1

Pneumonia

20/03/2022
DR PRATEEK KUMAR PANDA
MD, DNB, DM (PEDIATRIC NEUROLOGY)
CO-CONVENOR, DM PEDIATRIC NEUROLOGY
PROGRAM
CO-CHAIR, PEDIATRIC NEUROLOGY DIVISION
ASSISTANT PROFESSOR
DEPARTMENT OF PEDIATRICS
AIIMS, RISHIKESH
 2

Community-Acquired Pneumonia

20/03/2022
 CONTENTS:
 Introduction
 Definition
 Etiology
 Pathophysiology
 Approach
 Management
 Prevention
 INTRODUCTION 3

20/03/2022
 Every 39 seconds a child die.

 Nearly 1.4 million die/year- 90% in developing nations.(1)

 Objective of SDG is to reduce < 5 Mortality rate to as low as 25/1000 children.

Anand Manoharan et al. Invasive pneumococcal disease in children aged younger than 5 years in India: a surveillance study. Lancer Infect Dis.2017
Mar;17(3):305-12.
 4

DEFINITION

20/03/2022
 Pneumonia is defined as inflammation of lung parenchyma (Nelson 20 th edition)

 Pneumonia is considered in children when there is persistent fever >38.5 C together

with Chest recession & raised Respiratory rate- BTS Guidelines.

 CAP: Defined clinically by presence of signs and symptoms of pneumonia

in a previously healthy child which has been acquired Outside hospital.

OR

Any child who has presented with signs and symptoms of pneumonia &

developed new pulmonary infiltrates with in 48 hours of admission.

 WHO CLASSIFICATION 5

20/03/2022
 WHO categorized CAP into Pneumonia, Severe Pneumonia-for assessing
severity.

 Pneumonia: Fast breathing with or with out chest in-drawing.

 Severe Pneumonia: Fast breathing with any of the danger signs.

 Fast breathing definition: Depends on age

-- 0 to 2 months: ≥ 60/min

-- 2 months-12 months: ≥ 50/min

-- 1 year- 5 years: ≥ 40/min.

Mimics/Risk factors for Pneumonia 6

20/03/2022
 Anatomical defects: Pulmonary sequestration, TEF, Vascular rings

 Aspiration of gastric contents: GERD, TEF, Cleft palate, NMD.

 Cardiovascular: ACHD, Pulmonary edema, Pulmonary embolism.

 Neoplastic: Endobronchial tumor, Lung cancer.

 Immunological/ Allergic: PID, Vasculitis, Hyper eosinophilic pneumonia/PEM.

 Drugs/ Chemical exposure: Smoking, Cytotoxic drugs, Radiation therapy.

 Others: Foreign body, Near drowning event.

Alves dos Santos et al. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med.2004;98: 488-94
 7

IMNCI Guidelines under NRHM

20/03/2022
8

20/03/2022
So what are your interpretations in 9

a febrile child?

20/03/2022
 High grade or low grade.

 How is the child in Inter febrile period

 Response to Paracetamol

 Rhythmicity

 Progression as days progresses

 Accompanying symptoms:

Vomiting, irritability, Tachypnoea, cough, cold, Throat pain, rashes.

Rule out serious illness at presentation

 So what are your interpretations in 10
a fast breathing child?

20/03/2022
 LRT involvement (Infectious and Non-infectious)

 URT involvement

 Metabolic causes

 CVS causes

 Aspiration syndromes secondary to GERD

 Exercise induced, Foreign body inhalation.

 Dehydration/ Fever/ Shock

 So what are your interpretations in 11

a coughing child?

20/03/2022
 Onset: Insidious/ Sudden in onset.

 Nature of cough: Dry/ Wet

 Is it chief complaint or part of complaint?

 Any diurnal variation

 Characteristic of cough: Whooping cough/ Barking cough.

 Aggravation to any posture

 Any family member having cough for long time.

