The McMaster at night

Pediatric Curriculum

Based on CPS Practice Point “Pneumonia in healthy Canadian children and youth” and the

British Thoracic Society Guidelines on CAP

Community Acquired Pneumonia

Objectives •  To describe the clinical signs and symptoms of community-

associated pneumonia (CAP) •  To outline appropriate diagnostic investigations for CAP based

current evidence and guidelines •  To discuss the most responsible microorganisms for CAP, and

develop an approach to empiric antimicrobial therapy in the outpatient and inpatient setting

•  To outline management, including reasons for admission, for

CAP based on clinical severity •  To discuss complications of CAP

Background •  Acute inflammation of parenchyma of LRT caused by

microbial pathogen •  CAP = clinical signs/symptoms of pneumonia in

previously healthy children due to infection acquired outside of hospital •  In developed countries, often verified by CXR

•  Common! •  One in 20 children <5 years old will contract

pneumonia each year •  Single largest cause of death worldwide as per WHO

Background ���  •  This presentation does not address persistent

(chronic) pneumonia syndromes, aspiration pneumonia, or recurrent pneumonias, or those associated with chronic medical problems such as immunodeficiency ���  

The Case •  4 year old Lila presents to the ER with a three day

history of cough. She has been persistently febrile over the past 1 day.

•  In triage, her vitals are: •  T39°C (oral), HR 130, RR40, SpO2 94% on RA

History

What would you ask?

History •  Constitutional

•  Level of activity and energy •  Fever* •  Chills and rigours

•  Respiratory symptoms •  Shortness of breath •  Cough •  Work of breathing •  Chest pain

•  Feeding •  Poor feeding and vomiting common •  Always assess for level of hydration (i.e. ask about amount of

voids/wet diapers)!

•  Abdominal pain •  Common in lower lobe pneumonias, can mimic appendicitis

Physical Exam

What would you look for?

Physical Exam •  Vitals

•  Tachypnea** •  Highest sensitivity + specificity for radiographically proven

pneumonia •  Oxygen saturation and need for supplemental O2

Physical Exam •  Inspection

•  Level of activity and mental status •  Work of breathing •  Level of hydration

•  Respiratory •  êVesicular breath sounds •  éBronchial breath sounds •  Dullness to percussion •  Crackles •  All of the above are specific, NOT sensitive

•  Absence might help you rule out pneumonia!

•  **Wheezing is unlikely in pneumonia; indicates atelectasis and mucus plugging from asthma or bronchiolitis

Physical Exam •  Cardiovascular

•  Assess perfusion and cardiovascular status •  Look for signs of sepsis! •  Ask yourself: do they look ‘toxic’ or unwell?

Physical Exam •  The Bottom Line •  Consider pneumonia in any child with persistent

or repetitive fever >38.5°C with tachypnea or retractions

Test your Knowledge

•  What is the most common cause of pneumonia in infants and preschool children?

A.  Streptococcus pneumoniae B.  Mycoplasma pneumoniae C.  Viruses D.  Haemophilus influenzae

non-typeable

Test your Knowledge

•  What is the most common cause of pneumonia in infants and preschool children?

A.  Streptococcus pneumoniae B.  Mycoplasma pneumoniae C.  Viruses D.  Haemophilus influenzae

non-typeable

The Answer

•  In preschool children, viruses (i.e. RSV, influenza, parainfluenza) that circulate in winter are the most common cause

•  Viruses as the sole cause of pneumonia are less common in older children, except for influenza

•  Name some bacterial causes!

?

Bacterial Etiologies •  Streptococcus pneumoniae** (most common) •  Group A strep •  Staphylococcus aureus •  Haemophilus influenza non-typeable •  Mycoplasma pneumoniae •  Chlamydophila pneumoniae

•  There is no reliable way of clinically distinguishing between viral and bacterial etiologies

Seen  in  children  >3-­‐4  years  of  age  

Workup

What would you order?

Workup

•  Chest X-ray

•  “Pneumonia is over-diagnosed in the absence of radiological confirmation. It is encouraged whenever possible to support the clinical diagnosis” (CPS Statement)

•  BTS suggests that CXR should not be routinely done in a child with

clinical signs and symptoms of pneumonia who is not admitted to hospital

•  Obtain PA view •  Sensitivity & specificity 100% of frontal x-ray alone •  Lateral view is not routinely performed in CAP (BTS guideline)

Workup

Images  from:  h8p://emedicine.medscape.com/ar<cle/967822-­‐overview  

Lobar  pneumonia  (S  pneumoniae)   Viral  pneumonia  

Workup

Images  from:  h8p://radiopaedia.org/ar<cles/atypical-­‐pneumonia  h8p://osp.mans.edu.eg/tmahdy/Students/X-­‐Ray/CHEST/pages/STAPH%20PNEUMONIA2.htm  

