cari protocol

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

Dr. TRIASTA, MAMC, 2012

A child with cough or difficult breathing

ASSESS

Ask: How old is the child? Is the child coughing? For how long? Ages 2mos. – 5y.o: Is the child able to

drink? Age less than 2mos: Has the young

infant stopped feeding well? Does the child has fever? Has the child had convulsions?

LOOK, LISTEN

Count the breaths in one minute

Look for chest indrawing

Look and listen for stridor

Look and listen for wheeze

Is it recurrent

See if the child is abnormally sleepy or difficult to wake

Feel for fever or low body temperature

Look for severe malnutrtion

FAST BREATHING

Young infant age less than 2 months:

60 breaths per minute or more

Child age 2 months up to 12months:

50 breaths per minute or more

Child age 1 to 5 years:

40 breaths per minute or more

A child has INDRAWING if:

The lower chest wall goes in when the child breathes in

CHEST INDRAWING is a sign of severe pneumonia in children aged 2 months up to 5 years

Only SEVERE CHEST INDRAWING is a sign of severe pneumonia in young infants

CLASSIFY THE ILLNESS2 months up to 5 years

SIGNS: Not able to

drink Convulsions Abnormally

sleepy or difficult to wake

Stridor in calm child

Severe

malnutrition

Classify VERY SEVERE

DISEASE

Treatment: Refer Urgently

to hospital Give first dose

of antibiotics Treat fever if

present Treat

wheezing, if present

Age less than 2months

SIGNS: Stopped feeding

well Convulsions Abnormally sleepy Stridor in calm

child Wheezing Fever or low body

temperature

CLASSIFY: VERY SEVERE

DISEASE

TREATMENT Refer URGENTY

to hospital Keep infant warm Give first dose of

an antibiotic

< 2 months old

No Pneumonia

Severe Pneumonia

Very Pneumonia

RR < 60 bpm

No chest indrawing

RR > 60 bpm

Severe chest indrawing

Central cyanosis

Poor feeding

wheezing

Stridor, sleepy

Home care

Admit

Pen G + Genta

Pen G + Genta

2 months - 5 yearsNo pneumonia

Pneumonia

Severe Pneumonia

RR< 50 bpm <40 1-5y.o No chest

indrawing

RR >40 bpm No chest

indrawing

Chest indrawing No central

cyanosis

Able to drink

cough > 30days ASSESS

homecare

Homecare Cotri PO, Amox,

Ampi or Pen

Admit Pen IM/IV

2 months - 5 years

Very severe Pneumonia

Central cyanosis Inability to feed/drink Stridor Convulsions Sleepy

Admit Chloram IM/IV Worse Chloram--

Cloxa+ Genta (Staph pneumonia)

Most common pathogens: Streptococcus pneumoniae Chlamydia pneumoniae Mycoplasma pneumoniae

Major causes of hospitalizations: Streptococcus pneumoniae Haemophilus influenzae Staphycoccus aureus

Neonates: Group B, E.coli,Strep pneumonia, H.influenzae

< 3 Respiratory syncytial virus, Strep pneumonial,

Influenzae virus

Introduction

Pneumonia - is defined as the inflammation of lung tissue caused by an infectious agent that results in Acute respiratory signs and symptoms

It can be either Acquired (Community Acquired) or within the hospital (Hospital acquired)

It is ranked to be the 3rd in ten leading cause of morbidity

Etiologic causes of Pneumonia

AGE GROUP ETIOLOGY

1. Neonates Group B StrepcoccusE. ColiL. Monocytogenes

2. Infants younger than 3 mos. Group B StrepcoccusChlamydia Trachomatis

3. Older infants, pre schoolers, younger than 5 years old

Strep.pneumoniaeH.Influenzae

4.Older than 5 years old

5. 5-10 years old

S.PneumoniaeMycoplasma PneumoniaeC. PneumoniaeM. Pneumonaie

SIGNS AND SYMPTOMS

COUGH FEVER

SIGNS AND SYMPTOMS

DIFFICULTY OF BREATHING CHEST PAIN

SIGNS AND SYMPTOMS

VOMITING ABDOMINAL PAIN

Who shall be considered as having Community Acquired Pneumonia? Predictors of Community Acquired

