre
   (DRSP/ B-Lactamase producing - Use of corticosteroids &
     organisms)                   - B-Lactames in previous
                                1 month

E) Possibility of                    Viral + Bacterial
   Polymicrobial Aetiology                 or
                                  Bacterial + atypical Bacterial
Q : What complications can I
    expect if not treated properly ?
•   Empyema
•   Pneumothorax
•   Lobar Atelectesis
•   Septicemia
•   Bronchogenic dissemination
•   Osteomylitis
•   Septic Arthritis
•   Multiple Systemic Abscesses
•   Meningitis etc…
Q : How should I follow up & should I chase for
    follow up x-rays ?
                      “NO”
-   Follow up should be clinical for 3-4 weeks
-   No chase for follow up x-rays except in case of -
    Lobar collapse
    - Round Pneumonia
    - Symptomatic child
                       Radiographic resolution
                            56% - 2 weeks
                            74% - 4 weeks
                            98% - 6 weeks
Q : How can I contribute in prevention of
    CAP in community ?

i)   Promotion of Immunisation – Measles, Influenza,
     HIB & Pneumococus vaccines
ii) Prevention of passive smoking & air pollution
iii) Judicious use of corticosteroids & antibiotics
     particularly B-Lactams)
iv) Supplementation of Vit A, Vit D & Zinc
v) Promotion of Breastfeeding & demotion of bottle
     feeding
vi) Treatment of malnutrition
Key points
1. Aetiological diagnosis in CAP is not only difficult
   but not always possible (>60%)
2. Emperical Antimicrobial therapy is ‘Rational’ &
   ‘Prudent’
3. Age is a good predictor of likely pathogens
4. Streptococcus pneumoniae is the most common
   cause of CAP in childhood followed by viruses
5. Chest radiography though supports the diagnosis
   – is poor indicator of aetiology.
6. Followup x-rays are not required unless in special
   circumstances
Key Points – Contd..
7.  Acute phase reactants do not distinguish between viral &
    bacterial infections
8. Pulse oxymetery monitoring should be performed in every
    admitted child with CAP.
9. Blood cultures though desirable yields only 10-20%
    positivity.
10. Amoxycillin is the drug of choice for CAP from infancy to
    adolescent alternatives are co-amoxiclav, cefuroxime or
    macrolide
11. Child remaining febrile & symptomatic for more than 48-
    72 hrs after hospitalization should be re-evaluated for
    complications, underlying comorbid conditions, co-mimics,
    immunosuppression or drug resistance.

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3 community acquired pneumonia

  • 1. Community acquired Pneumonia Dr Yog Raj Khinchi
  • 2. Introduction • Pneumonia, especially CAP has been a subject of challenge to the medical fraternity despite extensive research since ‘Antiquity’
  • 3. Introduction – Contd.. • It is tragedy that in this era of easy vaccine availability millions of children die across the globe, particularly in developing countries due to vaccine preventable ‘Lower Respiratory Tract Infections’
  • 4. Pneumonia Congenital Acquired Opportunistic Aspiration Nosocomial Community Acquired Pneumonia (CAP)
  • 5. Definition - CAP Pneumonia acquired outside the hospital environment by an immunocompetant healthy child
  • 6. Disease Burden - CAP • Global Scenario : - 100 million cases per year < 5 yrs - 80% OPD cases with 1% mortality - 20% IPD cases with 10 -12 % mortality - 2 – 2.3 million deaths / year, 90% in developing countries
  • 7. Disease Burden – CAP Indian Scenario : CAP contributes 13% of deaths (< 5 years of age) 24% National Burden of Disease (NBD) 7.5 million total cases .37 to .46 million deaths per year. [Estimates on different studies done at Delhi – Pune – Kolkatta – Varanasi – Rajasthan – Maharashtra - Haryana & Tripura [Source S.K.Kabra - National consensus on child survival & development]
  • 8. Risk Factors Comorbid Pul. Illnesses Comorbid extra pul. Rampant use of antibiotics conditions particularly 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 [Study by Burman et al -Epidemiology of ARI in children of developing countries Rev. Inf. Dis. (1991)
  • 9. Q : Do I need to chase an aetiological diagnosis in CAP before starting antimicrobial treatment?? A : NO ! Q : WHY ? A : It is not only “difficult” but often “not possible” to document Aetiological factor by lab diagnostics (> 60%) THM: It is Prudent and Rational to start “Emperical Antimicrobial” therapy before establishing microbial aetiology Diagnosis per se is always - almost clinical
  • 10. Diagnosis Q : Then how do I make the diagnosis ? A : Clinically – Triad of fever, cough, tachyponea With or without Chest pain, Sputum, Grunting, Crackles, Bronchial breathing, ↑ Vocal fremitus, Feeding difficulties, Chest recession, Cyanosis. WHO ARI Control Program  Tachyponea most sensitive sign New borns > 70/min Infants (upto 2 yrs) > 50/min Children (> 2 yrs) > 40/min
  • 11. Diagnosis Q : Does ancillary lab investigations support the diagnosis ? A : Yes ! to some extent Non invasive & easily Non invasive but not easily Invasive & not cost accessible accessible effective CBC X-rays BAL ESR Blood culture Lung Biopsy CRP Sputum and gastric aspirate CT Scan culture Mx Serology PCR Gram stain of sputum & Pleural Tap Rapid Antigen naso pharyngeal detection test secretions Less specific Some what specific More specific
  • 12. Q : How do I decide whether it is bacterial or viral ? A : There are no definite markers to differentiate between bacterial or viral. Features suggestive of bacterial pneumonia : • Fever > 38.5oC. Toxic look • Respiratory rate > 50 breaths / min • Chest recession (Respiratory distress) • Radiologically Lobar consolidation, Segmental consolidation and Round consolidation.
