3 community acquired pneumonia
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Community acquired Pneumonia
Dr Yog Raj Khinchi
• Pneumonia, especially CAP has been a subject of challenge to the medical fraternity despite extensive research since ‘Antiquity’
Introduction
Introduction – Contd..
• It is tragedy that in this era of easy vaccine availability millions of children die across the globe, particularly in developing countries due to vaccine preventable ‘Lower Respiratory Tract Infections’
Pneumonia
Congenital
OpportunisticAspiration
Nosocomial
Acquired
Community Acquired Pneumonia (CAP)
Definition - CAP
Pneumonia acquired outside the hospital environment by an immunocompetant healthy child
Disease Burden - CAP
• Global Scenario :
- 100 million cases per year < 5 yrs- 80% OPD cases with 1% mortality- 20% IPD cases with 10 -12 % mortality- 2 – 2.3 million deaths / year, 90% in developing countries
Disease Burden – CAP Indian Scenario :
CAP contributes 13% of deaths
(< 5 years of age) 24% National Burden of Disease (NBD)
7.5 million total cases
.37 to .46 million deaths per year.
[Estimates on different studies done at Delhi – Pune – Kolkatta – Varanasi –
Rajasthan – Maharashtra - Haryana & Tripura [Source S.K.Kabra - National consensus
on child survival & development]
Risk FactorsComorbid Pul. Illnesses
Rampant use of antibiotics particularly
B-lactames in viral URTIs
Poor Socio Economic Status
Immunosuppressed conditions
Viral URTIsAir Pollution & Passive Smoking
Malnutrition, Vit A, D & Zinc def.
Lack of Breast Feeding
Low Birth Weight
Comorbid extra pul. conditions
CAP
[Study by Burman et al -Epidemiology of ARI in children of developing countries Rev. Inf. Dis. (1991)
Q : Do I need to chase an aetiological diagnosis in CAP before starting antimicrobial treatment??
A : NO !
Q : WHY ?
A : It is not only “difficult” but often “not possible” to document Aetiological factor by lab diagnostics
(> 60%) THM:
It is Prudent and Rational to start “Emperical Antimicrobial” therapy before establishing microbial
aetiologyDiagnosis per se is always - almost clinical
Q : Then how do I make the diagnosis ?
A : Clinically – Triad of fever, cough, tachyponeaWith or without
Chest pain, Sputum, Grunting, Crackles, Bronchial breathing,
↑ Vocal fremitus, Feeding difficulties, Chest recession, Cyanosis.
WHO ARI Control Program Tachyponea most sensitive sign
New borns > 70/minInfants (upto 2 yrs) > 50/minChildren (> 2 yrs) > 40/min
Diagnosis
Q : Does ancillary lab investigations support the diagnosis ?
A : Yes ! to some extentNon invasive & easily
accessibleNon invasive but not easily
accessibleInvasive & not cost
effective
CBC X-rays BAL
ESR Blood culture Lung Biopsy
CRP Sputum and gastric aspirate culture
CT Scan
Mx Serology PCR
Gram stain of sputum & naso pharyngeal
secretions
Pleural Tap Rapid Antigen detection test
Less specific Some what specific More specific
Diagnosis
Q : How do I decide whether it is bacterial or viral ?
A : There are no definite markers to differentiate between bacterial or viral.Features suggestive of bacterial pneumonia :• Fever > 38.5oC. Toxic look• Respiratory rate > 50 breaths / min• Chest recession (Respiratory distress)• Radiologically Lobar consolidation, Segmental consolidation
and Round consolidation.
Features suggestive of viral pneumonia
• Infants and young children• Fever < 38.5oC • Mucosal congestion• Wheeze• Hyperinflation• Marked recession• Respiratory rate normal or raised• Radiologically Hyperinflation, Diffuse
infilterates & Segmental collapse.
Features suggestive of Pneumonia by Atypical organisms
• School Age children• Cough• Wheeze• Chest pain• Respiratory distress• Anemia and reticulo cytosis• Radiologically Lobar consolidation and hilar
adenopathy, Interstitial infiltrates
Source – British Thoracic Society guidelines for the diagnosis and management of Community Acquired Pneumonia in children.
