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COMMUNITY ACQUIRED
PNEUMONIA
DR MANDAR HAVAL
MBBS DCH DNB
FELLOW IN NEONATOLOGY
MAGNITUDE OF THE PROBLEM
• Acute respiratory Infections (ARI) in children
less than 5 years old are the leading cause of
childhood morbidity and mortality in the
world.
• Recent WHO estimates suggest the median
incidence of clinical pneumonia is 0.28
episodes per child per year.
• More than 95% of all episodes of clinical
pneumonia in young children worldwide occur
in developing countries.
RECENT ESTIMATES FROM INDIA
• ARI in children under 5 years of age
constitutes 24% of the National Burden of
disease and 13% of deaths
• Mortality estimates suggest that 2.3 million
children less than 5 years of age die every year
in India and 20% of these deaths are due to
ARI.
IDENTIFICATION OF ETIOLOGICAL
AGENTS
• The Identification of the etiological agent / agents
responsible for pneumonia remains a challenge.
This is primarily because of difficulty in obtaining
adequate samples for culture, differentiating
infection from colonization and lack of reliable
diagnostic tests.
• The gold standard would be lung puncture
samples taken directly from the infected area of
the lungg. However this is an invasive test and
not routinely preferred
WHAT IS 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
or
• Has been hospitalized less than 4 days prior to
onset of symptoms.
WHAT ARE THE COMMON
PATHOGENS INVOLVED?
• Age is a good predictor of the likely pathogen of
pneumonia and can help narrow the list of
etiological agents.
• While Gram negative agents are common under
3 months of age.
• S. pneumoniae is common at all ages thereafter
• H. influenzae is a common organism upto 2 years
of age.
• Staphylococcus though not very common is an
important formidable enemy
COMMUNITY ACQUIRED PNEUMONIA
COMMUNITY ACQUIRED PNEUMONIA
COMMUNITY ACQUIRED PNEUMONIA
HOW DOES ONE DIAGNOSE
PNEUMONIA IN A CHILD?
A. Children with suspected pneumonia can present
with symptoms like
1. Fever
2. Cough, may or may not be productive
3. Chest pain and/or abdominal pain
4. Difficulty in breathing (dyspnea) / rapid
breathing (tachypnoea)
5. Constitutional symptoms: malaise, lethargy,
headache, nausea / vomiting
2. Signs that suggest a high probability
of pneumonia and need for antibiotic
treatment
• Rapid respiration identifies children who have
a very high probability of having pneumonia
and are therefore candidates for antibiotic
therapy
• Age< 2 months - 60 or more
2 months upto 12 months- 50 or more
12 months upto 5 years - 40 or more
breaths/min.
Continue
• The presence of grunt, crackles, bronchial
breathing is suggestive of pneumonia but are
not so common
• Often there may be presence of signs of the
complications of pneumonia like para-
pneumonic effusions/ empyema,
pneumothorax
HOW DOES ONE ESTABLISH THE
DIAGNOSIS?
• Diagnosis of CAP can be established with a fair
degree of accuracy by judicious use of the
clinical signs detailed above.
• There are few clinical features to suggest
probable etiology yet some clues like presence
of skin boils, rapid progression /
deterioration, empyema or pneumothorax or
radiological evidence of pneumatocele
strongly incriminate Staphylococcus
Clinical differentiation of viral and
bacterial pneumonias is difficult
DIAGNOSING PNEUMONIA
AIMED AT
• Recognizing signs that suggest a high
probability of Pneumonia and need for
antibiotic treatment
• Assess severity of pneumonia to identify
patients requiring hospital care
STUDY
DIFFERENTIAL DIAGNOSIS
CONSIDER BRONCHIOLITIS-WALRI
• Age 1month-1year
• Presence of upper respiratory catarrh
• Progressive increase in resp distress
(tachypnea, retractions)
• Wheeze ± crackles
• Clinical and radiological evidence of
hyperinflation
CONSIDER LTB-CROUP
• Hoarseness of voice and barking/brassy cough
• Stridor
• Mild to marked respiratory distress
• Sonorous rhonchi
• Fever usually mild (or spiking as in tracheitis,
however this disease entity is rare)
CONSIDER ASTHMA
• Recurrent afebrile episodes, 3 or more
• Wheeze
• Good response to bronchodilator
• Hyperinflation
• Family/personal history of atopy
INVESTIGATION
RADIOLOGY
• Not a very reliable diagnostic tool due to wide
inter- and intra-observer error in reading
radiographs
• Those needing domiciliary care usually do not
benefit from radiographs
• Those sick enough to need hospitalization
may benefit
INDICATIONS FOR CXR IN EITHER
PRIMARY CARE OR HOSPITAL CARE
• For diagnosis of child under 5 years with fever
of 39 C of unknown origin,If complications
suspected, (for example, pleural effusion as
suggested by diminished air entry),
• Ambiguous features, Unresponsive to
treatment after 48 hrs of treatment /
deteriorates
MICROBIOLOGICAL TESTS ARE OF
NO USE ROUTINELY
ACUTE PHASE REACTANTS
• TLC, DLC, CRP are not diagnostic but may be
useful to monitor the response to treatment.
