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Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD Department.

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Presentation on theme: "Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD Department."— Presentation transcript:

1 Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD Department of Pediatrics, Boonshoft School of Medicine, Wright State University, The Children’s Medical Center of Dayton

2 Clin Infect Dis 2011; 53 (7): 617-630

3 Objectives 1. 1.List common pathogens causing community-acquired pneumonia (CAP) in infants and children. 2. 2.Discuss appropriate use of diagnostic laboratory and imaging tests in a child with CAP in an outpatient or inpatient setting. 3. 3.Review choice of anti-infective therapy and duration of treatment provided to a child with suspected CAP in the outpatient or inpatient setting.

4 “Teasers are docile male horses, usually old and past prime with undesirable genes, who set up aggressive just off-the-track mares to be bred by the wild testosterone crazed prize stallions whose only job is to deliver the goods, which they do. “

5 A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient? 1. Complete blood count 2. Chest radiograph 3. Pulse oximetry 4. Blood culture 5. All of the above

6 A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient? 1. Complete blood count 2. Chest radiograph 3. Pulse oximetry 4. Blood culture 5. All of the above

7 A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria? 1. Able to tolerate outpatient meds, greater level of activity, improving appetite. 2. Afebrile for over 24 hours 3. Pulse oximetry measurements >90% in room air at least 12 hours 4. A and C 5. A, B, and C

8 Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient? 1. A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days. 2. Amoxicillin 90mg/kg/day divided 2 times a day for 10 days 3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5 4. Combined treatment with both amoxicilln and azithromycin as noted above 5. No anti-infective therapy indicated

9 A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended? 1. A third-generation parenteral cephalosporin (e.g., cefotaxime or ceftriaxone) 2. Intravenous clindamycin 3. A third-generation parenteral cephalosporin plus azithromycin 4. Intravenous ampicillin 5. Intravenous vancomycin

10 A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of: 1. Ceftriaxone intravenously at 100mg/kg/day 2. Levofloxacin intravenously at 20 mg/kg/day 3. Ampicillin intravenously at 400 mg/kg/day 4. A or C 5. A, B, or C

11 Introduction The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple subspecialists and expert consultants to create and review guidelines The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple subspecialists and expert consultants to create and review guidelines Guidelines endorsed by AAP, American College of Emergency Physicians, Society of Critical Care Medicine…. Guidelines endorsed by AAP, American College of Emergency Physicians, Society of Critical Care Medicine…. The guidelines grade method of recommendation, low or very low evidence situations require clinical judgment The guidelines grade method of recommendation, low or very low evidence situations require clinical judgment

12 Strength of Recommendations

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14 Inpatient Criteria Age 3-6 months with a suspicion of bacterial pneumonia Age 3-6 months with a suspicion of bacterial pneumonia Suspicion or documentation of methicillin- resistant Staphylococcus aureus (MRSA) pneumonia Suspicion or documentation of methicillin- resistant Staphylococcus aureus (MRSA) pneumonia Concern for follow up or administration of home therapy Concern for follow up or administration of home therapy

15 Patients Requiring Hospitalization

16 Diagnostic approach to the child with pneumonia

17 Outpatient Diagnostics Chest radiography, blood culture, CBC, ESR/CRP not necessary Chest radiography, blood culture, CBC, ESR/CRP not necessary Pulse oximetry should be obtained in all patients Pulse oximetry should be obtained in all patients If available a rapid test for influenza and for other viral pathogens should be obtained If available a rapid test for influenza and for other viral pathogens should be obtained Testing for Mycoplasma pneumoniae should be obtained if suspicious Testing for Mycoplasma pneumoniae should be obtained if suspicious If no improvement on antibiotics for 48-72 hrs, a CXR and blood culture should be obtained If no improvement on antibiotics for 48-72 hrs, a CXR and blood culture should be obtained

18 Inpatient Workup All pt’s should have CXR All pt’s should have CXR Blood culture Blood culture CBC CBC ESR/CRP ESR/CRP Urinary antigen for Pneumococcal infection is not recommended Urinary antigen for Pneumococcal infection is not recommended Sputum samples if able (weak; low evidence) Sputum samples if able (weak; low evidence) Rapid tests for Influenza and viruses should be used Rapid tests for Influenza and viruses should be used Mycoplasma pneumoniae should be tested for if suspicious Mycoplasma pneumoniae should be tested for if suspicious No reliable test for Chlamydophila pneumoniae No reliable test for Chlamydophila pneumoniae

