pneumonia in children: etiology, diagnosis and treatment
DESCRIPTION
Pneumonia in children: etiology, diagnosis and treatment. Prof. Galyna Pavlyshyn. Plan. 1. Discuss the common causes of pneumonia in children of various ages; 2. Classifications of pneumonia in children; 3. Clinical manifestations of pneumonia in children; - PowerPoint PPT PresentationTRANSCRIPT
Pneumonia in childrenPneumonia in children etiology diagnosis and treatment etiology diagnosis and treatment
Prof Galyna Prof Galyna PavlyshynPavlyshyn
PlanPlan
1 Discuss the common causes of 1 Discuss the common causes of pneumonia in children of various ages pneumonia in children of various ages
2 Classifications of pneumonia in children2 Classifications of pneumonia in children 3 Clinical manifestations of pneumonia in 3 Clinical manifestations of pneumonia in
childrenchildren 4 Outline the approach to the diagnosis of 4 Outline the approach to the diagnosis of
pneumonia in children pneumonia in children 5 Select appropriate antibiotic therapy for 5 Select appropriate antibiotic therapy for
a child with pneumonia based on childrsquos a child with pneumonia based on childrsquos age and severity of illnessage and severity of illness
6 Discuss the diagnosis and management 6 Discuss the diagnosis and management of common complications of pneumoniaof common complications of pneumonia
Pneumonia in pediatric patientsPneumonia in pediatric patientsBasic factsBasic facts Childhood pneumonia remains an important cause Childhood pneumonia remains an important cause of morbidity and mortality in developing world ndash of morbidity and mortality in developing world ndash 4 4 million deaths annuallymillion deaths annually in the developing in the developing worldworld About About 20 of all deaths20 of all deaths in children under 5 ysin children under 5 ys are due toare due to Acute Lower Respiratory Infections Acute Lower Respiratory Infections (ALRIs - pneumonia bronchiolitis and bronchitis) (ALRIs - pneumonia bronchiolitis and bronchitis) 90 of these deaths90 of these deaths are due toare due to pneumonia pneumonia Annual incidence in the US inAnnual incidence in the US in- Children under 5 yo is Children under 5 yo is ~~ 40 cases1000 40 cases1000- Children age 12-15 Children age 12-15 ~ 7 cases1000~ 7 cases1000- Mortality rate Mortality rate lt 11000 in the USlt 11000 in the US
Disease PatternDisease Pattern
One in every One in every two child two child deaths in deaths in
developing developing countries are countries are
due to just due to just five infections five infections diseases and diseases and malnutritionmalnutrition
Causes of 105 million deaths among Causes of 105 million deaths among children lt 5 in developing countrieschildren lt 5 in developing countries
Pneumonia in pediatric patientsPneumonia in pediatric patients Early recognition and prompt treatment of Early recognition and prompt treatment of pneumonia is life savingpneumonia is life saving Low birth weight malnourished and Low birth weight malnourished and non-breastfed children and those living in non-breastfed children and those living in overcrowded conditionsovercrowded conditions are at higher risk are at higher risk of getting pneumoniaof getting pneumonia These children are also at a higher risk of These children are also at a higher risk of death from pneumoniadeath from pneumonia About one-half of all children About one-half of all children lt 5 yo with lt 5 yo with community-acquired pneumonia will require community-acquired pneumonia will require hospitalizationhospitalization
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
PlanPlan
1 Discuss the common causes of 1 Discuss the common causes of pneumonia in children of various ages pneumonia in children of various ages
2 Classifications of pneumonia in children2 Classifications of pneumonia in children 3 Clinical manifestations of pneumonia in 3 Clinical manifestations of pneumonia in
childrenchildren 4 Outline the approach to the diagnosis of 4 Outline the approach to the diagnosis of
pneumonia in children pneumonia in children 5 Select appropriate antibiotic therapy for 5 Select appropriate antibiotic therapy for
a child with pneumonia based on childrsquos a child with pneumonia based on childrsquos age and severity of illnessage and severity of illness
6 Discuss the diagnosis and management 6 Discuss the diagnosis and management of common complications of pneumoniaof common complications of pneumonia
Pneumonia in pediatric patientsPneumonia in pediatric patientsBasic factsBasic facts Childhood pneumonia remains an important cause Childhood pneumonia remains an important cause of morbidity and mortality in developing world ndash of morbidity and mortality in developing world ndash 4 4 million deaths annuallymillion deaths annually in the developing in the developing worldworld About About 20 of all deaths20 of all deaths in children under 5 ysin children under 5 ys are due toare due to Acute Lower Respiratory Infections Acute Lower Respiratory Infections (ALRIs - pneumonia bronchiolitis and bronchitis) (ALRIs - pneumonia bronchiolitis and bronchitis) 90 of these deaths90 of these deaths are due toare due to pneumonia pneumonia Annual incidence in the US inAnnual incidence in the US in- Children under 5 yo is Children under 5 yo is ~~ 40 cases1000 40 cases1000- Children age 12-15 Children age 12-15 ~ 7 cases1000~ 7 cases1000- Mortality rate Mortality rate lt 11000 in the USlt 11000 in the US