• A normal test may be more useful in
EXCLUDING the diagnosis as compared to
confirmation on the basis of a positive test
ASSESSING PNEMONIA
ASSESSING SEVERITY OF PNEUMONIA
• WHO criteria of assessment of severity is
simpler and useful at all levels of care
WHY AND HOW DOES ONE ASSESS
SEVERITY?
• Assess for severity to decide the level of
facility at which to treat and also to
determine the choice of treatment including
antibiotics.
COMMUNITY ACQUIRED PNEUMONIA
COMMUNITY ACQUIRED PNEUMONIA
Note..
• Hypoxaemia is a good indicator of the severity
of Pneumonia, and pulse oxymetry should
therefore be performed on every child
deemed ill enough to be admitted.
Indications For Admission To Hospital In
Pneumonia Among Children?
1. Mild to moderate cases do not need
admission (refer to ‘FACTS’)
2. Infants less than 3 months of age are best
treated as inpatients.
COMMUNITY ACQUIRED PNEUMONIA
THE INDICATIONS FOR TRANSFER TO
PEDIATRIC INTENSIVE CARE UNIT
(PICU)
• There is failure to maintain SaO2 >92% in FiO2
>0.6
• The patient is in peripheral circulatory failure
• There are rising respiratory and pulse rates
with clinical evidence of severe respiratory
distress and exhaustion with or without raised
PaCO2
• There is recurrent apnoea or slow irregular
breathing.
COMMUNITY ACQUIRED PNEUMONIA
HOW DOES ONE TREAT SUCH CASES?
• The components of management are
(a) Oxygen as indicated by pulse
oxymetry and/ or clinical signs of hypoxia
(b) Supportive therapy
(c) Antibiotic
USING ANTIBIOTICS FOR CAP -
GENERAL PRINCIPLES
• Empiric therapy should be based on knowing
the most likely pathogen in each community.
S. pneumoniae is an important causative
agent for Community Acquired Pneumonia at
all ages.
• Because it is difficult to distinguish between
bacterial, viral, and mixed infections, most
children with Community Acquired
Pneumonia are treated with antibiotics.
• Selection of antibiotic is dictated by the age
of the child and epidemiological factors and
sometimes the results of the chest
radiography.
COMMUNITY ACQUIRED PNEUMONIA
COMMUNITY ACQUIRED PNEUMONIA
SIMPLE WAY OF APPROACH
COMMUNITY ACQUIRED PNEUMONIA
When to start second line of drug?
• Deterioration of clinical condition at anytime
on first line antibiotics
OR
• No response even on DAY 4 of antibiotic
therapy
QUINOLONES
SELECTION OF ANTIBIOTICS
UNDERLYING DISEASE
• Children with hemoglobinopathy or nephrotic
syndrome are more susesptible to
Pneumococcal
• Cystic fibrosis – Staphylococcus, H influenza,
Pseudomonas
• Immunodeficiency – opportunistic infection
• HIV – Gram negative bacilli, P.jiroveci and
Fungal
NOTE – PROGRESSION IN IMMUNODEFICIENCY
IS RAPID HENCE MORE EFFICIENT ANTIBIOTIC
COMBINATION USED AS A FIRST LINE
• Neutropenia – Gram Negative bacilli,
Staphylococcus along with common pathogen
like S.pneumoniae and H. influenzae
• Drug of choice – CEFTAZIDIME with
AMINOGLYCOSIDE
• If no response then add ANTIFUNGAL or
SEPTRAN
• History of Hospitalization – Gram Negative
bacilli.