Etiology of Pneumonia 12

20/03/2022
 13

Etiology by Exposure history

20/03/2022
EXPOSURE HISTORY INFECTIOUS AGENT
In School Outbreaks Mycoplasma, Pertussis, Streptococcus
Travel history or contact history Covid-19
Family history Viral infections
Seasons/Rains Swineflu/Influenza
Closed A/C atmosphere Atypical organism
Construction site exposure Legionella
Zoonotic exposure Brucellosis, Anthrax, Q fever.
 Differentiating viral vs Bacterial 14
Viral Bacterial

20/03/2022
Common in pre- school age Common in neonates and > 5 yrs child

Child illness can start as rhinitis, rashes, fever, Child presents with High grade fever,
conjunctivitis, wheezing, Inter-febrile activity. Tachypnoea, Chest pain, Abdominal
Fever+ Fast breathing+ Vomiting+ Diarrhea + pain- Child looks sick
Muco-cutaneous inflammation- Think of
COVID-19/MIS-C.
Family members can have URTI symptoms Usually absent
Investigations:
a) WBC <15,000 a) WBC- 20000 to 40000
b) Lymphocyte predominant b) Neutrophil predominant
c) CRP <20 mg/dl c) CRP >60mg/dl
d) Procalcitonin <0.1 mcg/L d) Procalcitonin >0.5 mcg/L

Chest x-ray: B/L Interstitial infiltrates, Chest x-ray: U/L lung finding
Peribronchial cuffing. Pneumatoceles, Lobar pneumonia.

Olli Ruuskanen et al. Cause and Pathogenesis of community acquired pneumonia in children: Lancet Infect. Dis. 2011; 377: 1264-75.
 15

ATYPICAL PNEUMONIA

20/03/2022
 How is it different from pneumococcal?

 Characteristically Gradual in onset, Constitutional and respiratory symptoms,

pulmonary changes more in x-ray than Examination and response to β-Lactams.

 It usually does not cause lobar ,empyema, toxemia.

 But in reality all cant be walking pneumonia

 Now it is recommended atypical pneumonia is obsolete?

 It recommends to use term proved mycoplasma, legionella pneumonia.

David R murdoch et al. An acute infection of the respiratory tract with atypical pneumonia: Lancer Infect Dis 2009; 9:512-19
 16

PATHOPHYSIOLOGY

20/03/2022
 It results due to disruption of a complex LRT ecosystem

 This is the site of dynamic interaction between Pneumonia pathogens,

resident microbial communities and host immune defenses.

 Viral Pneumonia: Direct injury of respiratory epithelium- Swelling,

Abnormal secretions and cellular debris.

 Bac. Pneumonia: Attaches to resp. epithelium and inhibits ciliary action

and causes inflammatory response in submucosa.

 17

Conti…..

20/03/2022
 Examples like S. Pneumonia causes focal/ round pneumonia

Why PNEUMATOCELE in S. Aureus?

Kim Y, Donnelly LF. Round Pneumonia: Imaging findings in a large series of children. Pediatr Radiol.2007;37:1235-1240.
 CLINICAL FEATURES 18

20/03/2022
 Infants and younger children:

Frequently URTI symptoms like rhinitis, cough, fever followed

by Tachypnoea, retractions, increased Work of breathing,

cyanosis, lethargy/Irritability/ poor feeding.

 Older children and adolescents:

Typically presents with high fever, cough, Tachypnoea, chest pain

rarely Abdominal pain.

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RISK FACTORS

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Lack of Preventive measures Deficiency of Protection mechanisms
Hand hygiene Suboptimal breast feeding
Immunization coverage Malnutrition/LBW
Pollution/Poor ventilation Immune status/Pre existing illness.
Zn/ Vit A deficiency Poor antibiotic coverage.

 Jakhar et al. Etiology and risk factors Determining Poor Outcomes of pneumonia in Under-Five Children. Indian J Pediatr. 2017.

Collaborators G.B.D.R.L.I Quantifying risks and interventions that have affected the burden of lower respiratory infections: An an analysis

for the Globel Burden Of Disease Study 2017. Lancet Infect. Dis.2020, 20, 60-79.
 20

HISTORY

20/03/2022
 H/o Rhinorrhea, Conjunctivitis, Rashes, fever, Cough- URTI/ Viral etiology.
 H/o Hoarseness of voice/ Drooling saliva/ Dysphagia- Laryngitis, Tonsillitis.
 H/o high grade fever, Fast breathing, cough- LRTI.
 H/o Diarrhea, vomiting- Viral/ Atypical pneumonia.
 H/o BLN/ Suck-rest-suck cycle/ Excessive sweating/ Cyanosis- CVS causes.
 H/o Breast abscess in mother/ Pustules or Cellulitis in child- Staph etiology.
 H/o Animal exposure, Travelling history.
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Continue….

20/03/2022
 Birth history: H/o repeated infections since birth, Any h/o NICU stay.

 Developmental history: GDD/CP child- prone for recurrent pneumonia

 Immunization history: BCG, PENTAVALENT, PCV, MMR, INFLUENZA

 Nutritional history: EBM or not, protein- calorie deficit or SAM features.