Disease PatternDisease Pattern
One in every One in every two child two child deaths in deaths in
developing developing countries are countries are
due to just due to just five infections five infections diseases and diseases and malnutritionmalnutrition
Causes of 105 million deaths among Causes of 105 million deaths among children lt 5 in developing countrieschildren lt 5 in developing countries
Pneumonia in pediatric patientsPneumonia in pediatric patients Early recognition and prompt treatment of Early recognition and prompt treatment of pneumonia is life savingpneumonia is life saving Low birth weight malnourished and Low birth weight malnourished and non-breastfed children and those living in non-breastfed children and those living in overcrowded conditionsovercrowded conditions are at higher risk are at higher risk of getting pneumoniaof getting pneumonia These children are also at a higher risk of These children are also at a higher risk of death from pneumoniadeath from pneumonia About one-half of all children About one-half of all children lt 5 yo with lt 5 yo with community-acquired pneumonia will require community-acquired pneumonia will require hospitalizationhospitalization
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Pneumonia in pediatric patientsPneumonia in pediatric patientsBasic factsBasic facts Childhood pneumonia remains an important cause Childhood pneumonia remains an important cause of morbidity and mortality in developing world ndash of morbidity and mortality in developing world ndash 4 4 million deaths annuallymillion deaths annually in the developing in the developing worldworld About About 20 of all deaths20 of all deaths in children under 5 ysin children under 5 ys are due toare due to Acute Lower Respiratory Infections Acute Lower Respiratory Infections (ALRIs - pneumonia bronchiolitis and bronchitis) (ALRIs - pneumonia bronchiolitis and bronchitis) 90 of these deaths90 of these deaths are due toare due to pneumonia pneumonia Annual incidence in the US inAnnual incidence in the US in- Children under 5 yo is Children under 5 yo is ~~ 40 cases1000 40 cases1000- Children age 12-15 Children age 12-15 ~ 7 cases1000~ 7 cases1000- Mortality rate Mortality rate lt 11000 in the USlt 11000 in the US
Disease PatternDisease Pattern
One in every One in every two child two child deaths in deaths in
developing developing countries are countries are
due to just due to just five infections five infections diseases and diseases and malnutritionmalnutrition
Causes of 105 million deaths among Causes of 105 million deaths among children lt 5 in developing countrieschildren lt 5 in developing countries
Pneumonia in pediatric patientsPneumonia in pediatric patients Early recognition and prompt treatment of Early recognition and prompt treatment of pneumonia is life savingpneumonia is life saving Low birth weight malnourished and Low birth weight malnourished and non-breastfed children and those living in non-breastfed children and those living in overcrowded conditionsovercrowded conditions are at higher risk are at higher risk of getting pneumoniaof getting pneumonia These children are also at a higher risk of These children are also at a higher risk of death from pneumoniadeath from pneumonia About one-half of all children About one-half of all children lt 5 yo with lt 5 yo with community-acquired pneumonia will require community-acquired pneumonia will require hospitalizationhospitalization
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Disease PatternDisease Pattern
One in every One in every two child two child deaths in deaths in
developing developing countries are countries are
due to just due to just five infections five infections diseases and diseases and malnutritionmalnutrition
Causes of 105 million deaths among Causes of 105 million deaths among children lt 5 in developing countrieschildren lt 5 in developing countries
Pneumonia in pediatric patientsPneumonia in pediatric patients Early recognition and prompt treatment of Early recognition and prompt treatment of pneumonia is life savingpneumonia is life saving Low birth weight malnourished and Low birth weight malnourished and non-breastfed children and those living in non-breastfed children and those living in overcrowded conditionsovercrowded conditions are at higher risk are at higher risk of getting pneumoniaof getting pneumonia These children are also at a higher risk of These children are also at a higher risk of death from pneumoniadeath from pneumonia About one-half of all children About one-half of all children lt 5 yo with lt 5 yo with community-acquired pneumonia will require community-acquired pneumonia will require hospitalizationhospitalization