• NOTE – STAPHYLOCOCCAL infection in
hospital setting is Resistance to PENICILLIN
and need VANCOMYCIN or LINIZOLID
History of previous antibiotics
• Current episode OR recent past (2-4 week)
should be consider
• Idea of possible RESISTANT ORGANISMS. So
change antibiotic accordingly.
NUTRITIONAL STATUS
• The symptoms of pneumonia may be MASKED
in severe malnutrition
• Added predisposition to GRAM NEGATIVE
organisms
DURATION OF ILLNESS
• Short duration – possible BACTERIAL etiology
• Prolonged duration – M. TUBERCULOSIS,
ATYPICAL ORGANISM, ADENOVIRUS
INDICATION FOR IV ANTIBIOTICS
• SEVERE PNEUMONIA
• DISTURBED CONSCIOUSNESS
• IMPROPER SWALLOWLING
• FREQUENT VOMITING
• MALABSORPTION
• Note – switch to ORAL when child start
accepting orally or clinically improving
SUPPORTIVE THERAPY FOR CAP
• Oxygen as indicated by pulse oxymetry and/
or clinical signs of hypoxia
• IV fluids : If dehydrated,If tachypnoea is
severe enough to make the child unable to
drink, or Impending respiratory failure.
• Fever management
• Bronchodilators, indicated only in the
presence of wheeze, should be used to
decrease the work of breathing.
HOW LONG DOES ONE CONTINUE
TREATMENT?
• Domiciliary cases: Total of 5-7 days
• Admitted cases: Switch to oral as soon as patient
can accept orally. Total 5-7 days.
• However, if on second line therapy, then use IV
antibiotics for 7-10 days.
• If suspected or confirmed Staphylococcal based
disease, treat for 2 weeks at least in
uncomplicated cases and for 4-6 weeks for those
with complications like empyema, metastatic
abscesses etc.
HOW DOES ONE MONITOR
RESPONSE?
• Clinical response in the form of absence of
fever, improvement in breathing is a useful
method.
The end of treatment X-ray is not
needed in every case except when:
1. The response is delayed or incomplete, or
2. There were any ambiguous signs in initial
film, or
3. There are any associated complications, or
4. Children with lobar collapse or ongoing
symptoms.
PREVENTION OF PNEUMONIA
• ROUTEIN IMMUNIZATION against PERTUSSIS,
MEASLES, H.influenzae type B
THANK YOU

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COMMUNITY ACQUIRED PNEUMONIA

  • 1. COMMUNITY ACQUIRED PNEUMONIA DR MANDAR HAVAL MBBS DCH DNB FELLOW IN NEONATOLOGY
  • 2. MAGNITUDE OF THE PROBLEM • Acute respiratory Infections (ARI) in children less than 5 years old are the leading cause of childhood morbidity and mortality in the world. • Recent WHO estimates suggest the median incidence of clinical pneumonia is 0.28 episodes per child per year. • More than 95% of all episodes of clinical pneumonia in young children worldwide occur in developing countries.
  • 3. RECENT ESTIMATES FROM INDIA • ARI in children under 5 years of age constitutes 24% of the National Burden of disease and 13% of deaths • Mortality estimates suggest that 2.3 million children less than 5 years of age die every year in India and 20% of these deaths are due to ARI.
  • 4. IDENTIFICATION OF ETIOLOGICAL AGENTS • The Identification of the etiological agent / agents responsible for pneumonia remains a challenge. This is primarily because of difficulty in obtaining adequate samples for culture, differentiating infection from colonization and lack of reliable diagnostic tests. • The gold standard would be lung puncture samples taken directly from the infected area of the lungg. However this is an invasive test and not routinely preferred
  • 5. WHAT IS 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 or • Has been hospitalized less than 4 days prior to onset of symptoms.
