Pediatric Community-Acquired Pneumonia

CC Trisha Pamela Oquendo

Epidemiology
Inflammation of the lung parenchyma
Leading cause of death globally among
children <5y.o
◦ Approximately 1.2 million deaths annually
Etiology
Non-infectious
◦ Aspiration – food, gastric acid, lipoid substances
◦ Hypersensitivity reactions
◦ Drug- or radiation-induced pneumonitis
Infectious
◦ Viral
◦ Bacterial
Viral
Viral pathogens are a prominent cause of
LRTI in infants and children older than 1
month but younger than 5 years of age
Respiratory syncytial virus (RSV) &
Rhinoviruses are the most common
Influenza virus, parainfluenza viruses,
adenoviruses
Bacterial
Streptococcus pneumonia (pneumococcus) is
the most common bacterial pathogen in
children 3 weeks to 4 year of age
Mycoplasma pneumonia and Chlamydophila
pneumonia are the most frequent in 5 years
and older
PATHOGENESIS
Pathogenesis of Viral Pneumonia
Results from spread of infection along the
airways
Direct injury of the respiratory epithelium
Results in airway obstruction from swelling,
abnormal secretions, and cellular deris
Bacterial Superinfection
Frequently preceded by viral infection
Impaired cough reflex
Interruption of mucociliary clearance
◦ Kartagener syndrome
◦ Cystic fibrosis
Bacterial Pneumonia
When organisms colonize the trachea and
gain access to the lungs
May also result from direct seeding of lung
tissue after bacteremia
Pathologic process varies according to the
invading organism
Morphology (Robbins)
Bronchopneumonia
 Patchy consolidation of the lung
Lobar Pneumonia
 Consolidation of a large portion of a lobe or of an
entire lobe
S. pneumoniae
Focal lobar involvement
local edema  proliferation of the organism
 spread into adjacent portions of the lung
S. aureus
Confluent bronchopneumonia, often
unilateral
Presence of extensive areas of hemorrhagic
necrosis
Irregular areas of cavitation of the lung
parenchyma, resulting in pneumatoceles,
empyema, or bronchopulmonary fistulas
M. pneumoniae
Age is the best predictor of the underlying
etiology of pediatric pneumonia
First 2 years of life: viral
Bacterial pathogens become more prevalent
as age increases
Haemophlis influnzae should be considered
in a patient below 5 years of age who has not
completed the primary series of Hib
immunization
CPG Guidelines
CQ 1. Who shall be considered as having
CAP?
CQ 1. Who shall be considered as having CAP?
1. A patient presenting initially with cough
and/or respiratory difficulty
At the ER:
◦ O2 saturation of less than or equal to 94% at
room air in a patient aged 3mos – 5 years and
above 5 years in the absence of any comorbid
neurologic, musculoskeletal or cardiac conditions
that may potentially affect oxygenation
Tachypnea
Most sensitive and specific criterion of
pneumonia used by WHO
 CQ 1. Who shall be considered as having CAP?
For ages 3 months to 5 years
◦ tachypnea and/or chest wall retractions
For ages 5 to 12 years
◦ fever, tachypnea, and crackles
Beyond 12 years:
◦ Fever, tachypnea and tachycardia and
◦ At least one abnormal chest findings of diminished breath sounds, rhonchi,
crackles, wheezes or grunting
For any age:
◦ Fever, grunting wheezing, decreased breath sounds, nasal flaring, cyanosis,
crackles or localized chest findings
Important physical findings
Early:diminished breath sounds, crackles and
rhonchi
With the development of increasing consolidation
or complications, dullness on percussion is noted
Lag in respiratory excursion on affected side
Abdominal distention from swallowed air
Liver may seem enlarged
CQ2. Who will require admission?
A patient who is at moderate to high risk to
develop pneumonia-related mortality should
be admitted
A patient who is at minimal to low risk can
be managed on out-patient basis
 A patient may be classified as pCAP A,B,C, or D w/in 48 hours after
consult based on the following risk classification:
PARAMETERS RISK CLASSIFICATION
IDENTIFIED AT
INITIAL SITE-OF- pCAP A pCAP B pCAP C pCAP D
CARE