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Pneumonia in pediatric patientsPneumonia in pediatric patients Early recognition and prompt treatment of Early recognition and prompt treatment of pneumonia is life savingpneumonia is life saving Low birth weight malnourished and Low birth weight malnourished and non-breastfed children and those living in non-breastfed children and those living in overcrowded conditionsovercrowded conditions are at higher risk are at higher risk of getting pneumoniaof getting pneumonia These children are also at a higher risk of These children are also at a higher risk of death from pneumoniadeath from pneumonia About one-half of all children About one-half of all children lt 5 yo with lt 5 yo with community-acquired pneumonia will require community-acquired pneumonia will require hospitalizationhospitalization
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
What is pneumonia What is pneumonia (PNA)(PNA)
Prevalence 1000 Patient age (yrs)35-40 lt130-35 2-4
15 5-9lt10 gt9
Has been defined as inflammation of lung Has been defined as inflammation of lung parenchyma ndash the portion of the lower parenchyma ndash the portion of the lower respiratory tract consisting of the respiratory respiratory tract consisting of the respiratory bronchioles alveolar ducts alveolar sacs bronchioles alveolar ducts alveolar sacs alveolialveoli
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
PneumoniaPneumonia
is an acute infectious is an acute infectious inflammatory disease of inflammatory disease of various nature with involving various nature with involving of lower respiratory tract into of lower respiratory tract into pathologic process and intra-pathologic process and intra-alveolar inflammatory alveolar inflammatory exudationexudation
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Possible causes of Possible causes of PneumoniaPneumonia
Bacterial ndash Bacterial ndash streptococcus pneumonia mycoplasma mycoplasma (atypical)(atypical)ndash And any otherAnd any other
Viral ndash RSV (Viral ndash RSV (respiratory syncytial virus)ndash In children younger than 2 years viral In children younger than 2 years viral
infections were found in 80 of children with infections were found in 80 of children with pneumonia in children older than 5 years viral pneumonia in children older than 5 years viral infections were detected only 37 of the timeinfections were detected only 37 of the time
AspirationAspiration Depends on patient age immune status Depends on patient age immune status
and location (hospital vs community)and location (hospital vs community)
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
NeonatesNeonatesndash Group B StreptococciGroup B Streptococcindash GN Enterics - Esherichia coli Klebsiella GN Enterics - Esherichia coli Klebsiella
pneumoniae pneumoniae ndash Listeria monocytogenesListeria monocytogenesndash rarerare St aureusSt aureus
2 w- 2mo2 w- 2mo- ChlamydiaChlamydia- VirusesViruses- Str Pneumoniae St aureus H influenzaeStr Pneumoniae St aureus H influenzae
Etiology Etiology Age-dependentAge-dependent
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Children 2-6 moChildren 2-6 mo
Esherichia coli Klebsiella pneumoniaeEsherichia coli Klebsiella pneumoniae
Strep Pneumoniae and Hemophylus Strep Pneumoniae and Hemophylus influenzaeinfluenzae typetype ββ
Chlamydia pneumoniaeChlamydia pneumoniae
rarerare St aureusSt aureus
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
6 mo -6 yrs6 mo -6 yrs
Strep Pneumoniae -Strep Pneumoniae - 50 50 Viruses - RSV parainfluenza influenza Viruses - RSV parainfluenza influenza
adenovirus rhinovirus coronavirus adenovirus rhinovirus coronavirus herpesvirus human metapneumovirusherpesvirus human metapneumovirus
Hemophylus infHemophylus inf typetype ββ -- 10 10 Mycoplasma pneumoniaeMycoplasma pneumoniae - - 10 10 Rare St aureus Chlamydia Rare St aureus Chlamydia
pneumoniaepneumoniae
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
7-18 yrs7-18 yrs Strep Pneumonie -Strep Pneumonie - 35-40 35-40 Atypical pneumonia (Mycoplasma Atypical pneumonia (Mycoplasma
pneumoniae) -pneumoniae) - 30-50 30-50 Moraxella catarrhalis Moraxella catarrhalis
Hemophylus influezaeHemophylus influezae VirusesViruses
hospital (nosocomial)hospital (nosocomial)ndash Ps aeruginosa Ps aeruginosa ndash rarerare Kl pneumoniae St aureus ProteusKl pneumoniae St aureus Proteus
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Infectious causes of pneumonia
Age Causative organisms
Perinatal + 4 weeks
Group B haemolytic streptococci E coli and other gram negative enteric organisms Chlamydia trachomatis
Infancy Viruses - RSVPneumococcusHaemophilus influenzae
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
PathophysiologyPathophysiology Often follows upper respiratory tract Often follows upper respiratory tract
infectioninfection Lower respiratory tract invaded by bacteria Lower respiratory tract invaded by bacteria