  • 6. WHAT ARE THE COMMON PATHOGENS INVOLVED? • Age is a good predictor of the likely pathogen of pneumonia and can help narrow the list of etiological agents. • While Gram negative agents are common under 3 months of age. • S. pneumoniae is common at all ages thereafter • H. influenzae is a common organism upto 2 years of age. • Staphylococcus though not very common is an important formidable enemy
  • 10. HOW DOES ONE DIAGNOSE PNEUMONIA IN A CHILD? A. Children with suspected pneumonia can present with symptoms like 1. Fever 2. Cough, may or may not be productive 3. Chest pain and/or abdominal pain 4. Difficulty in breathing (dyspnea) / rapid breathing (tachypnoea) 5. Constitutional symptoms: malaise, lethargy, headache, nausea / vomiting
  • 11. 2. Signs that suggest a high probability of pneumonia and need for antibiotic treatment • Rapid respiration identifies children who have a very high probability of having pneumonia and are therefore candidates for antibiotic therapy • Age< 2 months - 60 or more 2 months upto 12 months- 50 or more 12 months upto 5 years - 40 or more breaths/min.
  • 12. Continue • The presence of grunt, crackles, bronchial breathing is suggestive of pneumonia but are not so common • Often there may be presence of signs of the complications of pneumonia like para- pneumonic effusions/ empyema, pneumothorax
  • 13. HOW DOES ONE ESTABLISH THE DIAGNOSIS? • Diagnosis of CAP can be established with a fair degree of accuracy by judicious use of the clinical signs detailed above. • There are few clinical features to suggest probable etiology yet some clues like presence of skin boils, rapid progression / deterioration, empyema or pneumothorax or radiological evidence of pneumatocele strongly incriminate Staphylococcus
  • 14. Clinical differentiation of viral and bacterial pneumonias is difficult
  • 15. DIAGNOSING PNEUMONIA AIMED AT • Recognizing signs that suggest a high probability of Pneumonia and need for antibiotic treatment • Assess severity of pneumonia to identify patients requiring hospital care
  • 16. STUDY
  • 18. CONSIDER BRONCHIOLITIS-WALRI • Age 1month-1year • Presence of upper respiratory catarrh • Progressive increase in resp distress (tachypnea, retractions) • Wheeze ± crackles • Clinical and radiological evidence of hyperinflation
  • 19. CONSIDER LTB-CROUP • Hoarseness of voice and barking/brassy cough • Stridor • Mild to marked respiratory distress • Sonorous rhonchi • Fever usually mild (or spiking as in tracheitis, however this disease entity is rare)
  • 20. CONSIDER ASTHMA • Recurrent afebrile episodes, 3 or more • Wheeze • Good response to bronchodilator • Hyperinflation • Family/personal history of atopy
  • 22. RADIOLOGY • Not a very reliable diagnostic tool due to wide inter- and intra-observer error in reading radiographs • Those needing domiciliary care usually do not benefit from radiographs • Those sick enough to need hospitalization may benefit
  • 23. INDICATIONS FOR CXR IN EITHER PRIMARY CARE OR HOSPITAL CARE • For diagnosis of child under 5 years with fever of 39 C of unknown origin,If complications suspected, (for example, pleural effusion as suggested by diminished air entry), • Ambiguous features, Unresponsive to treatment after 48 hrs of treatment / deteriorates
  • 24. MICROBIOLOGICAL TESTS ARE OF NO USE ROUTINELY
  • 25. ACUTE PHASE REACTANTS • TLC, DLC, CRP are not diagnostic but may be useful to monitor the response to treatment. • A normal test may be more useful in EXCLUDING the diagnosis as compared to confirmation on the basis of a positive test
  • 27. ASSESSING SEVERITY OF PNEUMONIA • WHO criteria of assessment of severity is simpler and useful at all levels of care
  • 28. WHY AND HOW DOES ONE ASSESS SEVERITY? • Assess for severity to decide the level of facility at which to treat and also to determine the choice of treatment including antibiotics.
  • 31. Note.. • Hypoxaemia is a good indicator of the severity of Pneumonia, and pulse oxymetry should therefore be performed on every child deemed ill enough to be admitted.
  • 32. Indications For Admission To Hospital In Pneumonia Among Children? 1. Mild to moderate cases do not need admission (refer to ‘FACTS’) 2. Infants less than 3 months of age are best treated as inpatients.
  • 34. THE INDICATIONS FOR TRANSFER TO PEDIATRIC INTENSIVE CARE UNIT (PICU) • There is failure to maintain SaO2 >92% in FiO2 >0.6 • The patient is in peripheral circulatory failure • There are rising respiratory and pulse rates with clinical evidence of severe respiratory distress and exhaustion with or without raised PaCO2 • There is recurrent apnoea or slow irregular breathing.