  • 13. Features suggestive of viral pneumonia • Infants and young children • Fever < 38.5oC • Mucosal congestion • Wheeze • Hyperinflation • Marked recession • Respiratory rate normal or raised • Radiologically Hyperinflation, Diffuse infilterates & Segmental collapse.
  • 14. Features suggestive of Pneumonia by Atypical organisms • School Age children • Cough • Wheeze • Chest pain • Respiratory distress • Anemia and reticulo cytosis • Radiologically Lobar consolidation and hilar adenopathy, Interstitial infiltrates
  • 15. CAP THM: 1. ‘S pneumoniae’ is the commonest causative organism of CAP in Infancy & childhood, accounting for 1 million deaths annually out of a total 1.9 million estimated deaths, particularly in developing countries. 2. Viruses are commonest cause in infants and young children (14-35% of CAP) 3. Significant proportion of CAP is due to mixed infections (8-40%) 4. In 20-60% cases pathogen is not identified. Source – British Thoracic Society guidelines for the diagnosis and management of Community Acquired Pneumonia in children.
  • 16. Q : What are other ‘Clues’ and ‘Parameters’ to catch aetiologocal diagnosis ? ‘CLUES’ Associated co-morbid conditions Otitis media S pneumoniae Purulent sinusitis S pneumoniae Pyoderma S aureus Empyema S aureus Measles S aureus Watery rhinorrhoea viral Meningitis S Pneumonia / HIB
  • 17. Parameters : Age is a good predictor of the likely pathogens Pathogens in infants < 3 months . Group B Steptococcus Gram negative enterococci & klebseilla Staph aureus Chlamydia trachomatis
  • 18. Pathogens in Children 3 months to 5 yrs of age • More Common : - ‘S’ pneumoniae - Viruses (RSV, PIV3, Adenovirus) - H influenzae b Less Common : - M.catarrhalis - Staph aureus - Group A streptococci
  • 19. Pathogens in Children > 5 yrs of age • Mycoplasma pneumoniae • Chlamydia pneumoniae • Streptococcus pneumoniae • Leigonella species
  • 20. Diagnostic Difficulties 1. No specific markers to differentiate viral from bacterial. 2. Sputum samples are not often obtainable 3. Nasopharyngeal secretions are unreliable due to high asymptomatic carriage rates. 4. Some common organisms like M pneumoniae, C pneumoniae & H influenzae cannot be cultured easily. 5. Bactec culture facilities are not available everywhere 6. Invasive tests which are more specific are not practical in practice and are not cost effective. 7. Infection may be polymicrobial
  • 21. Q : How do I manage a case of CAP ? Principles of Management a) Evaluation Diagnosis Grading of severity Mode of management b) Stabilization Supportive treatment ICU Management c) Specific Agents Antimicrobials
  • 22. Severity Assessment Mild Moderate Severe OPD Management IPD Management ICU Management Indicators Indicators Indicators Fever < 38.5oc, Fever > 38.5oc on two Altered sensorium Mild cough occ. at 8 hrs apart Cyanosis / Pso2 < 92 R.R< 50 / min Moderate to severe Pao2 < 60% No dehydration, cough Pco2 > 40% Adequate intake Tachyponea pH > 7.3 R.R.> 50 / min Systolic BP<60 mmHg Resp. distress BUN > 20 mg% Pso2 92% Exp. Grunt Grunting Severe Resp. Distress Refusal of feeds & dehyderation As per BTS & ATS guidelines on CAP management
  • 23. Mode of Management A) OPD - Appropriate oral Antibiotics for 3-5 days - Analgesics & Antipyretics - Symptomatic B) IPD - IV antibiotics for 3 - 5 days – switch to oral - IV fluid therapy & Electrolyte maintenance - Pulse oxymetry monitoring - Maintenance of Nutrition - Oxygen if required C) ICU - All of the above + ABG monitoring + Ventilatory life support if required
  • 24. Specific Antimicrobials Which antibiotic ? Which Route ? Duration ? When to switch to oral? “Age is a good predictor of the likely pathogen & choice of antibiotic is based on suspected pathogen”
  • 25. CAP Treatment AGE OPD IPD ICU Birth to 3 IV Ampicillin / Amoxycillin IV Ampicillin / Amoxycillin months 100-200 mg / kg / day + IV Aminoglycoside + IV Aminoglycoside with or without with or without IV Ceftazidime 3rd Generation Cefalosporin 50-100 mg / kg / day 100-150 mg / kg / day or Vancomycin / Teicoplanin 10- 15 mg / kg / day or Imipenem / Meropenem or Pipracillin / Tazobactum