viruses or other pathogensviruses or other pathogens Preceding viral illness (influenza Preceding viral illness (influenza
parainfluenza RSV adenovirus) leads to parainfluenza RSV adenovirus) leads to increased incidence of pneumococcal increased incidence of pneumococcal pneumoniapneumonia
Bacterial pneumonias usually due to spread Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx of invasive organisms from the nasopharynx by inhalation or aspirationby inhalation or aspiration
In children bacteremia may lead to In children bacteremia may lead to hematogenous seeding of the pulmonary hematogenous seeding of the pulmonary parenchyma and result in pneumoniaparenchyma and result in pneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
PathophysiologyPathophysiology
Immune response leads to inflammationImmune response leads to inflammation Lung compliance is decreased small Lung compliance is decreased small
airways become obstructed and air airways become obstructed and air space collapse progressesspace collapse progresses
Ventilation-perfusion mismatch and Ventilation-perfusion mismatch and decreased diffusion capacity leads to decreased diffusion capacity leads to hypoxemiahypoxemia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
CLASSIFICATION1048729 Etiology1048729 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial nterstitial pneumonia
1048729 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia1048729 Non complicated on complicated pneumonia complicated complicated pneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Morphological classification
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Complications of pneumonia
PulmonaryPulmonary- pleuritis pleuritis
parapneumonic parapneumonic effusions and effusions and empyemaempyema
- pneumothoraxpneumothorax- ffailure of resolution intra-alveolar scarring (carnification)
permanent loss of ventilatory function of affected parts of lung
Pneumonia may be complicated by a pleuritis
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Complications of pneumonia
Pulmonary Pulmonary aabscess formation
A thick-walled lung abscess
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Complications of pneumonia
ExtrapulmonaryExtrapulmonary- infective endocarditis- cerebral abscess meningitis- septic arthritis- Infectious-toxic shocknfectious-toxic shock
- DIC - DIC (disseminated intravascular coagulation)(disseminated intravascular coagulation) syndromesyndrome
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
SignificantSignificant Risk Factors Risk Factors
younger age (2-6 months)younger age (2-6 months) low parental educationlow parental education smoking at homesmoking at home prematurityprematurity weaning from breast milk at lt 6 monthsweaning from breast milk at lt 6 months anaemiaanaemia malnutritionmalnutrition
Trop Doct 2001 Jul31(3)139-41Trop Doct 2001 Jul31(3)139-41
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1 Clinical case 1
2 y old boy with complaints of fever 2 y old boy with complaints of fever cough vomiting decreased appetite chest cough vomiting decreased appetite chest painpain
right lower quadrant (RLQ) abdominal painright lower quadrant (RLQ) abdominal pain T 39 C chills HR 140 RR 50T 39 C chills HR 140 RR 50 Retractions signs of respiratory distressRetractions signs of respiratory distress Decreased breath sounds rales Decreased breath sounds rales
egophony dullness to percussion rateegophony dullness to percussion rate
Symptoms since yesterday afternoonSymptoms since yesterday afternoon Recent upper respiratory infection Recent upper respiratory infection
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1 Clinical case 1
What diagnoses are you What diagnoses are you consideringconsidering
What is the most likely diagnosis What is the most likely diagnosis
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1 Clinical case 1
WhyWhy
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1 Clinical case 1
What do you want to doWhat do you want to do
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
right upper lobe pneumoniaright upper lobe pneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Fever (T 39 C) ndash nonspecific and not Fever (T 39 C) ndash nonspecific and not
100 sensitive sign100 sensitive sign Hypoxemia (pulse oximetry ndash 5Hypoxemia (pulse oximetry ndash 5thth vital vital
sign) sign) Signs of respiratory distress (retractions Signs of respiratory distress (retractions
flaring grunting)flaring grunting)
X-ray infiltrates of lung tissue X-ray infiltrates of lung tissue
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
TachypneaTachypnea Is the most sensitive and specific Is the most sensitive and specific
sign of radiographically confirmed sign of radiographically confirmed pneumonia in childrenpneumonia in children
Is the twice as frequent in children Is the twice as frequent in children with radiographic pneumonia than with radiographic pneumonia than in those withoutin those without
Absence of tachypnea is the most Absence of tachypnea is the most valuable sign for excluding valuable sign for excluding pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1Clinical case 1