  • 36. HOW DOES ONE TREAT SUCH CASES? • The components of management are (a) Oxygen as indicated by pulse oxymetry and/ or clinical signs of hypoxia (b) Supportive therapy (c) Antibiotic
  • 37. USING ANTIBIOTICS FOR CAP - GENERAL PRINCIPLES • Empiric therapy should be based on knowing the most likely pathogen in each community. S. pneumoniae is an important causative agent for Community Acquired Pneumonia at all ages.
  • 38. • Because it is difficult to distinguish between bacterial, viral, and mixed infections, most children with Community Acquired Pneumonia are treated with antibiotics. • Selection of antibiotic is dictated by the age of the child and epidemiological factors and sometimes the results of the chest radiography.
  • 41. SIMPLE WAY OF APPROACH
  • 43. When to start second line of drug? • Deterioration of clinical condition at anytime on first line antibiotics OR • No response even on DAY 4 of antibiotic therapy
  • 46. UNDERLYING DISEASE • Children with hemoglobinopathy or nephrotic syndrome are more susesptible to Pneumococcal • Cystic fibrosis – Staphylococcus, H influenza, Pseudomonas
  • 47. • Immunodeficiency – opportunistic infection • HIV – Gram negative bacilli, P.jiroveci and Fungal NOTE – PROGRESSION IN IMMUNODEFICIENCY IS RAPID HENCE MORE EFFICIENT ANTIBIOTIC COMBINATION USED AS A FIRST LINE
  • 48. • Neutropenia – Gram Negative bacilli, Staphylococcus along with common pathogen like S.pneumoniae and H. influenzae • Drug of choice – CEFTAZIDIME with AMINOGLYCOSIDE • If no response then add ANTIFUNGAL or SEPTRAN
  • 49. • History of Hospitalization – Gram Negative bacilli. • NOTE – STAPHYLOCOCCAL infection in hospital setting is Resistance to PENICILLIN and need VANCOMYCIN or LINIZOLID
  • 50. History of previous antibiotics • Current episode OR recent past (2-4 week) should be consider • Idea of possible RESISTANT ORGANISMS. So change antibiotic accordingly.
  • 51. NUTRITIONAL STATUS • The symptoms of pneumonia may be MASKED in severe malnutrition • Added predisposition to GRAM NEGATIVE organisms
  • 52. DURATION OF ILLNESS • Short duration – possible BACTERIAL etiology • Prolonged duration – M. TUBERCULOSIS, ATYPICAL ORGANISM, ADENOVIRUS
  • 53. INDICATION FOR IV ANTIBIOTICS • SEVERE PNEUMONIA • DISTURBED CONSCIOUSNESS • IMPROPER SWALLOWLING • FREQUENT VOMITING • MALABSORPTION • Note – switch to ORAL when child start accepting orally or clinically improving
  • 54. SUPPORTIVE THERAPY FOR CAP • Oxygen as indicated by pulse oxymetry and/ or clinical signs of hypoxia • IV fluids : If dehydrated,If tachypnoea is severe enough to make the child unable to drink, or Impending respiratory failure.
  • 55. • Fever management • Bronchodilators, indicated only in the presence of wheeze, should be used to decrease the work of breathing.
  • 56. HOW LONG DOES ONE CONTINUE TREATMENT? • Domiciliary cases: Total of 5-7 days • Admitted cases: Switch to oral as soon as patient can accept orally. Total 5-7 days. • However, if on second line therapy, then use IV antibiotics for 7-10 days. • If suspected or confirmed Staphylococcal based disease, treat for 2 weeks at least in uncomplicated cases and for 4-6 weeks for those with complications like empyema, metastatic abscesses etc.
  • 57. HOW DOES ONE MONITOR RESPONSE? • Clinical response in the form of absence of fever, improvement in breathing is a useful method.
  • 58. The end of treatment X-ray is not needed in every case except when: 1. The response is delayed or incomplete, or 2. There were any ambiguous signs in initial film, or 3. There are any associated complications, or 4. Children with lobar collapse or ongoing symptoms.
  • 59. PREVENTION OF PNEUMONIA • ROUTEIN IMMUNIZATION against PERTUSSIS, MEASLES, H.influenzae type B