Atypical  pneumonia  •  Patchy  re<culnodular  

opaci<es  +  atelectasis  •  More  extensive  than  

clinical  findings  suggest  

Staph  aureus  pneumonia    •  Pneumatocele  

Workup •  Microbiological samples

•  NPS for viruses only if admitted •  Assists with cohorting patients

•  Most children cannot provide a sputum sample •  If available, send for Gram staining & culture

•  Pursue additional invasive testing if child fails to improve or worsens on therapy

•  Blood culture

•  <5–10% positive in pneumonia, obtain in admitted patients

Workup •  CBC

•  Higher WBC in bacterial pneumonia versus viral/atypical •  Indicated only in admitted patients

•  Acute Phase Reactants

•  i.e. CRP •  Not helpful in distinguishing viral versus bacterial causes •  Not useful for management of uncomplicated CAP

Management •  Most children can be managed as outpatients •  Indications for admission:

•  Unable to eat or drink, vomiting •  Inability to comply with oral therapy •  Dehydration •  Sepsis •  Hypotension •  SpO2<92% •  Increased WOB (chest retractions) •  Any evidence of empyema or abscess

•  There should be a low threshold for admitting children <6 months because it can be difficult for caregivers to recognize deterioration

Test Your Knowledge

•  In a 3 year –old child with CAP who does not require oxygen or admission, what is the suggested first line antimicrobial treatment?

A.  Cefuroxime po 150 mg/g/day B.  Azithromycin 10 mg/kg x 1 day then 5

mg/kg/day x 2–5 days C.  Amoxicillin 30–40 mg/kg/day D.  Amoxicillin 80–90 mg/kg/day

Test Your Knowledge

•  In a 3 year –old child with CAP who does not require oxygen or admission, what is the suggested first line antimicrobial treatment?

A.  Cefuroxime po 150 mg/g/day B.  Azithromycin 10 mg/kg x 1 day then 5

mg/kg/day x 2–5 days C.  Amoxicillin 30–40 mg/kg/day D.  Amoxicillin 80–90 mg/kg/day

Antimicrobial Therapy •  Viruses: supportive care •  Bacterial CAP: •  Non-severe* pneumonia: high dose amoxicillin

or ampicillin IV •  Non-severe pneumonia with features of atypical

pneumonia: clarithromycin or azithromycin po

•  *Non-severe pneumonia = does not require hospital admission or requires admission and requires minimal supplemental O2 (<30%) and is in minimal respiratory distress

Antimicrobial Therapy •  Bacterial CAP: •  Severe* pneumonia: Ceftriaxone IM/IV or

Cefotaxime IV plus clarithromycin PO or azithromycin PO/IV

•  *Severe pneumonia = requires significant supplemental oxygen, patient in moderate respiratory distress, or may require ICU

•  CTX offers better coverage for penicillin-resistant pneumococcus

•  Clarithromycin/azithromycin do NOT always cover pneumococcus but covers atypicals well

Antimicrobial Therapy •  Penicillin-allergic patients: •  Non-severe pneumonia: Clarithromycin PO or

azithromycin PO/IV •  Severe pneumonia: if not IgE mediated allergy,

cephalosporins (i.e. cefuroxime) can be used •  If IgE-mediated, consult with ID

Complications

•  Pleural effusion or empyema •  Consider if patient still febrile after >48 h antibiotics •  Assess with chest U/S

•  If moderate or large effusion, consider pleural tap (with surgical & ID consultation!)

•  Ceftriaxone/cefotaxime + azithromycin +/- cloxacillin •  Requires longer duration of therapy as determined

by clinical course

•  Abscess •  Assess with CT scan

Further Management

•  Repeat CXR •  Not recommended in uncomplicated CAP •  Children with lung abscess or pleural effusion

require repeat CXRs and follow-up until complete resolution

Summary •  Community-acquired pneumonia is common in healthy

children •  Consider in any child with tachypnea & fever

•  CXR should be used to confirm diagnosis •  Viruses are the most common cause, and Strep pneumoniae is

the most common bacterial cause •  Investigate with NPS, blood culture, CBC only if admitted •  High dose amoxicillin for non-severe pneumonia, and third

generation cephalosporin + macrolide for severe pneumonia •  Repeat CXRs are generally not necessary to follow-up for

resolution (clinical exam is enough!)

Fin

References  •  Le Saux N, Robinson JL. Pneumonia in healthy Canadian

children and youth: Practice points for management. (2011). Paediatr Child Health; 16(7): 417–20

•  Harris M, Clark J, Coote N, Fletcher P, Harnden A,

McKean M, Thomson A, on behalf of the British Thoracic Society Standards of Care Committee. British Thoracic Society Guidelines for management of community-acquired pneumonia: update 2011. (2011). Thorax; 66(2): ii1-ii23

•  Gereige RS and Laufer PL. Pneumonia. (2013).

Pediatrics in Review. 34(10): 438–456.