What definition of What definition of tachypnea tachypnea
in children do you knowin children do you know
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Definition of tachypneaDefinition of tachypnea (World Health Org)(World Health Org)
lt 2 months gt 60 breaths per minutelt 2 months gt 60 breaths per minute 2-12 mos gt 50 breaths per minute2-12 mos gt 50 breaths per minute 1-5 y gt 40 breaths per minute1-5 y gt 40 breaths per minute More 5 y gt 20 breath per minuteMore 5 y gt 20 breath per minute
Clinical case 1Clinical case 1Physical examinationPhysical examination
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 1Clinical case 1Physical examinationPhysical examination
Wheezing is rare with bacterial Wheezing is rare with bacterial pneumonia ndash more common in pneumonia ndash more common in pneumonia caused by atypical bacterial pneumonia caused by atypical bacterial or virusesor viruses
less than 5 of children with wheezing less than 5 of children with wheezing had pneumoniahad pneumonia
only 2 of children without fever in the only 2 of children without fever in the ED had pneumoniaED had pneumonia
hypoxemia (SpO2 hypoxemia (SpO2 lt lt 92 ) increased 92 ) increased riskrisk
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 2Clinical case 2
Patient 1 yo is transferred to the ED Patient 1 yo is transferred to the ED after 1 week of fever and respiratory after 1 week of fever and respiratory symptomssymptoms
Child is in moderate respiratory distress Child is in moderate respiratory distress pale appearing and quietpale appearing and quiet
T 397 C RR 65 HR 158 SpO2 91T 397 C RR 65 HR 158 SpO2 91 Marked decrease in breath sounds on Marked decrease in breath sounds on
right side moderate subcostal and right side moderate subcostal and intercostal retractionsintercostal retractions
Appears dehydratedAppears dehydrated
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 2Clinical case 2
Signs and symptoms include failure to improve Signs and symptoms include failure to improve with treatment of pneumonia persistent fever with treatment of pneumonia persistent fever malaise chest pain respiratory distressmalaise chest pain respiratory distress
Physical exam reveals decreased breath Physical exam reveals decreased breath sounds dullness to percussion and pleural rubsounds dullness to percussion and pleural rub
CXR shows white out of right chestCXR shows white out of right chest Decubitus X-rays suggest presence of Decubitus X-rays suggest presence of
loculationsloculations Ultrasound detects early loculations and Ultrasound detects early loculations and
septationsseptations
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
This radiograph reveals progression of pneumonia into the right This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic middle lobe and the development of a large parapneumonic pleural effusionpleural effusion
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Clinical case 2Clinical case 2
Draining large effusions may provide Draining large effusions may provide symptomatic reliefsymptomatic relief
Aspiration of pleural fluid may provide Aspiration of pleural fluid may provide an etiologic agent to direct therapyan etiologic agent to direct therapy
Diagnosis Diagnosis Complicated right lobal pneumonia Complicated right lobal pneumonia
- parapneumonic pleural effusion- parapneumonic pleural effusion
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Congenital pneumonia Congenital pneumonia
TachypneaTachypnea Irregular respiratory movements Irregular respiratory movements
(paradoxic)(paradoxic) ApneaApnea Flaring of alae nostrilFlaring of alae nostril Grunting (expiration sound)Grunting (expiration sound) Involving chest musclesInvolving chest muscles Temperature may be present in some Temperature may be present in some
termterm babies babies
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Congenital pneumonia Congenital pneumonia
Poor feedingPoor feeding Lethargy or irritabilityLethargy or irritability Temperature instabilityTemperature instability Poor color cyanosisPoor color cyanosis Abdominal distentionAbdominal distention tachycardiatachycardia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Congenital pneumonia Congenital pneumonia
Late onset of CP (after 7-14 days of life)Late onset of CP (after 7-14 days of life)
Mainly Chlamidia or Urea- and MycoplasmaMainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper Onset usually is preceded by upper
respiratory tract symptoms andor respiratory tract symptoms andor conjunctivitisconjunctivitis
Nonproductive coughNonproductive cough Fever is absent ldquoafebrile pneumonia Fever is absent ldquoafebrile pneumonia
syndromerdquosyndromerdquo
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Physical singsPhysical sings
The sings such as dullness to The sings such as dullness to percussion change in breath sounds percussion change in breath sounds and the presents of rales or rhonchi are and the presents of rales or rhonchi are virtually to appreciate in a neonatevirtually to appreciate in a neonate