19 Inpatient Diagnostics A routine repeat CXR is not necessary A routine repeat CXR is not necessary Repeat CXR should be obtained if no clinical improvement is demonstrated by 48-72 hrs Repeat CXR should be obtained if no clinical improvement is demonstrated by 48-72 hrs If blood culture yields MRSA, a repeat culture is mandatory todocument sterility of the blood. If blood culture yields MRSA, a repeat culture is mandatory todocument sterility of the blood. If blood culture is positive for another organism, repeat culture of blood is not mandatory If blood culture is positive for another organism, repeat culture of blood is not mandatory Tracheal aspirate should be obtained in patient with endotracheal intubation Tracheal aspirate should be obtained in patient with endotracheal intubation

20 Criteria for admission to an ICU

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22 Intubation, continuous CPAP or BIPAP Intubation, continuous CPAP or BIPAP Sustained tachycardia or hypotension Sustained tachycardia or hypotension 50% FiO2 50% FiO2 Altered mental status Altered mental status Clinical judgment should be used regardless of scores Clinical judgment should be used regardless of scores

23 Discharge Criteria Improved Clinical Status >12 hrs Improved Clinical Status >12 hrs RA with Sp02 >90% >12 hrs RA with Sp02 >90% >12 hrs No increased work of breathing, tachypnea or tachycardia No increased work of breathing, tachypnea or tachycardia Able to tolerate outpatient therapy Able to tolerate outpatient therapy Chest tube out for >12 hrs Chest tube out for >12 hrs

24 Antibiotics not routinely required for preschool-aged children Antibiotics not routinely required for preschool-aged children High-dose amoxicillin should be considered first line for presumed bacterial pneumonia in all ages High-dose amoxicillin should be considered first line for presumed bacterial pneumonia in all ages 90 mg/kg/day divided bid 90 mg/kg/day divided bid TID dosing is required for Pen-resistant pneumococcus (MIC > 2 µg/mL) TID dosing is required for Pen-resistant pneumococcus (MIC > 2 µg/mL) Macrolides (azithromycin) should be considered in school-aged and adolescents with illness consistent with atypical pneumonia Macrolides (azithromycin) should be considered in school-aged and adolescents with illness consistent with atypical pneumonia Outpatient Treatment of Pneumonia

25 Atypical vs. Bacterial Gradual onset Gradual onset Malaise, headache, sore throat, ear infections Malaise, headache, sore throat, ear infections Lower fevers (101-102) Lower fevers (101-102) Usually nonproductive, persistent cough Usually nonproductive, persistent cough May or may not have rales May or may not have rales Gradual or acute onset Fatigue, dyspnea, chest pain Fevers often higher (>103) Cough more often productive Decreased or bronchial breath sounds, rales, dullness to percussion, egophony

26 Manifestations of Mycoplasma pneumonia

27 Outpatient Treatment of Pneumonia For presumed atypical pneumonia, azithromycin is first-line For presumed atypical pneumonia, azithromycin is first-line 10 mg/kg on day 1; 5 mg/kg on days 2-5 10 mg/kg on day 1; 5 mg/kg on days 2-5 In season, treat influenza presumptively until a sensitive test is negative In season, treat influenza presumptively until a sensitive test is negative 10-day course of antibiotics is usually adequate 10-day course of antibiotics is usually adequate Azithromycin: 5 day course Azithromycin: 5 day course MRSA will require a longer course (and hospitalization!) MRSA will require a longer course (and hospitalization!)

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29 Inpatient Treatment of Pneumonia For the fully immunized child in regions that do not demonstrate high-level pneumococcal penicillin resistance: For the fully immunized child in regions that do not demonstrate high-level pneumococcal penicillin resistance: Ampicillin or Penicillin G are first-line Ampicillin or Penicillin G are first-line Azithromycin for suspected atypical pneumonia (with a beta-lactam if diagnosis is in question) Azithromycin for suspected atypical pneumonia (with a beta-lactam if diagnosis is in question) Vancomycin or clindamycin should be added when S. aureus is suspected by labs, clinical findings or imaging Vancomycin or clindamycin should be added when S. aureus is suspected by labs, clinical findings or imaging Ceftriaxone or cefotaxime are alternatives Ceftriaxone or cefotaxime are alternatives

30 Inpatient Treatment of Pneumonia For a not fully immunized child or in regions that demonstrate high-level pneumococcal penicillin resistance: For a not fully immunized child or in regions that demonstrate high-level pneumococcal penicillin resistance: Ceftriaxone or cefotaxime is preferred Ceftriaxone or cefotaxime is preferred Add azithromycin if considering atypical pneumonia Add azithromycin if considering atypical pneumonia Add vancomycin or clindamycin for S. aureus Add vancomycin or clindamycin for S. aureus Ceftriaxone or cefotaxime also preferred for life- threatening infections and empyema Ceftriaxone or cefotaxime also preferred for life- threatening infections and empyema