Pneumonia in patient with cough

1. For ages 3 months-5 years are tachypnea and or chest indrawing

2. For ages 5-12 years are fever, tachypnea, and crackles

3. Beyond 12 years old are the presence of the following features:

A. Fever, tachypnea and tachycardia B. At least one abnormal chest findings of diminished

breath sounds, rhonchi, crackles and wheezes

2. Who will require admission?

1. A patient who is at moderate risk to develop pneumonia-related mortality should be admitted.

2. A patient who is at minimal to low risk can be managed on out patient basis

Risk Classification for Pneumonia Based MortalityVARIABLE PCAP A

Min riskPCAP BLow risk

PCAP CMod risk

PCAP DHigh risk

1. Co-morbid illness

None Present Present Present

2.Compliant caregiver

Yes Yes No No

3.Ability to follow up

Possible Possible Not possible Not possible

4. Presence of dehydration

None Mild Moderate Severe

5.Abilty to feed Able Able Unable Unable

6. Age >11 mo. >11 mo. <11 mo. <11 mo.

7. RR2-12 mo.1-5 yrs>5 yrs

>50/min>40/min>30/min

>50/min>40/min>30/min

>60/min>50/min>35/min

>70/min>50/min> 35/min

Risk Classification for Pneumonia Based Mortality

8. Signs of resp. Failurea. Retractionb. Head bobbingc. Cyanosisd.Gruntinge. Apnea

f. Sensorium

NoneNoneNone

NoneNoneNoneAwake

NoneNoneNone

NoneNoneNoneAwake

Intercostal/SPresentPresent

PresentNoneNoneIrritable

Supra/Inter/Subcostal retsPresentPresent

PresentPresentPresentLethargic/StuPurous/comatose

9. Complications None None Present Present

ACTION PLAN OPD follow up at the end of the treatment

OPD follow up after 3 days

Admit to regular ward

Admit to crtitical care unitRefer to specialist

3.What diagnostic aids are initially requested for a patient classified as either PCAP A or B being managed in the ambulatory setting?

No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in the ambulatory setting

4. What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D being managed in a hospital setting?

1. The following should be routinely requested: A. Chest Xray PA-lateral B. White blood cell count C. Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and Pulse oximetry 2. The following maybe requested: Culture and sensitivity of sputum for older children 3. The following should not be routinely requested: A. Erythrocyte sedimentation rate C reactive protein

5 When is antibiotic recommended? An antibiotic is recommended 1. For a patient classified as either PCAP A or B and is A. Beyond 2 years of age B. Having high grade fever without wheeze 2. For a patient classified as PCAP C and is A. Beyond 2 years of age B. Having high grade fever without any wheeze C, Having alveolar consolidation in the Chest Xray D. Having a WBC of >15000 3 . For a patient classified as PCAP D

6.What empiric treatment should be administered if a bacterial etiology is strongly considered? 1. For a patient classified as PCAP A or B without

previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses) is the drug of choice.

2. For a patient classified as PCAP C without previous antibiotic and who has completed the primary immunization against Haemophilus influenzae type B, Penicillin G(100, 000 units/kg/day in 4 divided doses) is the drug of choice

If a primary immunization against Hib has not been completed, IV Ampicillin (100 mg/kg/day in 4 divided doses) should be given.

3. For a patient classified as PCAP D, a specialist should be consulted

7.What treatment should initially be given if a Viral etiology is strongly considered?

1. Ancillary treatment should be given 2. Olsetamivir (2mg/kg/dose BID for 5

days) or Amantadine (4-8 mg/kg/day for 3-5 days) may be given for Influenza that is either confirmed by laboratory or occuring as an outbreak

When can be a patient be considered as responding to the current antibiotic?

1. Decrease in respiratory signs (particularly tachypnea) and deferverescene within 72 hours after initiation of antibiotic are predictors of a favorable therapeutic response

2. Persistence of symptoms beyond 72 hours after initiation of antibiotic requires reevaluation

3. End of treatment Chest Xrat,WBC,ESR,CRP should not be done to asses therapeutic response to antibiotic

9.What should be done if a patient is not responding to a current antibiotic therapy 1. If an outpatient classified as either PCAP A or

PCAP B is not responding to the current antibiotic within 72 hours, consider any of the following

a. Change the initial antibiotic b. Start on an oral macrolide c. Reevaluate diagnosis 2. If an inpatient classified as PCAP C is not

responding to the current antibiotic within 72 hours, consider consultation with a specialist because of trhe following possibilities:

a. Penicillin resistant Strepcoccous pneumoniae

What should be done if a patient is not responding to a current antibiotic therapy

Continuation: b. Presence of complications

(pulmonary or extrapulmonary) c. Other diagnosis

3. If an inpatient classified as PCAP D is not responding to the current antibiotic within 72 hours, consider immediate re-consultation with a specialist

10. When can switch therapy in bacterial pneumonia could be started?

Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotics is recommended in a patient who

A. Is responding to the initial antibiotic therapy

B. Is able to feed with intact gastrointestinal absorption

C. Does not have any pulmonary or extrapulmonary complications

11. What ancillary treatment can be given? 1. Among inpatients, oxygen and

hydration should be given if needed 2. Cough preparations, chest

physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in Community acquired pneumonia.

3. In the presence of wheezing, a bronchodilatory maybe administered.

12. How can Pneumonia be prevented? 1. Vaccines recommended by the Philippine

Pediatric Society should be routine administered to prevent Pneumonia

2. Zinc supplementation (10 mg for infants and 20 mg for children)beyond 2 years of age given for a total of 4-6 months maybe administered to prevent Pneumonia

3. Vitamin A, immunomodulators and Vitamin C should not be routinely administered as preventive strategy.