Pneumonia in children: Management and complications

1. Pneumonia in children: Management and complications Pierre Goussard , Robert Gie Tygerberg Children`s Hospital and Stellenbosch University

2. 6 month old girl presents with cough and respiratory distress

4. Pneumonia is the single greatest cause of death in children worldwide . • Each year, 2 million children younger than 5 years die of pneumonia, representing 20% of all deaths in children within this age group . • 155 million cases of pneumonia occur in children every year worldwide • In many children with LRTI, diagnostic testing may identify 2 or 3 pathogens, including combinations of both viruses and bacteria, making it difficult to determine the significance of any single pathogen

5. CAP • CAP can be defined as acute infection (of less than 14 days’ duration), acquired in the community, of the lower respiratory tract leading to cough or difficult breathing, tachypnoea or chest-wall indrawing • CAP accounts for between 30% and 40% of hospital admissions, with associated case fatality rates of between 15% and 28%. • Mixed bacterial and viral infections may occur in 30 - 40% of cases of childhood CAP.

6. S. pneumoniae as the most common documented bacterial pathogen, occurring in 4%–44% of all children • Viral etiologies of CAP have been documented in up to 80%of children younger than 2 years; in contrast, older children, 10–16 years, who had both clinical and radiographic evidence of pneumonia, documented a much lower percentage of viral pathogens • RSV is consistently the most frequently detected, representing up to 40%of identified pathogens in those younger than 2 years, but rarely identified in older children with CAP. • Epidemiologic investigations of hospitalized children with CAP document that 2%–33% are simultaneously infected by 2 or more viruses

7. Terminology • Community acquired pneumonia • Hospital acquired pneumonia • Ventilator associated pneumonia

8. Terminology • ‘‘Simple pneumonia’’ as either bronchopneumonia (primary involvement of airways and surrounding interstitium), or lobar pneumonia involving a single lobe. • ‘‘Complicated pneumonia’’ is defined as a pulmonary parenchymal infection complicated by parapneumonic effusions, multilobar disease, abscesses or cavities, necrotizing pneumonia, empyema, pneumothorax or bronchopleural fistula

9. Causes of CAP

10. Etiology of CAP • < 3 months • Gram negative organisms • Group B streptococcus • Staphylococcus aureus • Haemophilus influenzae • Other atypical • chlamydia, ureoplasma

11. 3 months - 5 years • Streptococcus pneumoniae • Haemophilus influenzae • Staphylococcus aureus • > 5 years • Streptococcus pneumoniae • Mycoplasma pneumoniae • Staphylococcus aureus

12. Mycoplasma • Atypical pneumonia caused by Mycoplasma is characteristically slowly progressing, with malaise, sore throat,low-grade fever, and cough developing over 3–5 days

13. Causes of CAP in HIV positive children

14. Diagnosis of CAP • Diagnosis includes: • clinical evaluation • radiographic evaluation • aetiological investigations • To establish : • whether pneumonia is present • assess the severity of pneumonia • determine the causative organism

15. WHO defines pneumonia primarily as cough or difficult breathing and age-adjusted tachypnea: (age 2–11 months, RR > 50/min; 1–5 years, RR > 40/min; >5 years, >20 breaths/min) • Furthermore, severe pneumonia is defined as ‘‘cough or difficulty breathing plus one of the following: • lower chest indrawing • nasal flaring • grunting. • Very severe pneumonia is defined as ‘‘cough or difficulty breathing plus one of the following: • Cyanosis • severe respiratory distress • inability to drink or vomiting everything • lethargy/unconsciousness/convulsions.’’ • Infants and young children tend to have more severe pneumonia with a greater need for hospitalization and a higher risk of respiratory failure.

16. Diagnosis • Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting • Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy • C-reactive protein or serum procalcitonin concentration, cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP • Pulse oximetry should be performed in all children with pneumonia and suspected hypoxemia

17. Chest X-ray • Routine chest radiographs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting • Chest radiographs, posteroanterior and lateral, should be obtained in patient : • with suspected or documented hypoxemia • significant respiratory distress • Suspected PTB • Foreign body aspiration • those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax.

21. Indications for hospital admission in CAP

22. Impact of HIV infection on clinical diagnosis of CAP • Clinical signs of CAP are similar in HIV-infected and HIV uninfected children. • However, pneumonia resulting from opportunistic pathogens should also be considered in HIV infected children. • Of these, PCP is the most common and serious infection among infants, occurring commonly at 6 weeks - 6 months of age. • PCP is frequently (20 - 40%) the initial presenting feature of AIDS in HIV-infected children not taking co-trimoxazole prophylaxis. • Although PCP may present with a tetrad of features comprising tachypnoea, dyspnoea, fever and cough, these are not specific for pneumonia caused by P. jiroveci. • Hypoxia may be prominent and rapidly progressive. • Other stigmata of AIDS such as hepatosplenomegaly and generalised lymphadenopathy are not always present and adventitious sounds in the chest may be absent despite clinical signs of severe respiratory distress.