31 Empiric Inpatient Treatment of CAP

32 Pneumococcal Penicillin Resistance MIC < 0.06 µg/mL: very susceptible MIC < 0.06 µg/mL: very susceptible Standard-dose oral amoxicillin effective Standard-dose oral amoxicillin effective MIC 0.12-1 µg/mL: susceptible MIC 0.12-1 µg/mL: susceptible High-dose oral amoxicillin effective High-dose oral amoxicillin effective MIC 1-2: somewhat resistant MIC 1-2: somewhat resistant High-dose oral amoxicillin >90% effective High-dose oral amoxicillin >90% effective MIC 2-4: resistant MIC 2-4: resistant Oral therapy likely to fail; IV ampicillin or penicillin Oral therapy likely to fail; IV ampicillin or penicillin MIC >4: very resistant MIC >4: very resistant Standard-dose ampicillin likely to fail; ceftriaxone effective Standard-dose ampicillin likely to fail; ceftriaxone effective

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34 Specific Treatment for CAP

35 Specific Treatment of CAP

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37

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39 Viral Pneumonia in Children Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia (except influenza) Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia (except influenza) Hamano-Hasegawa, J Infect Chemother (2008) Hamano-Hasegawa, J Infect Chemother (2008) Younger children more likely to have viral pneumonia Younger children more likely to have viral pneumonia Evidence of bacterial co-infection in 33% Evidence of bacterial co-infection in 33% Michelow, Pediatrics (2004) Michelow, Pediatrics (2004) Bacterial co-infections seen in 54% of viral pneumonias Bacterial co-infections seen in 54% of viral pneumonias 67% of influenza pneumonia 67% of influenza pneumonia 55% of RSV pneumonia 55% of RSV pneumonia

40 Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.Pediatrics.

41 Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.Pediatrics.

42 Viral Pneumonia in Children A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pneumonia A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pneumonia 27% developed influenza-associated pneumonia 27% developed influenza-associated pneumonia Of these, 2% had a bacterial co-infection Of these, 2% had a bacterial co-infection 18 identified by blood cultures; 3 by pleural fluid 18 identified by blood cultures; 3 by pleural fluid The actual incidence of secondary bacterial pneumonia with influenza is likely much higher The actual incidence of secondary bacterial pneumonia with influenza is likely much higher Dagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized With Laboratory-Confirmed Influenza, 2003-2008.” Pediatr Infect Dis J. 2010 Jul;29(7):585-90.Pediatr Infect Dis J.

43 Adjunctive Therapy CXR should be obtained if suspicious for effusion CXR should be obtained if suspicious for effusion US or CT if CXR is inconclusive US or CT if CXR is inconclusive Size of effusion and respiratory compromise will determine treatment Size of effusion and respiratory compromise will determine treatment

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45 Pleural Fluid Tests Gram stain (+25-50%) Gram stain (+25-50%) Antigen or PCR if available (S. pneumoniae, S.aureus) Antigen or PCR if available (S. pneumoniae, S.aureus) Pleural fluid analysis rarely changes management and is not recommended Pleural fluid analysis rarely changes management and is not recommended WBC count with differntial helps differentiate source WBC count with differntial helps differentiate source Majority of cultures will be negative Majority of cultures will be negative

46 Effusion/Empyema Total antibiotic therapy 2-4 weeks or 10 days after resolution of fever Total antibiotic therapy 2-4 weeks or 10 days after resolution of fever If abscess or necrosis is identified tx should begin with IV antibiotics If abscess or necrosis is identified tx should begin with IV antibiotics If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV antibiotics If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV antibiotics Abscess secondary to congenital malformation requires surgery consultation Abscess secondary to congenital malformation requires surgery consultation Necrosis should not routinely be managed surgically given high rates of broncho-pleural fistulas Necrosis should not routinely be managed surgically given high rates of broncho-pleural fistulas

47 A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient? 1. Complete blood count 2. Chest radiograph 3. Pulse oximetry 4. Blood culture 5. All of the above

48 A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria? 1. Able to tolerate outpatient meds, greater level of activity, improving appetite. 2. Afebrile for over 24 hours 3. Pulse oximetry measurements >90% in room air at least 12 hours 4. A and C 5. A, B, and C

49 Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient? 1. A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days. 2. Amoxicillin 90mg/kg/day divided 2 times a day for 10 days 3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5 4. Combined treatment with both amoxicilln and azithromycin as noted above 5. No anti-infective therapy indicated

50 Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient? 1. A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days. 2. Amoxicillin 90mg/kg/day divided 2 times a day for 10 days 3. Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5 4. Combined treatment with both amoxicilln and azithromycin as noted above 5. No anti-infective therapy indicated

51 A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of: 1. Ceftriaxone intravenously at 100mg/kg/day 2. Levofloxacin intravenously at 20 mg/kg/day 3. Ampicillin intravenously at 400 mg/kg/day 4. A or C 5. A, B, or C

52 BMJ 2003; 327:1459-1461


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