 Family history: Cough& Cold/ Bronchial Asthma/ T.B Contact history.

 Socio-economic history: Hygiene practices, kutcha house, Firewood

cooking, Smoking.

 Past history: Similar complaints in the past.

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EXAMINATION

20/03/2022
 General appearance(Conscious/Oriented/ Lethargic), AVPU/GCS, Vitals.

Inspection
 Nasal flaring, retractions, irregular breathing.

 Head bobbing, Tracheal position, any Inspiratory/Expiratory sounds.

 Symmetrical chest, chest expansion during respiration,

 Head to toe examination- Especially in Recurrent Pneumonia.

 Continue…. 23

Palpation

20/03/2022
 Confirm inspection findings.
 Vocal fremitus- Increased in Pneumonia.
 Liver looks enlarged but liver span will be normal.

Percussion
 Impaired note seen in Pneumonia.
 Dullness- Pleural effusion.

Auscultation
 Crepitations all over/ over specific area. Decreased breath sounds
 Any Wheezing/ Rhonchi/Bronchial breath sounds.
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INVESTIAGATIONS

20/03/2022
 Blood specimens like CBC, ABG, KFT, LFT, CRP, Blood C/S, Blood PCR,

Mycoplasma IgG, IgM.

 Upper respiratory secretions through RT-PCR (Especially for Covid-19)

 Urine specimens like Urine antigen test (>5 years)

 Gold standard is direct sampling of lung tissue

 Secretion from the LRT through BAL or sputum induction

 Diagnostic pleural tapping- RT PCR, Gram staining, C/S.

Hammitt et al. Specimen collection for the Diagnosis of Pediatric Pneumonia. Clini Infect Dis 2012; 54:S132-9

Florin et al. Biomarkers and Disease Severity in Children with Community-Acquired Pneumonia. Pediatrics 2020,145.
 25

RADIOLOGICAL EVALUATION

20/03/2022
 X-ray images: Currently IDSA does not recommend x-ray in diagnosing
pneumonia who can be managed on outpatient basis.

 Indications:
 In severe Pneumonia to diagnose any complications.

 To confirm/ identify consolidation in hospitalized child.

 To exclude other pathology in recurrent Pneumonia.

Routine/ Repeat X-ray usually not indicated

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Chest x-ray

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Chest X-ray

20/03/2022
Chest Imaging findings of Covid-19 28

20/03/2022
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Others…..

20/03/2022
 USG Bed side: It can be specific- It is user dependent
30

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 31

New generation tests

20/03/2022
 Biofire- Nasopharyngeal PCR- can detect 21 pathogens in 2 hours

 Malditof- MS Matrix assisted Laser Desorption/ Ionization- time of flight

 Sequence based technology- 16 S RNA

Bizzini et al. Matrix assisted Laser Desorption/ Ionization- time of flight mass spectrometry, a revolution in clinical microbial identification. Clin Microbiol Infect 2010;16: 1614-9.
 32

TREATMENT

20/03/2022
 Treatment will be based on epidemiology, Clinical features, Blood C/S, Immunization
status.

 If viral pneumonia is suspected and confirmed by PCR, it is reasonable to

with hold antibiotics especially in younger age group.

 But any clinical deterioration should think of superimposed bacterial infection and
antibiotics should be initiated.

Bradley JS et al. The management of community- acquired pneumonia in infants and children older than 3 months of age: Pediatric Infectious

Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53:e25-76.
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TREATMENT

20/03/2022
 Which Antibiotic is the DOC?

 Amoxicillin/ Co-Amoxiclav/Ceftriaxone?

 Can we add Azithromycin or not?

 WHO recommends Amoxicillin -90 mg/kg/day.

 Indian studies -50 mg/kg/day in dividing doses.

Verghese VP et al. Increasing incidence of Penicillin and cefotaxime- resistant Streptococcus Pneumonia causing Meningitis in India. Indian journal medicine microbiology 2017;35:228-36.

Anand Manoharan et al. Invasive pneumococcal disease in children aged younger than 5 years in India: a surveillance study. Lancer Infect Dis.2017 Mar;17(3):305-12.
 Amoxicillin vs Co-Amoxiclav- Which one to 34
prefer?

20/03/2022
Co-Amoxiclav
 Emerging Empirical DOC if resistance to Penicillin increases in future.

 At present not used routinely indicated- as overuse can cause resistant in

Gram –ve Pathogens.