Nonsevere Severe or moderate Very severe/High risk

Clinical Parameters

1. Respiratory signs
1. Retraction None Intercostal/subcostal Supraclavicular/IC/
2. Head bobbing None Present subcostal
3. Cyanosis None None Present
4. Grunting None None Present
5. Apnea None Present
6. Tachypnea >60/min to ≤70/min Present
1. 3-12 mos ≥50/min to ≤60/min >50/min
2. 1-5 yrs ≥40/min to ≤50/min >35/min >70/min
3. >5 years ≥30/min to ≤35/min >50/min
>35/min
 2. Central Nervous system signs
Altered sensorium None Irritable lethargic/stuporous/coma
Convulsion None Present present

3. Circulatory signs
Poor perfusion None CRT >3s Shock
Pallor None Present Present

4. General considerations
Malnutrition None Mild Moderate Severe
Inability to drink No No Yes Yes
None Present Present Present
Comorbid conditions
Ancillary paramenters
5. Chest X-Ray finidings or None Present Present
effusion, abscess, air leak, or
multilobar consolidation
6. Oxygen saturation at room air 95% 91% to 94% <90%
using pulse oximentry
A patientmay be classified as pCAP A or pCAP B but is not
responding to treatment after 48 hours may be admitted.
pCAP C may be:
◦ Admitted to regular ward
◦ Managed initially on out-patient basis if all of the ff are not present:
 <2 y.o
 Convulsion
 CXR w/ effusion, lung abscess, air leak, or multilobar consolidation
 O2 saturation ≤95% at room air
pCAP D may be admitted to a critical care unit.
CQ3. What Diagnostic aids are initially
requested for a patient classified either as
PCAP A or PCAP B being managed in an
ambulatory setting?
Oxygen saturation
◦ Assess gas exchange
Gram stain and/or aerobic culture and sensitivity of
sputum
◦ For microbial determination of underlying etiology
CXR – PAL
◦ For multilobar consolidation, necrotizing pneumonia, lung
abscess, pleural effusion, pneumothorax, pneumomediastinum
CQ4. What diagnostic aids are initially
requested for a patient classified as either
PCAP C or PCAP D managed in the hospital
setting?
For gas exchange
◦ Oxygen saturation
◦ Arterial blood gas
For possible pathogen presence
◦ C-reactive proteins
◦ Procalcitonin
◦ CXR – PAL
◦ WBC
For Imaging:
◦ CXR – PAL
◦ Chest ultrasound
For determination of underlying microbial etiology
◦ Gram stain and/or aerobic culture and sensitivity of sputum,
nasopharyngeal aspirate, and or pleural fluid
◦ Blood culture and sensitivity
For determination of metabolic derangement
◦ pH in ABG
◦ Serum Sodium
◦ Serum Potassium
May be requested
 Culture and sensitivity of sputum for older children

Should not be routinely requested

 ESR
 C-reactive protein
CQ5. When is antibiotic recommended?
CQ5. When is antibiotic recommended?
1. For a patient classified as either PCAP A or B
and is
a) Beyond 2 years of age
b) Having high grade fever without wheeze
2. For patient classified as PCAP C and is
a) Beyond 2 years of age
b) Having high grade fever without wheeze or
c) Having alveolar consolidation in the chest xray
d) Having white blood cell count > 15,000

3. For a patient classified as PCAP D

 CQ6. What empiric treatment should be administered
if a bacterial etiology is strongly considered?

For PCAP A or B without previous antibiotic:

◦ Oral Amoxicillin (40-50 mg/kg/day in 3 divided doses) is
the drug of choice
◦ 90mg/kg/day in areas with proven high amoxicillin
resistance
If hypersensitivity to Amoxicillin
◦ Azithromycin (10mg/kg/day OD for 3 days or 10mg/kg/day
at day 1 then 5mg/kg/day for day 2-5)
For PCAP C without previous antibiotic
◦ Completed primary immunization against HiB
 Penicillin G (100,000 units/kg/day in 4 divided
doses)
◦ Not completed
 IV Ampicillin (100 mg/kg/day in 4 divided doses)

For PCAP D, a specialist should be consulted

CQ7. What treatment should be initially given
if a viral etiology is strongly considered?
For PCAP A,B,C or D in which non-influenza
virus is the suspected pathogen, antiviral therapy
may not be beneficial.