23. Which organism • PJP • CMV • Fungal • Gram negative • Other opportunistic virus infection • MTB

26. Hospitalization • Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory distress and hypoxemia (sustained saturation of peripheral oxygen [SpO2],,90 % at sea level) • Infants less than 3–6 months of age with suspected bacterial CAP • Children and infants with suspected or documented CAP caused by a pathogen with increased virulence, such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized

27. Antibiotic use in the treatment of CAP • Difficult to distinguish between pneumonia caused by bacteria and viral infections • 30-40% have mixed bacterial-viral infections • Children with pneumonia require an antibiotic • Most bacterial pneumonia respons to amoxicillin

28. Choice of antibiotic • CAP VS HAP • Age of child • Immunestatus of child • IV VS oral

29. Age • < 2 months risk of gram negative infection • Add aminoglycoside • > 5 years have more infection with Mycoplasma pneumoniae • Add macrolide

30. Immunestatus • Congenital immundefiency • T-cell defiency • B-cell defiency • Acquired immundefiency • HIV • Malnutrition • Cancer patient

31. Treatment with oral antibiotics • Amoxicillin should be used as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most prominent invasive bacterial pathogen • Amoxicillin should be used as first-line therapy for previously healthy appropriately immunized school-aged children and adolescents with mild to moderate CAP for S. pneumoniae, • Macrolide antibiotics should be prescribed for treatment of children (primarily school-aged children and adolescents) evaluated in an outpatient setting with findings compatible with CAP caused by atypical pathogens

32. Treatment of inpatients • Ampicillin or penicillin G should be administered to the fully immunized infant or school-aged child admitted to a hospital ward with CAP • Empiric combination therapy with a macrolide (oral or parenteral), in addition to a b-lactam antibiotic, should be prescribed for the hospitalized child for whom M. pneumoniae and C. pneumoniae are significant consideration

33. When S. aureus is suspected, cloxacillin is the drug of choice. • considered if there is radiological evidence of pneumatocele, empyema or abscess formation • child remains pyrexial 48 hours after starting amoxicillin. • HIV-infected children, approximately 60% of community acquired S. aureus may be resistant to cloxacillin and require treatment with vancomycin.

34. HIV-infected children requiring hospitalisation may have pneumonia caused by Gram-negative bacteria. • Children with a high risk of being HIV-infected or who have symptomatic HIV disease or who are severely malnourished should have an aminoglycoside added to their empirical treatment regimen • PCP is suspected, co-trimoxazole should be added.

35. IV treatment • < 3 months: • Ampicillin , gentamycin and cloxacillin • > 3 months : • Ampicillin IV • IF not improved after 24 – 48h • Ampicilin plus Cloxacillin IV • Or Cefuroxime IV

36. In children with pneumonia, the increasing resistance of pneumococcus to penicillin can be overcome by giving a higher dose of amoxicillin. • Although standard doses of amoxicillin (15 mg/kg/dose three times a day) are likely to treat most cases of pneumococcal pneumonia in South Africa, the use of high-dose amoxicillin (30 mg/kg/dose 3 times a day) is advocated so as to overcome and limit the emergence of resistant pneumococci, and to successfully treat those additional few children with high-level pneumococcal resistance (minimal inhibitory concentrations (MICs) of ≥ 2.0 μg/ml).

37. Duration of treatment • Generally recommended that 5 days of therapy is sufficient for uncomplicated pneumonia. • A recent study of HIV-uninfected children with uncomplicated pneumonia reported that the clinical efficacy of 3 days of oral amoxicillin (15 mg/kg/dose) was similar to 5 days for outpatient therapy. • Children with S.aureus pneumonia should be treated for 14 - 21 days depending on clinical response. • Children infected with M. pneumoniae or C. pneumoniae require erythromycin for 10 days; alternatively the newer macrolides such as azithromycin may be used for 3 - 5 days.

38. Supportive treatment in themanagement of CAP • Oxygen therapy • Nasal prongs are recommended for most children maximum fractional concentration of inspired oxygen (FIO2) of 28 - 35% • Facemask oxygen is designed to deliver 28% - 65% oxygen at a flow rate of 6 - 10 l/min • polymask whereby FIO22 concentrations of 60 - 80% may be achieved. The flow rate should be regulated to keep the bag of the mask inflated during inspiration and expiration.

39. IV Fluids • In children with severe or complicated pneumonia, serum urea and electrolytes should be measured before instituting IV fluid as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is common. • In these children, intake should be restricted to 40 - 60% of normal

40. Vitamin A should not be given to children with acute pneumonia unless this is measles associated • In children with acute pneumonia, adjuvant treatment with 20 mg zinc per day until discharge was found to accelerate recovery from severe pneumonia, reducing the duration of hypoxia • Zinc should therefore be considered for use in children hospitalized with pneumonia, particularly if there is coexisting malnutrition.

41. Nonsense supportive therapy • Chest physiotherapy. • Cocktails of nebulized drugs including mucolytics • Bronchoscopy is not indicated since Pneomonia is not an endobronchial disease.

43. Measures of no value in the treatment of CAP • Chest physiotherapy • Mucolytic agents • Nebulized bronchodilators or saline do not improve the outcome of CAP. • No evidence to support the use of oral or inhaled corticosteroids

44. Complications of pneumonia • Empyema • Lung abscess • Necrotising pneumonia

46. Empyema • Pus in the thoracic cage • Byington et al. found, among 540 children admitted to hospital with community-acquired bacterial pneumonia, 153 (28%) had parapneumonic effusions • Rise in hospital admissions • 40/100000 to 120/100000 in Leuven • Streptococcus pneumonia remains the most important pathogen.

49. Imaging • Ultrasound imaging gives some idea on staging but does not provide a high level of accuracy. • Role: • estimate the size of the effusion • presence of loculi • And presents of pleural thickening

50. Criteria of RW Light • Parapneumonic effusions are exudates • Least one of the following criteria is fulfilled: (1) pleural fluid LDH/plasma LDH>0.6 of pleural >200 IU/l, (2) pleural fluid protein/plasma protein >0.5, (3) glucose levels <60 mg/d