Weakened breathing during auscultationWeakened breathing during auscultation Moist or bubbly sounds crepitatingMoist or bubbly sounds crepitating Respiratory failure develops graduallyRespiratory failure develops gradually
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Atypical PneumoniaAtypical Pneumonia Chlamydia ndash Chlamydia ndash
ndash Diffuse intersitial markingsDiffuse intersitial markingsndash hyperinflationhyperinflation
Mycoplasma ndash Mycoplasma ndash ndash Normal or can look like viral or typical Normal or can look like viral or typical
bacterial PNAbacterial PNA
CXR inCXR in
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Viral pneumonia Viral pneumonia
Respiratory syncytial virus is the most Respiratory syncytial virus is the most common viral cause other common common viral cause other common causes include parainfluenza virus causes include parainfluenza virus adenovirus enterovirusadenovirus enterovirus Clinical features- begin with several Clinical features- begin with several days of rhinitis cough followed by fever days of rhinitis cough followed by fever and more pronounced respiratory tract and more pronounced respiratory tract symptoms such as dyspnea intercostal symptoms such as dyspnea intercostal retractionretraction
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Viral pneumoniaViral pneumoniaDiagnosisDiagnosis
Laboratory findings ndash preponderance of Laboratory findings ndash preponderance of lymphocytes observed on CBC lymphocytes observed on CBC Diffuse or bilateral infiltrates visible on Diffuse or bilateral infiltrates visible on chest ragiographchest ragiograph Rapid test for viral antigen culturing Rapid test for viral antigen culturing nasopharyngeal specimens for virusesnasopharyngeal specimens for viruses
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
CXR in viral PNACXR in viral PNA
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
CXR in AspirationCXR in Aspiration
opacification in right upper lobes of opacification in right upper lobes of infants and in the posterior or bases of infants and in the posterior or bases of the lung in older childrenthe lung in older children
Specific testingSpecific testing barium swallowbarium swallow pH probe and pH probe and flexible endoscopic evaluation of flexible endoscopic evaluation of
swallowing and sensory testingswallowing and sensory testing
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Possible Exam Signs of PNAPossible Exam Signs of PNA Tachypnia Tachypnia
ndash gt 50min if younger gt 50min if younger than 1 year gt than 1 year gt 40min if older than 1 40min if older than 1 yearyear
CyanosisCyanosis RetractionsRetractions Inspiratory cracklesInspiratory crackles Bronchial breath Bronchial breath
soundssounds
Egophany ( E to A)Egophany ( E to A) Bronchophany Bronchophany
(99)(99) Whispered Whispered
pectoriloquy pectoriloquy (pectorophony)(pectorophony)
Dullness to Dullness to percussionpercussion
Tactile fremitusTactile fremitus
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Symptoms and signsSymptoms and signs 5 categories5 categories
Nonspecific and toxicityNonspecific and toxicity Signs of lower respiratory diseaseSigns of lower respiratory disease Signs of pneumoniaSigns of pneumonia Sign of pleural effusion and Sign of pleural effusion and
empyemaempyema Extrapulmonary diseaseExtrapulmonary disease
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Symptoms amp signsSymptoms amp signs non-specific non-specific
Fever malaise headacheFever malaise headache GI complaints GI complaints ApprehensionApprehension restlessnessrestlessness
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Symptoms-lower Symptoms-lower respiratoryrespiratory
Tachypnea dyspneaTachypnea dyspnea Shallow or grunting respirationShallow or grunting respiration CoughCough Nasal flaring intercostal Nasal flaring intercostal
retractionretraction
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Symptoms-pleuritic Symptoms-pleuritic
Referred pain to neck and backReferred pain to neck and back Abdominal pain if diaphragmatic Abdominal pain if diaphragmatic
involvementinvolvement
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Symptoms-Symptoms-extrapulmonaryextrapulmonary
Disseminated diseaseDisseminated disease Skin and soft tissue involvement Skin and soft tissue involvement
arising from bacteremia arising from bacteremia meningitismeningitis
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Plan of examination Plan of examination CBC - CBC - so called ldquoseptic investigationrdquo - so called ldquoseptic investigationrdquo - blood analysis (blood analysis (uarr WBC more than 20109l oruarr WBC more than 20109l or darr darrWBC less than 5109l)WBC less than 5109l) IIncreased WBC with left stiff strongly ncreased WBC with left stiff strongly
suggests bacterial processsuggests bacterial process Pneumococcus associated with marked Pneumococcus associated with marked
