Introduction

Pneumonia is defined as the inflammation of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms. It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired)

Who shall be considered as having community-acquired Pneumonia?

For ages 3 months to 5 years are tachypnea and/or chest indrawing For ages 5 to 12 years are fever, tachypnea, and crackles

Who shall be considered as having community-acquired Pneumonia?

Beyond 12 years of ages are the presence of the following features:

y Fever, tachypnea, and tachycardia y At least one abnormal chest findings of

diminished breathing sounds, ronchi, crackles or wheezes

Tachypnea is still the best predictor of pneumonia

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 minimal to low risk can be managed on an outpatient basis

Risk Classification of Pneumonia

Variables PCAP A Minimal risk None Yes Possible None Able >11 mos PCAP B Low risk Present Yes Possible Mild Able >11 mos PCAP C Moderate risk Present No Not possible Moderate Unable <11 mos PCAP D High risk Present No Not possible Severe Unable <11 mos Co-morbid illness Compliant caregiver Ability to follow up Presence of dehydration Ability to feed Age Respiratory rate 2-12mos 1-5years >5 years

50/min 40/min 30/min

>50/min >40/min >30/min

>60/min >50/min >35/min

>70/min >50/min >35/min

Risk Classification of Pneumonia

Variables PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium None None None None None Awake None None None None None Awake Intercostal/Subcostal Present Present None None Irritable Supraclavicular/Interco stal/Subcostal Present Present Present Present Lethargic/Stuporous/ Comatose

Complication (effusion, pneumothorax) Action Plan

None

None

Present

Present

OPD follow up at end of treatment

OPD follow up after 3 days

Admit to regular ward

Admit to ICU Refer to specialist

The presence of retraction on admission was the best single predictor of death

Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia

Diagnostic Tools
Chest X-Ray PA-lateral White cell count Acute Phase Reactants

y ESR and CRP have not been demonstrated

to differentiate viral from bacterial infection

Diagnostic Tools

Microbiology
y Blood C/S y Plueral fluid C/S y Tracheal aspiration C/S y Sputum C/S

Oxygen saturation and/or Blood Gas

y To help the clinician in deciding the

appropriate intervention

What diagnostic aids are requested for a patient classified as PCAP A or PCAP B?

No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting

What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D?

The following should be routinely requested:

y Chest x-ray PA-lateral y White blood cell count y Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and/or pulse oximetry

What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D?

The following may be requested:

y Culture and sensitivity of sputum for older children

The following should not be routinely requested:

y Erythrocyte sedimentation rate y C-reactive protein

When is antibiotic recommended?

For a patient classified as either PCAP A or B and is:

y Beyond 2 years of age y Having high grade fever without wheeze

For a patient classified as PCAP C and is:

y Beyond 2 years of age y Having high grade fever without wheeze y Having alveolar consolidation in the CXR y Having WBC > 15,000

For a patient classified as PCAP D

Etiology

First 2 years: viruses As age increases bacterial pathogens become more prevalent

PCAP managed as an outpatient:

y Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen

in more than half (Others: M. pneumoniae, C. pneumoniae)

PCAP managed as an inpatient:

y Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen

in little more than half (Others: H. influenzae b, M. pneumoniae, C. pneumoniae)

Haemophilus influenzae type b should be given in patient below 5 years of age who has not completed the primary series of Hib immunization

Bacterial vs Viral
Features Fever Wheeze Bacterial T>38.5C Absent Viral T<38.5C Present

Alveolar infiltrates in Chest Xray or an elevated white cell count favors bacterial pathogen

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

For a patient classified as PCAP A or B without previous antibiotic, oral Amoxicillin (40-50mg/kg/day in 3 divided doses) is the DOC For a patient classified as PCAP C without previous antibiotic who has completed primary immunization against H.Influenza type b, Penicillin G (100,000units/kg/day in 4 divided doses) is the DOC

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

y If a primary immunization againts Hib has not

been completed, intravenous Ampicillin (100mg/kg/day in 4 divided doses) should be given

For a patient classified as PCAP D, a specialist should be consulted

What treatment should be given if a viral etiology is strongly considered?

Ancillary treatment should be given Oseltamivir (2mg/kg/dose BID for 5 days) or Amantadine (4.4-8.8mg/kg/day for 3-5days) may be given for influenza that is either confirmed by laboratory or occurring as an outbreak

When can a patient be considered as responding to the current antibiotic?

Decrease in respiratory signs (particularly tachypnea) and defervescence within 72hours after initiation of antibiotic Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation End of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic

What should be done if a patient is not responding to current antibiotic therapy?

If an outpatient classified as either PCAP A or B is not responding within 72hours, consider any one of the following:
y Change the initial antibiotic y Start an oral macrolide y Reevaluate diagnosis

What should be done if a patient is not responding to current antibiotic therapy?

If an inpatient classified as PCAP C is not responding within 72hours, consider consultation with a specialist because of the following possibilities:
y Penicillin resistant Streptococcus pneumoniae y Presence of complication (pulmonary or

extrapulmonary) y Other diagnosis

What should be done if a patient is not responding to current antibiotic therapy?

If an inpatient classified as PCAP D is not responding within 72hours, consider immediate re-consultation with a specialist

When can switch therapy in bacterial pneumonia be started?

Switch from intravenous antibiotic administration to oral from 2-3 days after initiation is recommended in a patient who: Is responding to the initial antibiotic therapy Is able to feed with intact gastrointestinal absorption Does not have any pulmonary or extra pulmonary complication

What ancillary treatment can be given?

Among inpatient, oxygen and hydration should be given if needed Cough preparations, chest physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in community-acquired pneumonia

What ancillary treatment can be given?

In the presence of wheezing, a bronchodilator may be administered

How can Pneumonia be prevented?

Vaccines recommended by the Philippines Pediatric Society should be routinely administered Zinc supplementation may be administered Vitamin A, Immunomodulators, and Vitamin C should not be routinely administered as a preventive strategy

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