  • 26. CAP Treatment AGE OPD IPD ICU 3 months Oral Amoxycillin IV Amoxycillin IV Ampicillin + Cloxacillin to 5 yrs 50-100 mg/kg/day 100-200 mg / kg / day 200 mg/kg/day or or Co-amoxiclav with or without IV B-Lactames 50-100 mg/kg/day a) co-amoxiclav or a) Cefotaxime b) Cefuroxime Cefaclor 100-150 mg/kg/day c) Ceftriaxone 25-30 mg/kg/day b) Ceftriaxone or 100-150 mg/kg/day with or without Cefuroxime or 15-25 mg/kg/day B-Lactames Aminoglycoside And / Or a) Co-amoxiclav or Macrolide 100-150 mg/kg/day Vancomycin / Teicoplanin a)Azithromycin b) Cefuroxime 10mg/kg/day 50-100 mg/kg/day b) Clarithromycin with or without 15mg/kg/day Oral Macrolide
  • 27. CAP Treatment AGE OPD IPD ICU > 5 yrs Oral Amoxycillin IV Co-amoxiclav IV Co-amoxiclav 60-90 mg/kg/day 100 mg / kg / day 100-150 mg/kg/day + and / or and / or IV Ceftriaxone 100-200 mg/kg/day Macrolide IV Cefuroxime + a) Azithromycin 100-150 mg/kg/day IV Macrolide 10mg/kg/day or b) Clarithromycin with or without IV Fluroquinolone 15 mg/kg/day (Newer anti Pneumococcal) or IV Cefotaxime c) Doxycycline 100 mg/kg/day (> 8 yrs) 5 mg / kg / day with or without Oral macrolide
  • 28. Failure of clinical response !! What should I Do ? A) Check the diagnosis May be wrong diagnosis - Aspiration Pneumonia - Interstitial Lung Disease - Tuberculous Pneumonia - Foreign body Aspiration B) Look for underlying cardio pulmonary conditions like : - Lung Abscess - Empyema - Cystic Fibrosis - Bronchiectasis - L-R shunt - GERD - Asthma
  • 29. Failure of clinical response !! Cont’d….. What should I Do ? C) Immunosupression in host - PCP Pneumonia - Fungal Pneumonia - Pseudomonal Pneumonia D) Think for drug resistance - Child from day care centre (DRSP/ B-Lactamase producing - Use of corticosteroids & organisms) - B-Lactames in previous 1 month E) Possibility of Viral + Bacterial Polymicrobial Aetiology or Bacterial + atypical Bacterial
  • 30. Q : What complications can I expect if not treated properly ? • Empyema • Pneumothorax • Lobar Atelectesis • Septicemia • Bronchogenic dissemination • Osteomylitis • Septic Arthritis • Multiple Systemic Abscesses • Meningitis etc…
  • 31. Q : How should I follow up & should I chase for follow up x-rays ? “NO” - Follow up should be clinical for 3-4 weeks - No chase for follow up x-rays except in case of - Lobar collapse - Round Pneumonia - Symptomatic child Radiographic resolution 56% - 2 weeks 74% - 4 weeks 98% - 6 weeks
  • 32. Q : How can I contribute in prevention of CAP in community ? i) Promotion of Immunisation – Measles, Influenza, HIB & Pneumococus vaccines ii) Prevention of passive smoking & air pollution iii) Judicious use of corticosteroids & antibiotics particularly B-Lactams) iv) Supplementation of Vit A, Vit D & Zinc v) Promotion of Breastfeeding & demotion of bottle feeding vi) Treatment of malnutrition
  • 33. Key points 1. Aetiological diagnosis in CAP is not only difficult but not always possible (>60%) 2. Emperical Antimicrobial therapy is ‘Rational’ & ‘Prudent’ 3. Age is a good predictor of likely pathogens 4. Streptococcus pneumoniae is the most common cause of CAP in childhood followed by viruses 5. Chest radiography though supports the diagnosis – is poor indicator of aetiology. 6. Followup x-rays are not required unless in special circumstances
  • 34. Key Points – Contd.. 7. Acute phase reactants do not distinguish between viral & bacterial infections 8. Pulse oxymetery monitoring should be performed in every admitted child with CAP. 9. Blood cultures though desirable yields only 10-20% positivity. 10. Amoxycillin is the drug of choice for CAP from infancy to adolescent alternatives are co-amoxiclav, cefuroxime or macrolide 11. Child remaining febrile & symptomatic for more than 48- 72 hrs after hospitalization should be re-evaluated for complications, underlying comorbid conditions, co-mimics, immunosuppression or drug resistance.