Paediatric Pneumonia

8/6/2019 Paediatric Pneumonia

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An infant seen in the ER, presents with a fever

and persistent cough. Physical examination and

a chest x-ray suggest pneumonia. What are theprobable microorganisms causing this infection?


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The probable microorganisms that may cause

pneumonia include :

- Streptococcus pneumoniae

- Staphylococcus aureus- Haemophilus influenzae

- Respiratory syncytial virus (RSV)

- Parainfluenza viruses- Chlamydia trachomatis


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Streptococcus pneumoniae

- most common bacterial pathogen causing

pneumonia in infant

- an encapsulated gram positive coccus

- diameter : 0.5 1.2m

- shape : oval

- arrangement : pairs or short chains

- normal inhabitant of upper respiratory tract

- can multiply in the tissues


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largest cause of death in children worldwide

an acute lower respiratory infection that specificallyaffects the lungs

bacterial pathogens that are present in a childs nose orthroat are inhaled into the lungs

infants with weakened natural defenses cannot protecttheir lungs from invading pathogens

alveoli are filled with pus and fluid in one or both lungs,and thus results in breathing difficulty and decreasedoxygen intake

risk factors are malnutrition, AIDS and environmentalfactors

symptoms include tachypnea, shortness of breath,cough, fever, chills, headache, loss of appetite, andwheezing


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Chest X-ray

-Indicated when symptoms suggest pneumonia.

-X-ray results may:

Suggest the type of organism (bacterial, viral,

or fungal) causing pneumonia.

Show complications of pneumonia.

Show conditions that may occur with

pneumonia, such as fluid in the chest cavity

or a collapsed lung.


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Normal Pneumonia


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Complete WBC & Differential count

-Helpful as an increased white blood countwith predominance ofpolymorphonuclear cells may suggestbacterial cause.

- However, leucopoenia can either suggesta viral cause or severe overwhelminginfection.


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Blood Culture

- The gold standard for determining the

precise aetiology of pneumonia.

- Blood samples are drawn into vials that

contain nutrients which support the growthof microorganisms.

- Sensitivity is very low. (10-30% pneumonia

patient will have positive results.)

- Performed in severe pneumonia or poor

response to 1st line antibiotics.


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Sputum Culture & Gram Stain

-Primary tests ordered to detect andidentify the cause of bacterialpneumonia

Susceptibility Testing

-Performed on pathogenic bacteria grownin culture and identified by testing.

-Determines which antibiotic

is to be used.


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Culture from Respiratory Secretions- Bacteria from throat swabs and upper

respiratory tract secretions are notrepresentative of pathogens in the lowerrespiratory tract.

- Samples from the nasopharynx and throathave no predictive values.

Other tests- Bronchoalveolar lavage (BAL) is usually

necessary for the diagnosis of Pneumocystiscarini infections in immunosuppressedchildren.

- Done only when facilities and expertise areavailable.


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Mild Pneumonia Fast breathing

Severe pneumonia Chest indrawing

Very severe pneumonia Not able to

drink

Convulsions

Drowsiness

Malnutrition


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Desired outcome in treating pneumonia

Eradication of the offending organism

through selection of appropriate antibioticand complete clinical cure

Minimize associated morbidity

Focus on designing the most cost-effective

approach therapy Oral route is preferable over parenteral for

drug administration, encouraging outpatientmanagement than that of hospitalization.


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humidified oxygen for hypoxemia

bronchodilators (albuterol) when

bronchospasm is present rehydration fluids control of fever

chest physiotherapy for masked

accumulation of retained respiratorysecretion postural drainage.

Antibiotics regimens should be selectedbased on causative pathogens.


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Antibiotic concentration in respiratory secretions inexcess of the pathogen MIC (minimum inhibitoryconcentration) are necessary for successfultreatment of pulmonary infection

Antimicrobial therapy should be initiated inhospitalized patients with acute pneumonia within 8hours of admission because an increase in mortalityhas been demonstrated when therapy was delayedbeyond 8 hours of admission

Pneumococcal vaccination is recommended forpatients at high risk for severe pneumococcalinfections.


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Empirical antimicrobial therapy forpneumonia in pediatric patients

1 month: Group B streptococcus(Streptococcus agalactiae)orStaphylococcus aureus with presumptivetherapy of ampicillin-sulbactam,cephalosporin carbapenem

1-3 months: Pneumococcus, S. aureus withsemisynthetic penicillin or cephalosporin

> 3months: pneumococcus with amoxicillinor cephalosporin


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Community-acquired pneumonias, forexample, are usually caused by the typicalbacteria Streptococcuspneumoniae, Haemophilus influenzae,orMoraxella catarrhalis, which werepreviously treated with related antibiotics.