 Indication: Aspiration Pneumonia/ Children recovering from Influenza infection.

Balaji Veeraraghavan et al. Orally Administered Amoxicillin/Clavulanate: Current role in Outpatient Therapy. Infect Dis Ther 2020: 374-7
 35

DRUG OF CHOICE

20/03/2022
 Ampicillin + Gentamycin: Streptococcus pneumonia In-Patient child.

 Ceftriaxone: Severe pneumonia or Child not responded/Deteriorated.

 Cloxacillin I.V /Cefazolin/ Oral Cephalexin: MSSA

 Vancomycin/Linezolid/Teicoplanin: MRSA

 Azithromycin/ Doxycycline: Mycoplasma/ Chlamydia etc….

 Treatment- At Home/OPD basis 36

20/03/2022
 WHO recommends until the health care providers are well trained give
antibiotics to all children with fast breathing in a community level.

 Oral Amoxicillin x 5 days

 Nutrition/ Immunization

 Parental education- Red Flag Signs.

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20/03/2022
 38

When child need admission?

20/03/2022
 Age < 6 months

 Toxic appearance

 Hypoxemia (SPO2 <90%)

 Poor oral intake or vomiting

 Immunocompromised/ Malnutrition child.

 Failure to respond to oral therapy

 Social factors (Inadequate family supervision)

 39

TREATMENT OF IN PATIENT

20/03/2022
Supportive treatment of severe pneumonia
 Oxygen therapy to maintain saturation > 92%

 Anti- Pyretic like paracetamol is given

 Adequate hydration- Encourage Breast feeding

 If child cant take orally NG and IV Maintenance

 Correct if any electrolyte imbalance, Hypoglycemia.

 Role of Bronchodilators??
 40

Specific treatment

20/03/2022
 This study says that Multi drug resistance (1%)

was lower than other Asian countries(70%)

 But this finding is of great concern since it

leads to treatment non response in future.

Anand Manohran et al. Invasive pneumococcal disease in children aged younger than 5 years in india: a surveillance study. Lancer Infect Dis.2017 Mar;17(3):305-12 .
 41

Severe pneumonia

20/03/2022
 As per WHO, Ampicillin + Gentamycin- DOC in hospitalized child

 If no response in 48 hours- Shift to Ceftriaxone- WHO 2014

 Add Cloxacillin if features and x-ray s/o Staph. aureus

 Total duration of Antibiotics is 10-14 days

 Staphylococcus aureus- Total duration is 4-6 weeks

Dekate et al. Acute Community Acquired Pneumonia in Emergence Room. Indian J Pediatr 2011;78(9): 1127-35
 42

Atypical Pneumonia Rx

20/03/2022
 Severe CAP treated with β-Lactam+ macrolide lowered 28-day MR.

 BTS- ‘’If no response to first line therapy/ if atypical organism is

suspected clinically/ if child is deteriorating add Macrolide.’’

 IDSA- ‘’Any severe pneumonia, if clinician suspect atypical, if pneumonia didn’t

respond to 48 hours, then add azithromycin.’’

 It will not clear bacteremia, resistance to macrolide.

Even it is Atypical it is irrational to give only Macrolide in CAP.

Sligi WI et al. Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systemic review and meta-analysis. Crit Care Med 2014;42:420-32
 43

Drug dosage

20/03/2022
 Amoxicillin: 50 mg/kg/day TDS

 Co-Amoxiclav: 80-90mg/kg/day BD

 Gentamycin: 7.5 mg/kg/day OD

 Amikacin:15 mg/kg/day OD

 Cloxacillin:150-200 mg/kg/day QID.

 Vancomycin: 40-60 mg/kg/day

 Linezolid: 10 mg/kg/dose BD or TDS

 Azithromycin: 10 mg/kg on Day-1 f/b 5 mg/kg (Day-2 to 5)

 44

Role of Anti viral in pneumonia?

20/03/2022
 WHO removed OSELTAMAVIR from essential medicine list.

 Oseltamivir shortened the duration of illness of 16.7 hours.

 But did not reduce the number of people admitted to hospital or complications.

 WHO- Oseltamivir should be “restricted to severe illness due to confirmed or

suspected influenza virus infection in critically ill patients.’’

 BMJ 2014- Oseltamivir is given (cat B& C) based on epidemiology for viral but
should be given within 48 hours of symptom onset.
 45

Others….

20/03/2022
 Zn supplementation- Didn’t find any significant effect on clinical recovery and
duration of hospital stay in children with severe LRTI.

