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Starship Children’s Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.

PNEUMONIA

Author: Drs Best, Brabyn, Shepherd & Twiss Services: CED, Respiratory, ID, Gen Paeds Editor: Dr Raewyn Gavin Date Reviewed: August 2010 Pneumonia Page: 1 of 8

• Introduction

• Clinical features

• Causative Organisms

• Investigations

• Treatment

• Admission

• Follow-up

• Recurrent pneumonia or persistent symptoms

• Complications

• Prevention: Environment & underlying conditions

• References

IntroductionIntroductionIntroductionIntroduction

These guidelines may not be appropriate for the immunocompromised child or a child with chronic lung disease (e.g. cystic fibrosis, bronchiectasis, neonatal chronic lung disease). Pneumonia, bronchiolitis and asthma are all common illnesses that result in children presenting with acute lower respiratory symptoms and signs. Antibiotics should be given to children with bacterial pneumonia but not to children with bronchiolitis or asthma. The New Zealand population has high rates of pneumonia, complicated pneumonia and long term sequelae (eg bronchiectasis). Pneumonia is more common and more severe in younger children. In Auckland the hospitalisation rate of those < 2 years is 11 times higher than those aged ≥ 4.

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Most children with pneumonia present with cough or difficulty breathing, but only the minority of children with these symptoms have pneumonia. Bacterial pneumonia should be considered in children <3 years of age who present with fever > 38.5, chest recession and increased respiratory rate >50 breaths/minute. Older children with bacterial pneumonia often present with difficultly breathing in combination with tachypnoea. If wheeze is present in a preschool child, primary bacterial pneumonia is unlikely however in school age children it may suggest Mycoplasma pneumoniae (see below). Tachypnoea is a key clinical sign Tachypnoea by age (World Health Organisation) < 2 months age > 60 breaths per minute 2- 12 months age > 50 breaths per minute 12 months to 5 years age > 40 breaths per minute

If chest indrawing, nasal flaring, grunting or crepitations are also present then the probability of pneumonia is increased further. Atypical presentations without obvious respiratory symptoms are not rare (abdominal pain and vomiting mimicking an acute abdomen, meningism mimicking meningitis).



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Causative OrganismsCausative OrganismsCausative OrganismsCausative Organisms

In developed countries the aetiology of community acquired pneumonia has been defined by the child’s age as well as the severity of the episode of illness. Likely causative organisms by age group are shown in Table 1. Mycoplasma pneumoniae should be suspected in school age children especially if the onset of symptoms is insidious and/or the child has wheeze, headache or arthralgia. Cold agglutinins and serial mycoplasma serology may be helpful in confirming mycoplasma but seldom influence management decisions so aren’t routinely recommended.

Table 1: Aetiology of Pneumonia by Age Group in Developed Countries*

Age group Predominant organisms**

0 to 1 months Group B streptococcus Gram negative organisms Chlamydia trachomatis Listeria monocytogenes

1 to 24 months

Respiratory syncytial virus (RSV) and other viruses †

Streptococcus pneumoniae Haemophilus influenzae (non typeable) Bordetella pertussis

2 to 5 years Respiratory syncytial viruses (RSV)

and other viruses †

Streptococcus pneumoniae Haemophilus influenzae (non typeable)

6 to 18 years Mycoplasma pneumoniae Chlamydia pneumoniae Streptococcus pneumoniae accounts for up to 30% Respiratory viruses account for < 15% of episodes

* The proportion of pneumonia due to bacteria increases with age and within each age group likelihood of bacterial infection increases with increasing severity. † Other respiratory viruses = Influenza A and B, parainfluenzae 1-3 , adenoviruses, human metapneumovirus, human coronavirus. Mixed bacterial and viral infection can occur in up to 40%. ** Staphylococcus aureus is an important pathogen of serious pneumonia to remember in all age groups

InvestigationsInvestigationsInvestigationsInvestigations

Many children with pneumonia may be diagnosed and managed on clinical grounds alone. Radiology does not reliably distinguish bacterial from viral pneumonia so does not determine the need for antibiotics. A chest x-ray may be indicated if:

• Presentation is atypical

• There is diagnostic uncertainty

• Infants <3 months of age

• Child who is severely unwell

• Child has a history suggesting underlying respiratory disease

• Complications (such as effusion) are suspected (based on clinical signs or not making anticipated clinical progress).



