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’
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.