 Vitamin A supplementation should only be given to children with poor nutritional

status.

 Ribavirin could be considered for severe pneumonia caused by RSV especially in

Immunocompromised child.

Bansal et al. Zinc supplementation in severe acute lower respiratory tract infection in children: a triple- blind randomized placebo controlled trial. Indian Journal of Pediatrics 2011;78(1):33.

Chen et al. VitA for preventing acute lower respiratory tract infection in children upto 7 years of age. Cochrane Database of Systematic Reviews. 2018; Issue 1.
What do u think if child didn’t respond to 46

Rx: Non- Responding CAP

20/03/2022
 Look for inadequate dose, antibiotic of choice.

 Rule out complications like Pleural effusion, Empyema.

 To know Host factors

 Think of Alternate diagnosis

 Repeat culture if needed to see any resistant/ unusual organism

Alves dos Santos et al. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med.2004;98: 488-94
 47

COVID-19 vs CAP

20/03/2022
 It is crucial to differentiate CAP from Covid-19 Pneumonia in this pandemic as
both require different type of management.

Differential features
 In Covid-19, more sever respiratory compromise is seen.

 Lower levels of Laboratory parameters compared to Bacterial CAP.

 More frequently B/L peripheral GGO distribution.

Huang C et al. Clinical features of patients infected with 2019 novel corona virus in Wuhan, China(J). The lancet 2020,395:497-506.
 48

COVID-19 Clinical features

20/03/2022
 Symptoms and Signs of COVID-19 are non-specific and mimic

any viral illness.

When to suspect COVID-19

Fever, Rapid breathing, Cough, Coryza, Fatigue.
Diarrhea, Vomiting, Abdominal pain.
Poor feeding in infant, Loss of taste or smell >8 years.
Rash, Conjunctival congestion, mucositis.
Close/Household contact with Covid-19 case.

Huang C et al. Clinical features of patients infected with 2019 novel corona virus in Wuhan, China(J). The lancet 2020,395:497-506.
 Severity of Covid-19 pneumonia 49

20/03/2022
‘’Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease” Centers for Disease Control and Prevention.
Updated 12 May 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp.html Accessed on 14th May 2020.
 50

COVID-19 Treatment

20/03/2022
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Prevention of CAP

20/03/2022
Primary prevention
 Health education- Mainly to pregnant women and Lactating mother.

 Promote Breast feeding.

 Improve nutrition of child.

 Increase Immunization coverage.

 Improve socio-economic conditions.

 Decrease Over crowding, Avoid passive smoking.

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Conti…..

20/03/2022
Secondary prevention
 Differentiation or identification of clinical condition and its severity

 Initiation of appropriate antibiotics

 Timely referring the child/ Follow up.

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GLOBAL ACTION PLAN

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20/03/2022
Nosocomial
Pneumonia
Nosocomial Pneumonia

Epidemiology
 Common hospital-acquired infection
 Occurs at a rate of approximately 5-10 cases per 1000 hospital admissions
 Incidence increases by 6-20 fold in patients being ventilated mechanically.
 One study suggested that the risk for developing VAP increases 1% per day
 Another study suggested, highest risk occur in the first 5 days after intubation
Nosocomial Pneumonia

Site Distribution in Adult ICUs

Major Types of Infection (NNIS data, 1992-1997)

Other
6%
LRTI 4% Urinary tract infections (UTI)
EENT
4% UTI
Pneumonia (Pneu)
CVS 31%
4%
GI
Primary bloodstream infections (BSI)
5%
Gastrointestinal infections (GI)

Cardiovascular system (CVS)

BSI Eye, ear, nose, and throat infection (EENT)

19%

Lower respiratory infections (LRTI) (other than pneumonia)

Pneu
27%
N = 14,177 Other

Copyright © 2001 ican, INC.

Richards, et al. Crit Care Med. 1999;27:887-892.
Nosocomial Pneumonia

Epidemiology
 Nosocomial pneumonia is the leading cause of death due to
hospital acquired infections
 Associated with substantial morbidity
 Has an associated crude mortality of 30-50%
 Hospital stay increases by 7-9 days per patient
 Estimated cost > 1 billion dollars/year
 Mortality and Time of Presentation of HAP
P<.001

50 P<.00 P
1 = .504 *
*
Hospital Mortality (%)
40

30

20

*
10

0
None Early Onset Late Onset

*Upper 95% confidence interval Nosocomial Pneumonia

Ibrahim, et al. Chest. 2000;117:1434-1442.