THM:1. ‘S pneumoniae’ is the commonest causative
organism of CAP in Infancy & childhood, accounting for 1 million deaths annually out of a total 1.9 million estimated deaths, particularly in developing countries.
2. Viruses are commonest cause in infants and young children (14-35% of CAP)
3. Significant proportion of CAP is due to mixed infections (8-40%)
4. In 20-60% cases pathogen is not identified.
CAP
Q : What are other ‘Clues’ and ‘Parameters’ to
catch aetiologocal diagnosis ?
‘CLUES’ Associated co-morbid conditions
Otitis media S pneumoniae
Purulent sinusitis S pneumoniae
Pyoderma S aureus
Empyema S aureus
Measles S aureus
Watery rhinorrhoea viral
Meningitis S Pneumonia / HIB
Pathogens in infants < 3 months
. Group B Steptococcus
Gram negative enterococci & klebseilla
Staph aureus
Chlamydia trachomatis
Parameters : Age is a good predictor of the likely pathogens
Pathogens in Children 3 months to 5 yrs of age
• More Common : - ‘S’ pneumoniae- Viruses (RSV, PIV3,
Adenovirus)- H influenzae b
Less Common : - M.catarrhalis- Staph aureus- Group A streptococci
Pathogens in Children > 5 yrs of age
• Mycoplasma pneumoniae• Chlamydia pneumoniae• Streptococcus pneumoniae• Leigonella species
Diagnostic Difficulties1. No specific markers to differentiate viral from
bacterial.2. Sputum samples are not often obtainable3. Nasopharyngeal secretions are unreliable due to
high asymptomatic carriage rates.4. Some common organisms like M pneumoniae, C
pneumoniae & H influenzae cannot be cultured easily.
5. Bactec culture facilities are not available everywhere
6. Invasive tests which are more specific are not practical in practice and are not cost effective.
7. Infection may be polymicrobial
a) Evaluation Diagnosis
Grading of severity
Mode of management
b) Stabilization Supportive treatment
ICU Management
c) Specific Agents Antimicrobials
Q : How do I manage a case of CAP ?
Principles of Management
Mild OPD Management
Moderate IPD Management
Severe ICU Management
Indicators Indicators IndicatorsFever < 38.5oc, Mild cough R.R< 50 / minNo dehydration,Adequate intake
Fever > 38.5oc on two occ. at 8 hrs apartModerate to severe coughTachyponeaR.R.> 50 / minResp. distressPso2 92% GruntingRefusal of feeds & dehyderation
Altered sensoriumCyanosis / Pso2 < 92Pao2 < 60% Pco2 > 40%pH > 7.3Systolic BP<60 mmHgBUN > 20 mg% Exp. GruntSevere Resp. Distress
As per BTS & ATS guidelines on CAP management
Severity Assessment
Mode of Management
A) OPD - Appropriate oral Antibiotics for 3-5 days- Analgesics & Antipyretics- Symptomatic
B) IPD - IV antibiotics for 3 - 5 days – switch to oral
- IV fluid therapy & Electrolyte maintenance
- Pulse oxymetry monitoring- Maintenance of Nutrition- Oxygen if required
C) ICU - All of the above + ABG monitoring + Ventilatory life support if required
Specific Antimicrobials
Which antibiotic ? Which Route ?Duration ? When to switch to oral?
