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Community Acquired Pneumonia in Children June 2014 Pediatric Continuity Clinic Curriculum Created by: Cecile Besingi.

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Presentation on theme: "Community Acquired Pneumonia in Children June 2014 Pediatric Continuity Clinic Curriculum Created by: Cecile Besingi."— Presentation transcript:

1 Community Acquired Pneumonia in Children June 2014 Pediatric Continuity Clinic Curriculum Created by: Cecile Besingi

2 Objectives Describe clinical manifestations of CAP. Discuss outpatient treatment options for CAP. Discuss indications for hospitalization.

3 Case # 1 A 5 yr. old female presents to the outpatient acute clinic with a 10 day history of cough and rhinorrhea. Rhinorrhea has been improving but cough is getting worse and patient has been febrile for the past 2 days. She also reports abdominal pain since yesterday. Discussion Questions: What other findings on exam, if present would help rule in a diagnosis of pneumonia? What is the most likely organism causing this patient’s symptoms?

4 What other findings on exam, if present would help rule in a diagnosis of pneumonia? In general, signs and symptoms of pneumonia are non- specific, and vary depending on the patient’s age, responsible pathogen and severity of infection. Fever and cough are the hallmark of pneumonia in all age groups. Other signs and symptoms that are highly specific but not sensitive for pneumonia include: – Crackles (rales) – Rhonchi – Retractions (and nasal flaring in young infants)

5 What other findings on exam, if present would help rule in a diagnosis of pneumonia? The WHO uses tachypnea and retractions to diagnose pneumonia in children < 5 yrs. old. Tachypnea becomes less sensitive and specific as age increases. Upper Lobe pneumonias may mimic meningitis due to radiating neck pain. Lower Lobe pneumonias may mimic appendicitis due to vague abdominal pain

6 What is the most likely organism causing this patient’s symptoms? Answer: Streptococcus pneumoniae Rationale: Our patient had fever, cough, and abdominal pain which is suggestive of a lower lobe pneumonia. Pneumococcal pneumonia is typically lobar, presenting with fever, nonproductive cough, tachypnea and decreased breath sounds (or crackles) over the affected lobe. It is often difficult to differentiate between Atypical bacterial pneumonia and viral pneumonia.

7 Viral and atypical pneumonias Viral pneumonia: – More common in children less than 5 yrs. old – Usually a gradual insidious onset – Usually with URI symptoms – Auscultatory findings are more likely to be diffuse. – Wheezing is more frequent in viral vs. bacterial pneumonia Atypical pneumonia: – More common in school aged children (< 5 yrs. old) – Usually caused by Mycoplasma or Chlamydia pneumoniae. – Symptoms may include abrupt onset of fever, malaise, myalgia, headache, sore throat, hoarseness and gradually worsening prolonged non-productive cough. – Diffuse auscultatory findings including wheezing

8 Case # 2-1 7 yr. old female presents with nonproductive cough and fever of three days duration. You note crackles on auscultation of right middle lobe area and diagnose a lobar pneumonia. She is otherwise well appearing. Discussion Question: What antimicrobial therapy is appropriate for empiric treatment of this infection? Case # 2-2 Your patient has been on the 1 st line antimicrobial therapy for > 72 hours and is still febrile with no significant improvement in her cough. She now reports mild intermittent shortness of breath with activity but no other new symptoms. Discussion question: What are possible reasons for presumed treatment failure?

9 What antimicrobial therapy is appropriate for empiric treatment of this infection? Answer: 1 st line therapy with Amoxicillin or amoxicillin- clavulanate. Rationale: S. pneumoniae remains the most common implicated pathogen. Clavulanate adds the benefit of action against B-lactamase producing organisms such as H. influenza and Moraxella catarrhalis. For patients with penicillin allergy, 2 nd line options include 2 nd or 3 rd generation cephalosporins (e.g. cefdinir), clindamycin, macrolides (e.g. azithromycin) and levofloxacin.

10 Antibiotic Choice—Outpatient (Table from pediatric care online – AAP)

11 What are possible reasons for presumed treatment failure (in patient already on 1 st line therapy for lobar pneumonia)? 1.Ineffective antibiotic coverage a.Lack of coverage for actual etiology, e.g. organism is atypical b.Resistant organism 2.Pneumonia complications (more likely with bacterial rather than atypical or viral pneumonias) a)Pleural effusion or empyema (distant breath sounds, friction rub on exam) 3.Alternative or coincident diagnosis e.g. Foreign body aspiration.

12 Additional information – diagnostic testing Pulse oximetry is recommended in all children with pneumonia and suspected hypoxemia. Initial Chest X-Ray (Table from pediatric care online – AAP)

13 Case #3 A 14 month old male presents to your outpatient acute clinic with a 2 day history of cough and fever. Vital signs reveal RR 52, HR 175, O2 sat of 88% on room air. On exam, you note crackles in the right lower lobe area, intercostal retractions, but no wheezing. You start the patient on oxygen via nasal cannula and O2 saturation increases to 94%. Discussion question: What is your next course of action?

14 Answer: Call the ED and transfer patient to the hospital for further evaluation and possible admission.

15 Indications for Hospitalization Hypoxia (oxygen saturations < 90 to 92%) Infants < 3 months with suspected bacterial infection. Respiratory distress (grunting, difficulty breathing, poor feeding). Tachypnea ( 70 or children with RR > 50). Inability to maintain hydration or oral intake Failure of outpatient therapy (48 to 72 hours with no response). Caretaker unable to provide appropriate observation or comply with prescribed home therapy.

16 General approach to childhood pneumonia Gereige R S, and Laufer P M Pediatrics in Review 2013;34:438-456

17 PREP Question Prevention of pneumonia in children includes active immunization of adult caretakers of infants younger than 6 months against which of the following pathogens? A. Bordetella pertussis. B. Haemophilus influenzae type b. C. Neisseria meningitidis. D. Respiratory syncytial virus. E. Tuberculosis.

18 PREP Question Prevention of pneumonia in children includes active immunization of adult caretakers of infants younger than 6 months against which of the following pathogens? A. Bordetella pertussis. B. Haemophilus influenzae type b. C. Neisseria meningitidis. D. Respiratory syncytial virus. E. Tuberculosis.

19 PREP Question A 10-year-old boy presents with a history of fever, headache, malaise, mild sore throat, and worsening nonproductive cough. Lung examination reveals diffuse crackles. Chest radiographs reveal bilateral diffuse patchy infiltrates. The next step in management is to prescribe: A. Amoxicillin. B. Amoxicillin-clavulanate. C. Azithromycin. D. Cephalexin. E. Penicillin.

20 PREP Question A 10-year-old boy presents with a history of fever, headache, malaise, mild sore throat, and worsening nonproductive cough. Lung examination reveals diffuse crackles. Chest radiographs reveal bilateral diffuse patchy infiltrates. The next step in management is to prescribe: A. Amoxicillin. B. Amoxicillin-clavulanate. C. Azithromycin. D. Cephalexin. E. Penicillin.

21 References and Future Reading Pneumonia: Pediatrics in Review October 2013 Current diagnosis & Treatment of CAP in children - Highlights of the PIDS/IDSA National guidelines: Pediatric Care Online AAP


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