Nosocomial Pneumonia

 Hence, the importance of focusing on:

 Accurate diagnosis
 Appropriate treatment
 Preventive measures
Nosocomial Pneumonia

 Pathogenesis
 Risk factors
 Etiologic agents
 Differential diagnosis
 Treatment
 Prevention
Nosocomial
Pneumonia
PATHOGENESIS
Nosocomial Pneumonia

 Microaspiration may occur in up to 45% of healthy volunteers

during sleep
 Oropharynx of hospitalized patients is colonized with GNR in
35-75% of patients depending on the severity and type of
underlying illness
 Multiple factors are associated with higher risk of colonization
with pathogenic bacteria and higher risk of aspiration
Nosocomial Pneumonia

 Pathogenesis
 Invasion of the lower respiratory tract by:
 Aspiration of oropharyngeal/GI organisms
 Inhalation of aerosols containing bacteria
 Hematogenous spread
Colonization Aspiration

MRSA*

HAP
Nosocomial
Pneumonia
RISK FACTORS
Nosocomial Pneumonia

 Risk Factors
 Host Factors
 Extremes of age, severe acute or chronic illnesses, immunosupression,
coma, alcoholism, malnutrition, COPD, DM
 Factorsthat enhance colonization of the oropharynx and stomach
by pathogenic microorganisms
 admission to an ICU, administration of antibiotics, chronic lung disease,
endotracheal intubation, etc.
Nosocomial Pneumonia

 Risk Factors
 Conditions favoring aspiration or reflux
 Supine position, depressed consciousness, endotracheal intubation, insertion of
nasogastric tube
 Mechanical ventilation
 Impaired mucociliary function, injury of mucosa favoring bacterial binding,
pooling of secretions in the subglottic area, potential exposure to contaminated
respiratory equipment and contact with contaminated or colonized hands of
HCWs
 Factors that impede adequate pulmonary toilet
 Surgical procedures that involve the head and neck, being immobilized as a
result of trauma or illness, sedation etc.
Nosocomial
Pneumonia
ETIOLOGIC AGENTS
Nosocomial Pneumonia

 Etiologic Agents
 S.aureus
 Enterobacteriaceae
 P.aeruginosa
 Acinetobacter sp.
 Polymicrobial
 Anaerobic bacteria
 Legionella sp.
 Aspergillus sp.
 Viral
 Pathogens Associated With HAP
P = .003 Early-onset NP
40
Late-onset NP
Nosocomial Pneumonia (%)
35
PA = P aeruginosa
OSSA = Oxacillin-sensitive
30 S aureus
ORSA = Oxacillin-resistant
P = .408 S aureus
25 ES = Enterobacter
P = .043 species
20 SM = S marcescens

15 P = .985 P = .144

10

0
PA OSSA ORSA ES SM
Pathoge
n
Ibrahim, et al. Chest. 2000;117:1434-1442.
Nosocomial
Pneumonia
DIAGNOSIS
Nosocomial Pneumonia

 Diagnosis
 Not necessarily easy to accurately diagnose HAP
 Criteria frequently include:
 Clinical
 fever ; cough with purulent sputum,
 Radiographic
 new or progressive infiltrates on CXR,
 Laboratorial
 leukocytosis or leukopenia
 Microbiologic
 Suggestive gram stain and positive cultures of sputum, tracheal aspirate, BAL,
bronchial brushing, pleural fluid or blood
 Quantitative cultures
Nosocomial Pneumonia

 Problems
 All above criteria fairly sensitive, but very non- specific,
particularly in mechanically ventilated patients
 Other criteria/problems include
 Positive cultures of blood and pleural fluid plus clinical findings (specific
but poor sensitivity)
 Rapid cavitation of pulmonary infiltrate absent Tb or cancer (rare)
 Histopathologic examination of lung tissue (invasive)
Nosocomial pneumonia

 Bronchoscopically Directed Techniques for diagnosis of VAP and

Quantitative cultures
 Bronchoscopy with BAL/bronchial brushings (10,000 to 100,000 CFU/ml and
less than 1% of squamous cells)

 Protected specimen brush method (>10³ CFU/ml)

 Protected BAL with a balloon tipped catheter (>5% of neutrophils or

macrophages with intracellular organisms on a Wright-Giemsa stain)
Nosocomial pneumonia

 Multiple studies looked into the accuracy of quantitative culture and microscopic examination of LRT secretions as
compared to histopathologic examination and tissue cultures (either lung biopsy or immediate post mortem
obtained samples)