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Sputum, throat swabs and NPA for bacterial cultures do not help determine who should receive antibiotics. An NPA may be indicated for cohorting patients being admitted, for diagnosis of suspected viral pneumonia (< 2years) and deciding who may benefit from antiviral medication such as oseltamavir. A blood culture is an insensitive test for bacterial pneumonia in children however blood cultures should be considered in the unwell child with pneumonia, especially the child suspected of having Staphylococcus aureus or complicated pneumonia. Fever magnitude, full blood count findings or CRP do not reliably differentiate viral from bacterial pneumonia.

TreatmentTreatmentTreatmentTreatment

Children suspected with bacterial pneumonia should be treated with antibiotics. Antibiotics do not prevent pneumonia in children with upper respiratory tract infections. In contrast to pneumococcal meningitis, respiratory infections with pneumococci with reduced susceptibility to penicillin have not been shown to have worse outcomes and decreased susceptibility can be overcome with the use of high oral or IV dosing of penicillin.

1. Oral Antibiotics

Oral antibiotics will provide adequate coverage for most mild to moderate episodes of pneumonia. This may include some of those requiring admission. There is no role for outpatient oral antibiotic therapy for infants < 3 months of age with pneumonia.

Age Antibiotic Dose Duration

3 months to 5 years High dose amoxycillin 30 mg/kg/dose TDS*,

maximum 500mg/dose

5-7 days

≥ 5 years High dose amoxycillin

30 mg/kg/dose TDS*

Maximum 1000mg/dose

5-7 days

Erythromycin, 12.5mg/kg/dose QID ≥ 5 years, Mycoplasma pneumonia suspected

OR, Roxithromycin (tablets only)

4mg/kg, BD

7-10 days

* Oral amoxycillin dose has been increased from previous guidelines in view of increased pneumococcal resistance (consistent with international best practice).



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2. Parenteral antibiotics Should only be used for those requiring admission (see below) A) Pneumonia Not Likely To Be Staphylococcal Suggested empirical IV therapy for inpatients with uncomplicated pneumonia (no suspicion of staphylococcal disease, no lung abscess nor pleural effusions) is:

Age Antibiotic Dose Interval

(hrs)

Less than 3 months Cefotaxime +

Amoxycillin

50 mg/kg/dose

50 mg/kg/dose

8i

6ii

≥ 3 months (fully immunisediv)

Amoxycillin 30- 50 mg /kg/dose

(maximum 2000 mg / dose)

8

i. In term babies < 7 days old, reduce to 12 hourly ii. In term babies < 7 days old, reduce to 8 hourly iii. In a child > 5 years, if suspicion of mycoplasma consider addition of an oral macrolide iv. Unimmunised children should be treated according to the complicated pneumonia

recommendations below.

Duration of therapy is determined by clinical response. Intravenous therapy should be used until the child is afebrile and, in the case of severe pneumonia, for several days after this. Total duration of therapy is usually 7 -10 days.

Monitor pulse rate, respiratory rate, temperature, and oxygen saturation. B) Complicated pneumonia

< 3 months Cefotaxime and amoxycillin as above

≥3 months Amoxycillin + Clavulanic acid* OR Cefuroxime*

30mg/kg/dose (max 1.2g/dose

q6h)

30mg/kg/dose (max 1.5g/dose)

6-8 hourly 8 hourly

* Following intravenous treatment options for oral antibiotics include amoxycillin-clavulanic acid syrup/tablets or cephalexin syrup/tablets