“Age is a good predictor of the likely
pathogen & choice of antibiotic is
based on suspected pathogen”
AGE OPD IPD ICU
Birth to 3 months
IV Ampicillin / Amoxycillin 100-200 mg / kg / day + IV Aminoglycoside with or without
3rd Generation Cefalosporin100-150 mg / kg / day
IV Ampicillin / Amoxycillin +IV Aminoglycoside
with or without
IV Ceftazidime 50-100 mg / kg / day or Vancomycin / Teicoplanin 10- 15 mg / kg / day orImipenem / Meropenem orPipracillin / Tazobactum
CAP Treatment
AGE OPD IPD ICU3 months to 5 yrs
Oral Amoxycillin50-100 mg/kg/day orCo-amoxiclav50-100 mg/kg/day orCefaclor25-30 mg/kg/day orCefuroxime15-25 mg/kg/day And / OrMacrolidea)Azithromycin10mg/kg/dayb) Clarithromycin15mg/kg/day
IV Amoxycillin 100-200 mg / kg / day
with or without
a) Cefotaxime 100-150 mg/kg/day b) Ceftriaxone100-150 mg/kg/day orB-Lactamesa) Co-amoxiclav100-150 mg/kg/dayb) Cefuroxime50-100 mg/kg/day with or withoutOral Macrolide
IV Ampicillin + Cloxacillin200 mg/kg/day orIV B-Lactamesa) co-amoxiclavb) Cefuroximec) Ceftriaxone
with or without
Aminoglycoside or Vancomycin / Teicoplanin
CAP Treatment
AGE OPD IPD ICU> 5 yrs Oral Amoxycillin
60-90 mg/kg/day
and / or
Macrolide a) Azithromycin10mg/kg/dayb) Clarithromycin15 mg/kg/day orc) Doxycycline (> 8 yrs) 5 mg / kg / day
IV Co-amoxiclav 100 mg / kg / day
and / or
IV Cefuroxime100-150 mg/kg/day
with or without
IV Cefotaxime100 mg/kg/day
with or without
Oral macrolide
IV Co-amoxiclav100-150 mg/kg/day +IV Ceftriaxone100-200 mg/kg/day + IV Macrolide or IV Fluroquinolone(Newer anti Pneumococcal)
CAP Treatment
Failure of clinical response !!What should I Do ?
A) Check the diagnosis May be wrong diagnosis - Aspiration Pneumonia
- Interstitial Lung Disease - Tuberculous Pneumonia - Foreign body Aspiration
B) Look for underlying cardio pulmonary conditions like : - Lung Abscess
- Empyema - Cystic Fibrosis - Bronchiectasis - L-R shunt - GERD - Asthma
Failure of clinical response !!What should I Do ?
C) Immunosupression in host - PCP Pneumonia - Fungal Pneumonia - Pseudomonal Pneumonia
D) Think for drug resistance - Child from day care centre (DRSP/ B-Lactamase producing - Use of corticosteroids &
organisms) - B-Lactames in previous 1 month
E) Possibility of Viral + Bacterial Polymicrobial Aetiology or
Bacterial + atypical Bacterial
Cont’d…..
• Empyema• Pneumothorax• Lobar Atelectesis• Septicemia• Bronchogenic dissemination• Osteomylitis• Septic Arthritis• Multiple Systemic Abscesses• Meningitis etc…
Q : What complications can I expect if not treated properly ?
Q : How should I follow up & should I chase for follow up x-rays ?
- Follow up should be clinical for 3-4 weeks- No chase for follow up x-rays except in case of -
Lobar collapse- Round Pneumonia- Symptomatic child
Radiographic resolution56% - 2 weeks74% - 4 weeks98% - 6 weeks
“NO”
Q : How can I contribute in prevention of CAP in community ?
i) Promotion of Immunisation – Measles, Influenza, HIB & Pneumococus vaccines
ii) Prevention of passive smoking & air pollutioniii) Judicious use of corticosteroids & antibiotics
particularly B-Lactams)iv) Supplementation of Vit A, Vit D & Zincv) Promotion of Breastfeeding & demotion of bottle
feedingvi) Treatment of malnutrition
1. Aetiological diagnosis in CAP is not only difficult but not always possible (>60%)
2. Emperical Antimicrobial therapy is ‘Rational’ & ‘Prudent’
3. Age is a good predictor of likely pathogens4. Streptococcus pneumoniae is the most common
cause of CAP in childhood followed by viruses5. Chest radiography though supports the diagnosis
– is poor indicator of aetiology.6. Followup x-rays are not required unless in special
circumstances
Key points
Key Points – Contd..7. Acute phase reactants do not distinguish between viral &
bacterial infections8. Pulse oxymetery monitoring should be performed in every
admitted child with CAP.9. Blood cultures though desirable yields only 10-20%
positivity.10. Amoxycillin is the drug of choice for CAP from infancy to
adolescent alternatives are co-amoxiclav, cefuroxime or macrolide
11. Child remaining febrile & symptomatic for more than 48-72 hrs after hospitalization should be re-evaluated for complications, underlying comorbid conditions, co-mimics, immunosuppression or drug resistance.
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