 Several trials conclude that use of FOB techniques and quantitative cultures are more accurate

 At least 4 studies concluded that bronchoscopically directed techniques were not more accurate for diagnosis of
VAP than clinical and X-ray criteria, combined with cultures of tracheal aspirate

 Therefore no gold standard criteria exist

 CDC- Emerging Infectious Diseases, March-April 2001

Nosocomial Pneumonia

 Differential diagnosis
 ARDS

 Pulmonary edema
 Pulmonary embolism
 Atelectasis

 Alveolar hemorrhage
 Lung contusion
Nosocomial
Pneumonia
TREATMENT
Nosocomial Pneumonia

 Antimicrobial Treatment
 Broad spectrum penicillins
 3rd and 4th generation cephalosporins
 Carbapenems

 Quinolones

 Aminoglycosides

 Vancomycin

 Linezolid
 Inadequate
Antibiotic
Therapy

Antibiotic
Resistance
Clinical Pulmonary Infection Score (CPIS)

>6 £6 Randomize

Antibiotics Ciprofloxacin Antibiotics

10-21 days 3 days 10-21 days
Reevaluate CPIS at 3 days

>6: treat as £6: discontinue

pneumonia Ciprofloxacin
Singh, et al. Am J Respir Crit Care Med. 2000;162:505-511.
Outcomes

Variable Ciprofloxacin Control P Value

(n = 39) (n = 42)

Death* 13% 31% .06

ABs>3d 28% 97% .0001
Mean AB costs† $259 $640 .0001

*At 30 days
†
For patients with CPIS 6 at day 3

Singh, et al. Am J Respir Crit Care Med. 2000;162:505-511.

Antimicrobial Superinfections
and Resistance (S&R)
Variable Ciprofloxacin Control P Value

S&R 15% 35% .017

MRSA 5% 14%
Candida species 8% 14%
P aeruginosa 8% 16%

Singh, et al. Am J Respir Crit Care Med. 2000;162:505-511.

Nosocomial Pneumonia- Treatment
 Micek et al.Chest,May 2004
 Randomized, controlled trial of antibiotic discontinuation for patients with suspected VAP
 Discontinuation group vs. conventional group (clinical judgment of treating ICU physician)
 Discontinuation policy(clinical criteria)
 Non-infectious etiology identified or
 Signs and symptoms suggestive of infection had resolved (fever, leukocytosis, purulent sputum,
PaO2/FiO2 ratio > 250, improvement of CXR)
 Only statistically different outcome was duration of antibiotic therapy
 Mortality, length of ICU stay and 2nd episode of VAP were similar in both groups
Proposed Strategy for Management of Suspected Ventilator-Associated Pneumonia

Torres, A. et al. N Engl J Med 2004;350:433-435

Treatment of Nosocomial Pneumonia

 Vancomycin versus Linezolid for MRSA pneumonia

 Rubinstein et al. CID2001;32:402-12

 Randomized, double blinded, multi-center study
 203 patients received Linezolid /193 patients received Vancomycin
 Clinical success equivalent( 66.4% linezolid vs.68.1% Vancomycin)
 Microbiological success equivalent (67.9% Linezolid and 71.8%Vanc)
 VRE in stools (0% linezolid vs. 4% Vancomycin)
Treatment of Nosocomial Pneumonia

 Vancomycin versus Linezolid for MRSA infections/pneumonia

 Stevens et al. CID 2002; 34:1481-90

 Randomized, open label study
 460 patients
 Clinical success equivalent( 73.2% linezolid vs.73.1% Vancomycin)
 Microbiological success equivalent (58.9% Linezolid and 63.2%Vanc)
 GI side effects higher in the Linezolid arm
Treatment of Nosocomial Pneumonia

 Vancomycin versus Linezolid for MRSA pneumonia

 Wunderink RG et al.Chest Nov.2003

 Retrospective analysis of 2 prospective double blind multinational studies
 160 patients with MRSA VAP received Linezolid or Vancomycin
 Outcome assessed 12-28 days post treatment
 Logistic regression analysis used to determine the effect of treatment, and other baseline
variables on outcome
 Cure rates showed linezolid to be superior ( 59% Linezolid vs.35.5% Vancomycin, p=0.009))
 Survival rates favored Linezolid (80% Linezolid vs. 63.5% Vancomycin, p=0.03)
Linezolid vs. Vancomycin for VAP