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C) Probable Staphylococcal Pneumonia Staphylococcal pneumonia is classically associated with lung abscess and empyema. Consider it in any child who is very unwell, has abscesses or metastatic infection or has developed pneumonia as a consequence of chicken pox, influenza or measles. Diagnosis should be confirmed by blood culture and/or aspirate. Staphylococcal pneumonia is a medical emergency – if you suspect it, you must discuss the child with your consultant. Appropriate initial IV antibiotics for probable S.aureus pneumonia are:

Flucloxacillin +/- Clindamycin*

50mg/kg (max 2000mg/dose)

10mg/kg (max 450mg/dose)

6 hourly

6-8 hourly

*Addition of clindamycin should be based on local methicillin resistant Staphylococcus aureus rate where >10% is suggestive of need to add anti-MRSa drug. *ID approval is required for use of Clindamycin >48 hours

• Multi-resistant-S.aureus remains uncommon as a cause of pneumonia, so Vancomycin is rarely required as empiric treatment.

• Antibiotic choice should be rationalised once culture results available.

AdmissionAdmissionAdmissionAdmission

Indications for admission include any of the following:

• Ill or toxic appearance.

• Age < 3 months.

• Hypoxaemia: oxygen saturation less than 93% on air

• Respiratory distress interfering significantly with feeding.

• Significant dehydration.

• Complicated pneumonia.

• Deterioration despite appropriate oral antibiotics.

• Significant co-morbidity

• Social concerns: no car, no phone, language or communication barrier

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Most children with pneumonia respond to quickly to treatment and make uneventful, full recoveries. Resolution of cough is expected in 4-6 weeks and when this does not occur the family should see their General Practitioner for further follow up and consideration of referral to General Paediatric outpatient clinic. A follow up chest x-ray is not routinely required but may be indicated in those with complicated pneumonia – see below, (including significant atelectasis / collapse) or chronic / recurrent symptoms.



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Children with recurrent pneumonia or persistent symptomsChildren with recurrent pneumonia or persistent symptomsChildren with recurrent pneumonia or persistent symptomsChildren with recurrent pneumonia or persistent symptoms

A history of recurrent pneumonia or chronic cough / respiratory symptoms should be sought at admission. This may be a sign of underlying vulnerabilities, chronic lung disease or environmental factors (see table below). History & clinical examination is the best starting point to investigate further. See Starship Guideline on ‘COUGH - investigation of chronic cough &/or confirmed bronchiectasis’ The child with recurrent pneumonia or persistent symptoms needs referral to General Paediatric outpatient clinic with further investigations arranged. It may be appropriate to discuss this referral prior to discharge from CED.

Pneumonia ComplicationsPneumonia ComplicationsPneumonia ComplicationsPneumonia Complications

Health professionals caring for children with pneumonia should be aware of the range of potential complications, how to recognise them and their management. The following serves to highlight these complications but is not intended as a full list nor a comprehensive guide to their management.

(a) Syndrome of inappropriate anti-diuretic hormone (SIADH): Inappropriate secretion of anti-diuretic hormone leads to retention of water and hyponatraemia. This is recognised frequently in paediatric respiratory illness. Most children should be managed with ¾ maintenance (see Intravenous Fluids guideline). Consider symptomatic hyponatraemia if there is irritability, an altered level of consciousness. Initial test is serum electrolytes. Seek expert advice on management.

(b) Lung necrosis: Necrosis and liquefaction of lung tissue. Suspicion may be raised by poor response to treatment, including persisting fever. Definitive diagnosis requires contrast chest CT (see expert advice before requesting this). Additional therapy or surgical intervention is not necessarily required and outcome with conservative management in childhood is usually good. Careful follow up is required as long term sequelae may follow.

(c) Pneumatocoele: These are thin-walled air-filled cysts that develop within the parenchyma. They are particularly associated with Staphylococcus aureus and will usually resolve over time without specific intervention. Careful follow up is recommended to ensure full recovery and resolution. Family should be notified that it may be unsafe for the child to fly while the pneumatocoele(s) are present.