leukocytosis leukocytosis LLeukocyte index gt 02 (immature forms eukocyte index gt 02 (immature forms
general count of neutrophils)general count of neutrophils) Trombocytopenia (lt 150000)Trombocytopenia (lt 150000)
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Examination Examination LaboratoryLaboratory
Biochemical blood test ndash acidosis Biochemical blood test ndash acidosis hypoproteinemiahypoproteinemia
Increased inflammatory markers (C-Increased inflammatory markers (C-reactive protein) reactive protein)
Bacteriological examination of Bacteriological examination of sputum (tracheal) blood (gold sputum (tracheal) blood (gold standard) standard)
Blood culture rarely give organism Blood culture rarely give organism but this test is necessarybut this test is necessary
Examination for virusesExamination for viruses
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Examination Examination Radiology Radiology
X-ray X-ray
Infiltrates bilateral involvement or Infiltrates bilateral involvement or pleural effusion - suggest more pleural effusion - suggest more serious diseaseserious disease
Focal or diffuse interstitial Focal or diffuse interstitial pneumonitis may reveal pneumonitis may reveal
Infiltrates may be less obvious in Infiltrates may be less obvious in dehydrated patientsdehydrated patients
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Bronchopneumonia -- intensified (increased) pulmonary picture diffuse focal infiltration
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Interstitial pneumoniaInterstitial pneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
CXR in Bacterial PNACXR in Bacterial PNA
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
CXR in Bacterial PNACXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
-
Lobar pneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Acute community-acquired pneumonia with complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Complicating pneumonia and empyema
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Bilateral necrotising Bilateral necrotising pneumonia complicated pneumonia complicated by right pneumothorax by right pneumothorax
Bilateral consolidation with scarring and early cavitation in the lower lung fields
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Pneumococcal pneumonia complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Lung abscess in the posterior segment of the right upper lobeLung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidationCT scan shows a thin-walled cavity with surrounding consolidation
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
What indications for What indications for disposition disposition
(hospitalization) patient (hospitalization) patient with pneumoniawith pneumonia do you know do you know
Most children can be treated Most children can be treated as outpatientsas outpatients
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
DispositionDisposition
Admit ifAdmit if Toxic appearanceToxic appearance Respiratory compromise including Respiratory compromise including
marked tachypnea (marked tachypnea (gt60 breathsmin in gt60 breathsmin in infant andinfant and
gt 40-50 breathsmin in older childrengt 40-50 breathsmin in older children)) Hypoxemia (SpO2 Hypoxemia (SpO2 lt 92-94 in room airlt 92-94 in room air)) Dehydration or inability to maintain oral Dehydration or inability to maintain oral
hydration or tolerate oral medicationshydration or tolerate oral medications Indications of severe disease Indications of severe disease
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
DispositionDisposition Admit ifAdmit if Young age - Young age - lt 4-6 months of agelt 4-6 months of age Underlying diseases Underlying diseases - cardiac disease- cardiac disease - renal disease- renal disease - hematological disease - hematological disease Inability of family to provide care at Inability of family to provide care at
homehome Failure of outpatient therapyFailure of outpatient therapy
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Treatment Treatment
Supportive care for childrenSupportive care for children Oxygen if neededOxygen if needed Fluids and insure hydrationFluids and insure hydration Antipyretics analgesicsAntipyretics analgesics Antitussives are NOT Antitussives are NOT
indicatedindicated
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Antibiotic therapyAntibiotic therapy I ndash beta-lactamI ndash beta-lactam- PenicillinPenicillin- CephalosporinCephalosporin- CarbopenemCarbopenem
AminoglycosideAminoglycoside MacrolideMacrolide LinkozamideLinkozamide ndash ndash
linkomycin clindomycinlinkomycin clindomycin VancomycinVancomycin
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Treatment Treatment bull Bacterial 1 month Ampicillin 75ndash100 mgkgday
and Gentamicin 5 mgkg d 1ndash3 months Cefuroxime (75ndash150
mgkgday) or co-amoxiclav (40 mgkgday) 3 months Benzylpenicillin or
erythromycin (change to cefuroxime or amoxycillin if no response)
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Treatment Treatment