Mild CAP in otherwise healthy patients betreated with oral macrolide antibiotics(azithromycin, clarithromycin, orerythromycin).


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Many cases of CAP are caused by S.

pneumoniae -- Gram-positive bacteriathat usually respond to antibiotics knownas beta-lactams and to macrolides.

However, resistant strains of S.pneumoniae are increasingly common.They responds to fluoroquinolines such aslevofloxacin, gemifloxacin or

moxifloxacin . Another common cause of community-

acquired pneumonia is H. influenzae.


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Current recommendations call for 7 - 10days of treatment forS. pneumoniae.Viral pneumonia may last longer.Mycoplasmal pneumonia may take 4 to

6 weeks to resolve completely.


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Penicillin (penicillinG/amoxicillin)remains the drug ofchoice for strains

that are fullysensitive

Cefotaxime andceftriaxone are thefirst-line alternatives

in cases with higherlevels of resistance.

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Treatment is usually with Beta-lactamantibiotics. In the 1960s, nearly all strains ofS. pneumoniae were susceptible topenicillin, but since that time, there hasbeen an increasing rate of resistance.

They may also be resistant to erythromycin,macrolides, and clindamycin and thequinolones.

Amoxicillin: first choice in < 5 years

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Most resistant speciesremain susceptible to

vancomycin, which is aless desirable antibioticbecause of dosing andtissue penetrationissues.

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newermacrolide antibiotics(clarithromycinazithromycin) possess

excellent activity against mostS.

pneumoniae and Mycoplasma organisms.

Azithromycin offers the added advantageof once-daily dosing and short-course

therapy because of the drugs extensivetissue distribution characteristics andprolonged elimination half-life.


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NewerFluoroquinolone may be effectivealternative agents for treatment of CAP.

However, fluoroquinolone use inpediatirc patients remains restricted andlimited due to possibility offluoroquinolone-induced destructivelesions of growing cartilage.


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Hospitalization should be considered forinfants who are younger than 2 months

or premature because of the risk ofapnea in this age group.

Red blood cells should be administeredto ensure a hemoglobin concentrationof 13-16 g/dL in acutely ill infants toensure optimal oxygen delivery to bodytissues.


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Increased respiratory support requirementssuch as increased inhaled oxygenconcentration are usually required beforerecovery begins.

Attempts at enteral feeding often arewithheld. Parenteral nutritional support ispreferred until respiratory and

hemodynamic status is sufficiently stable. Delivery of adequate amounts of glucose,

maintenance of thermoregulation andelectrolyte balance are also essential.


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If the patient has pleural effusion, chesttube placement for drainage of theeffusion or empyema may be performed.

Intrapleural instillation of a fibrinolytic agent(eg. tissue plasminogen activator) has beenused as an adjunctive agent whendrainage and medical management fail.

These agents may help to dissolveloculations and increase chest tubedrainage by breaking down fibrin in thepleural collection.


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The time to resolution of initial presentingsymptoms, and the lack of appearance ofnew associated symptoms should bedetermined.

For community-acquired pneumonia, thetime to resolution of cough, decreasingsputum production, fever and other

symptoms should be noted. If supplemental oxygen therapy is required,

the amount and need should also beassessed regularly.


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A gradual and persistent improvement inthe resolution of symptoms should be

observed. Initial resolution should be observed

within the first 2 days after treatment,and should progress to completeresolution within 5 to 7 days, but usuallyno more than 10 days.


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Research has shown that prevention andproper treatment of pneumonia could avertone million deaths in children every year.

The cost of treating all children withpneumonia in 42 of the world's poorest

countries is estimated at around US$ 600 millionper year. Treating pneumonia in South Asia and sub-

Saharan Africa which account for 85% ofdeaths would cost a third of this total, at

around US$ 200 million. The price includes the antibiotics themselves,

as well as the cost of training health workers,which strengthens the health systems as awhole.


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vaccination

vaccines stimulate antibody formation

7-valent conjugated pneumococcal vaccine (PCV7)

------> discontinued

13-valent conjugated pneumococcal vaccine (PCV13) influenza virus vaccine

- children aged 6 months and older

- inactivated vaccine ------> IM injection- cold-adapted attenuated vaccine ------> nasal

spray

adequate nutrition

good environmental factors


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Intrapleural Tissue Plasminogen Activator for Parapneumonic Effusion: Conclusionhttp://www.medscape.com/viewarticle/726343_10

Pediatric Pneumonia Treatment & Managementhttp://emedicine.medscape.com/article/967822-treatment#aw2aab6b6b1aa

Paediatric Pneumonia

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