(d) Atelectasis / Lobar collapse: This is not uncommon. Chest physiotherapy (airway clearance techniques) may be indicated. Follow up should be arranged to ensure resolution as may be associated with long term sequelae. Children with persistent lobar collapse should be referred to a respiratory paediatrician for review and potentially a flexible bronchoscopy.



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(e) Parapneumonic effusion / empyema: All children with pneumonia whose fever doesn’t settle on appropriate antibiotic therapy within 48hrs should be screened for a pleural collection (examination and chest x-ray). Children with parapneumonic effusions / empyema should be admitted on intravenous antibiotics (see complicated pneumonia above) to cover the likely organisms (Streptococcal species and Staphylococcus aureus but tuberculosis should be considered). Baseline full blood count, inflammatory markers and blood cultures are recommended. If the child is significantly compromised (high work of breathing, hypoxia, and/or persistent signs of sepsis), aren't making expected progress, or the effusion is very large, then additional intervention should be considered. This will usually be video-assisted thorascopic surgery (VATS) with a chest drain or a chest drain with fibrinolytic therapy. Both of these interventions result in more rapid recovery than a chest drain or antibiotics alone. A chest ultrasound is useful pre-intervention to confirm, quantify and characterise the effusion. Routine thoracocentesis or chest CT are not recommended. If you aren't familiar with empyema management, seek expert advise.

(f) Lung abscess: The symptoms and signs of lung abscess are the same as for pneumonia and they may be difficult to distinguish on clinical grounds alone. Diagnosis is usually made by chest x-ray supported by contrast CT chest. The presence of underlying lung disease or malformation, foreign body, aspiration, or immunodeficiency should be carefully considered. Blood cultures, full blood count and inflammatory markers should be obtained at diagnosis. Therapy is a prolonged course of antibiotics, usually a minimum of 4 weeks. Management of lung abscess should be guided by a respiratory paediatrician.

(g) Chronic bronchitis / bronchiectasis (sequelae): Children with persistent symptoms and/or signs including chronic productive cough, persistent crackles, clubbing and/or x-ray findings should be evaluated further for possible underlying bronchitis/bronchiectasis. See Starship Guideline on ‘COUGH - investigation of chronic cough &/or confirmed bronchiectasis’

Prevention: Environment and underlying conditions Prevention: Environment and underlying conditions Prevention: Environment and underlying conditions Prevention: Environment and underlying conditions associated with pneumoniaassociated with pneumoniaassociated with pneumoniaassociated with pneumonia

Environmental factors Underlying conditions

• tobacco smoke exposure

• poor nutrition

• poor housing

• over-crowding

• lack of immunisation

• chronic lung diseases (chronic bronchitis / bronchiectasis)

• cystic fibrosis

• primary immunodeficiency

• chronic aspiration

• congenital lung malformation

• airway malformation



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ReferencesReferencesReferencesReferences

Guidelines for the management of community acquired pneumonia. British Thoracic Society Standards of Care Committee. Thorax 2002;57(Suppl I):1-24. http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/paediatriccap.pdf Craig JC, Williams GJ, Jones M et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15781 febrile illnesses. BMJ 2010;340:c1594. WHO. The management of acute respiratory infections in children. Practical guidelines for outpatient care. World Health Organization 1995;Geneva:14-35. Margolis P, Gadomski A. Does this infant have pneumonia? JAMA 1998; 279(4):308-13. Grant CC, Scragg R, Tan D, Pati A, Aickin R, Yee RL. Hospitalisation for pneumonia in children in Auckland, New Zealand. J Paediatr Child Health 1998;34(4):355-9. Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2010;3:CD004874. McCracken GH Jr. Etiology and treatment of pneumonia. Pediatr Infect Dis J. 2000;19(4):373-7. Hale KA, Isaacs D. Antibiotics in childhood pneumonia. Paediatr Respir Rev. 2006;7(2):145-51. Tan TQ, Mason EO Jr, Wald ER et al. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics 2002;110:1-6. http://www.surv.esr.cri.nz/PDF_surveillance/Antimicrobial/MRSA/aMRSA_

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