Supportive for atypical pneumonia bull Chlamydia and mycoplasma
should be treated with erythromycin
40ndash50 mgkgday usually orally bull If pneumocystis carinii
pneumonia is suspected co-trimoxazole 18ndash27 mgkgday IV should be prescribed
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Treatment Treatment Patients are treated as an outpatientPatients are treated as an outpatient
Children Children lt 5 yolt 5 yo - - high dose amoxicillin (80-90 mgkgd) for 7-10 dhigh dose amoxicillin (80-90 mgkgd) for 7-10 d Children gt 5 yoChildren gt 5 yo - - increased prevalence of M pneumoniae and increased prevalence of M pneumoniae and C pneumoniaeC pneumoniae - macrolide is reasonable choice- macrolide is reasonable choice Older children with signs most consistent Older children with signs most consistent
withwith S pneumoniae infection (lobar infiltrate S pneumoniae infection (lobar infiltrate
increased wbc or inflammatory markers) ndashincreased wbc or inflammatory markers) ndash AMOXICILLINAMOXICILLIN may be used may be used
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
TreatmentTreatmentPatients requiring admissionPatients requiring admission
IV AMPICILLIN 150-200 IV AMPICILLIN 150-200 mgkgd mgkgd
May used 2-nd or 3-rd generation May used 2-nd or 3-rd generation cephalosporinscephalosporins
Choice guided by local resistance Choice guided by local resistance patternspatterns
Consider combining beta-lactam Consider combining beta-lactam and macrolideand macrolide
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
TreatmentTreatmentChildren with more severe Children with more severe
diseasedisease
Consider other organisms including Consider other organisms including Methicillin-resistant S aures (MRSA)Methicillin-resistant S aures (MRSA)
3-rd generation cephalosporin 3-rd generation cephalosporin plus Clindamycinplus Clindamycin or or
VancomycinVancomycin
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Treatment Treatment
Age Start Alternative 6 mo-6 yr Ampicillin 100
mgkgday
Or Or amoksiklav 20-40 amoksiklav 20-40 mgkgmgkg(Amoxicillin(Amoxicillinclavulanate)clavulanate)
Cefotaxime (Claforan)
Cefuroxime (Zinacef) 100-150 mgkgday
Clarithromycin
Azithromycin
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Age Start6 mo-6 yrComplicated
Ceftazidime 150 mgkgday or or Cefotaxime or ceftriaxone + netilmicin (6-75 mgkg)(6-75 mgkg)
((amikacinum amikacinum 15 mgkg)15 mgkg)
Treatment Treatment
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Age Start6 mo ndash 6 yo
atypical -Clarithromycin 15-30 mgkgday or Azithromycin 10 mgkg
6 mo ndash 6yoatypical
complicated
Rovamycine Rovamycine 1500000 IU per 10 kg
Treatment Treatment
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Suggested Drug Suggested Drug TreatmentTreatment
Birth to 20 days Birth to 20 days AdmissionAdmission
3 weeks to 3 3 weeks to 3 months months ndash Afebrile oral Afebrile oral
erythromycinerythromycinndash Febrile add Febrile add
cefotaximecefotaxime
4 months to 5 4 months to 5 yearsyears
Amoxycillin Amoxycillin 80mgkgdose80mgkgdose
6-14 years6-14 years
ErythromycinErythromycin
NEJM Volume 346429-437Volume 346429-437
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Causative AgentsCausative Agents
The most often isolated bacteria The most often isolated bacteria pneumonia - Streptococcus pneumonia - Streptococcus pneumoniae (33) pneumoniae (33)
Haemophilus influenzae (21)Haemophilus influenzae (21)
Braz J Infect Dis 2001 Apr5(2)87-97Braz J Infect Dis 2001 Apr5(2)87-97
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Haemophilus influenzaeHaemophilus influenzaeTreatment with a combination of amoxicillin and clavulanic acid (Augmentin) is effective against thorn-lactamase-producing strains
Streptococcus pneumoniaeStreptococcus pneumoniae Penicillin is drug of choice for susceptible organisms
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
SummarySummary
bull Pneumonia is a common infection condition in children
bull Significant cause of morbidity and hardships for patients and families
bullPneumonia is the commonest cause of mortality
bullPneumonia in absence of cough is rare
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
SummarySummary
bullFast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis
bull Tachypnea is the most useful physical sign
bull Most children can be treated as outpatients
bull Therapy should be guided by probable etiology and severity of disease
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Test-controlTest-control
What are the most common What are the most common etiological agents of etiological agents of
pneumoniapneumonia
in neonatal periodin neonatal period
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Test-controlTest-control
What are the most valuable What are the most valuable signs of pneumonia in signs of pneumonia in
childrenchildren
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
Test-controlTest-control
What signs are auxiliary What signs are auxiliary methods of diagnosis of methods of diagnosis of
pneumoniapneumonia