80
70
60 Linezolid
50 Vancomycin

40
30
20
10
0
Cure Survival
rate rate
Nosocomial Pneumonia

 Duration of antimicrobial treatment

 Optimal duration of treatment has not been established

 Most experts recommend 14-21 days of treatment

 Recent data support shorter treatment regimens (8 days)

Treatment of Nosocomial Pneumonia

 Comparison of 8 vs.15 days of antibiotics for VAP

 Prospective, randomized, double blind clinical trial

 51 French ICUs
 401 patients with VAP (quantitative culture results)
 Clinical effectiveness comparable, with the possible exception of VAP caused by non
fermenting GNR

 JAMA 290 No 19, November 2003

Treatment of Nosocomial Pneumonia

45
42
39
36
33
30
27
24 8days
21 15 days
18
15
12
9
6
3
0
Mortality Recur P.aerug Abx Free
Infec Days
Nosocomial
Pneumonia
PREVENTION
Nosocomial pneumonia- Surveillance

Ventilator Utilization Rate

0.7

#P a tie n t Da ys
0.65

#V e n t Da ys/
0.6 Ventilator Utilization Rate
0.55 NNIS 25th percentile (0.37)
0.5
0.45 NNIS 50th percentile (0.47)
0.4 NNIS 75th percentile (0.53)
0.35
0.3
3qtr 2003 4qtr 2003 1qtr 2004 2qtr 2004
Quarter/Year

Ventilator Associated Pneumonias*

12
1000 Ventilator Days

10 Ventilator Associated
8 Pneumonias
# VAP/

6 NNIS 25th percentile (2.4)

4
NNIS 50th percentile (5.1)
2
0
NNIS 75th percentile (11.8)
3qtr 2003 4qtr 2003 1qtr 2004 2qtr 2004`
Quarter/Year

*Ventilator associated pneumonia benchmarks include only data from January 2002-June 2003. The number of pneumonias and ventilator days is a relatively small sampling and the data should be considered
provisional.
 
Quarter/Year # Infections #Ventilator Days # Vent pneumonia/1000 vent days
 
3qtr 2003 340 0.0
4qtr 2003 2 394 5.1
1qtr 2004 0 347 0.0
2qtr 2004 0 298 0.0
Last 4 qtrs 2 1379 1.5
Nosocomial Pneumonia

 Preventive Measures
 Incentive spirometry
 Promote early ambulation
 Avoid CNS depressants
 Decrease duration of immunosupression
 Infection control measures
 Educate and train personnel
Nosocomial Pneumonia

 Preventive Measures
 Avoid prolonged nasal intubation
 Suction secretions
 Semi-recumbent position( 30-45°head elevation)
 Do not change ventilator circuits routinely more often than every
48 hours
 Drain and discard tubing condensate
 Use sterile water for respiratory humidifying devices
 Subglottic secretions drainage
Craven, et al. Chest. 1995;108:s1-s16.
Nosocomial Pneumonia

 Preventive Measures
 Remove NGT when no longer needed
 Avoid gastric overdistention
 Stress ulcer prophylaxis:
 sulcrafate; antacids; H2 receptor antagonists
 Acidificationof enteral feedings
 Prophylactic antibiotics
 Inhaled antibiotics
 Selective digestive decontamination
 Chlorexidine oral rinses
 Vaccines ( Influenza; Strep.pneumoniae)
 100

QUIZ- Question-1

20/03/2022
 A two year child presented with fever and fast breathing for the past 4 days.
On examination child had subcostal retractions, normal sensorium child was
started on Ampicillin. 2 days after child had increased Respiratory rate and
high grade fever, hence x-ray done revealed this finding?

 Diagnosis, Differential diagnosis and management?

 101

20/03/2022
Piyush Gupta text book of Paediatrics- Volume 2
 102

20/03/2022
 A two year child presented with fever and fast breathing for the past 4
days. Child was treated in some local hospital, 2 days after child condition
deteriorated, hence Child was admitted in a tertiary Centre. X-ray done
revealed this finding?

 Probable diagnosis and treatment in this child?

 103

Question-2

20/03/2022
 104

Summary

20/03/2022
 Pneumonia is diagnosed clinically- No need of routine X-ray.

 Pneumonia should be differentiated from other ARI.

 When child presents look for Red Flag Signs.

 Pneumonia: EBM, Health education, Effective Antibiotics and follow-up.

 Severe Pneumonia: Choice of antibiotic is guided by associated features.

 Know the risk factors by taking proper history and advice preventive

measures to the parents.

 105

20/03/2022
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