For PCAP C or D:
◦ Antiviral drug therapy
Oseltamivir
◦ For infants 3-8 mos: 3mg/kg per dose BID for 5 days
◦ Infants 9-11 mos: 3.5mg/kg per dose BID for 5 days
◦ >12 mos old
 BW <15kg: 30mg BID for 5 days
 BW >15-23kg: 45mg BID for 5 days
 BW >23-40kg: 60mg BID for 5 days
 BW >40kg: 75mg BID for 5 days

Doses to be started within 48 hours of onset of

influenza like symptoms.
Zanamivir
◦ For children >7years old: 10mg (two 5mg inhalations) BID for
5 days, within 36 hours of onset of influenza-like symptoms.
CQ8. When can a patient be considered as
responding to the current antibiotic?
pCAP A or B
Clinicalstability may be assessed within 24-48
hours after consultation
Improvement in
◦ Cough
◦ Body temperature returned to normal
pCAP C
Clinicalstability assessed in 24-48hours after
admission if ANY of the following physiologic
parameters improved or returned to normal:
◦ Respiratory rate at full minute
◦ Oxygen saturation at room air
◦ Body temperature in Celsius
◦ Cardiac rate at full minute
◦ Work of breathing
pCAP D
Clinicalstability may be assessed within 48-72
hours after admission if ALL of the following
physiologic parameters have significantly improved:
◦ Respiratory rate at full minute
◦ Oxygen saturation
◦ Body temperature in celsius
◦ Cardiac rate at full minute
◦ Work of breathing
Good clinical response to current therapeutic management
may not require chest x-ray or complete blood count to
document treatment success at end of treatment.
CQ 9. What should be done if a patient is
not responding to current antibiotic therapy?
PCAP A or B not responding within 72 hrs
◦ Change the initial antibiotic, or
◦ Start an oral macrolide, or
◦ Reevaluate diagnosis:
 May have coexisting or other etiologic agents
 Etiologic agent is resistant to current antibiotic
 Other diagnosis
Patients <5y.o and patients >5y.o diagnosed with
pCAP C not improving within 48 hours:
◦ Diagnostic evaluation to determine if there are
any:
 Coexisting/other etiologic agents
 Etiologic agent resistant to current antibiotic
 Penicillin resistant S. pneumonia
◦ Other diagnosis
◦ Presence of complications
◦ consider consulting a specialist due to possible
Patient classified as pCAP D clinically worsening
within 24 hours:
◦ Referral to a specialist may be done.
CQ 10. When can switch therapy in
bacterial pneumonia be started?
For pCAP C, switch from IV antibiotic administration to
oral form may be beneficial to reduce length of hospital stay
provided all of the following are present:
Current parenteral antibiotic has been given for at least 24
hours
At least afebrile within the last 8 hours without current
antipyretic drug
Responsive to current antibiotic therapy
Able to feed and without vomiting or diarrhea
W/o any current pulmonary or extra pulmonary symptoms
O2 saturation ≥ 95% at room air
For pCAP D:
Referral to a specialist may be done if switch therapy is
considered.
CQ11. What anciliary treatment can be
given?
For pCAP A or pCAP B
Oralsteroid in a patient with coexisting asthma
Bronchodilator in the presence of wheezing

May not be beneficial:

◦ Cough preparation or parenteral steroid in a patient without asthma
◦ Elemental zinc, vitamin D2, and probiotic
For pCAP C
Nasal catheter or nasal prong in administering oxygen
Zinc supplement in reducing mortality
Use of bubble CPAP instead of low flow oxygen
Steroid or spirulina in reducing length of stay
Oxygen for O2 saturation <95% at room air in improving
oxygenation

May not be beneficial:

◦ Zinc supplement in reducing treatment failure or length of stay
◦ Vitamin D3 in reducing length of hospital stay
◦ Parenteral steroid, probiotic, virgin coconut oil, oral folate, and nebulization
using saline or acetylcysteine
For pCAP D
Referral to a specialist may be beneficial
CQ 12. How can Pneumonia be prevented
Beneficial in reducing the burden of hospitalization
because of pneumonia:
Conjugated vaccine (PCV10 or 13) against Streptococcus
pneumoniae
Vaccine against Haemophilus influenzae type B, influenza
sp, and Diphtheria, Pertussis, Rubeola, and Varicella
Breastfeeding
Avoidance of cigarette smoke and biomass fuel
Not beneficial in reducing the clinical impact of
pneumonia:
Zinc supplement
Vitamin D
References:
Nelson Textbook of Pediatrics 20th edition
3rd PAPP Update (2016) in the Evaluation and
Management of Pediatric Community-acquired
Pneumonia
Thank you!