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KONSEP PNEUMONIA

Community-acquired pneumonia (CAP) is a common


disorder that is potentially life threatening, especially in older adults and those with comorbid
disease.
A. DEFINISI
a common disorder that is potentially life threatening,
Pneumonia banyak terjadi dan mematikan
File Jr, T.M 2003

Pneumonia is a type of respiratory disease in which the lungs are infected


by bacteria, viruses or fungi. It makes our lungs not to be able to function
properly and thus can cause many unwanted, severe problems such as
respiratory difficulties. Besides that, pneumonia may lead to other
diseases such as meningitis, etc. (
Ming, C.K. 2011.

Pneumonia is a severe acute respiratory infection, a condition where fluids


fill the lungs and disrupt how oxygen is absorbed. Breathing can become
very difficult, especially for young children. Other symptoms can include
intense coughing, a high fever, and chills. As pneumonia progresses,
children can experience convulsions, unconsciousness, feeding problems,
and without timely treatment, often death.
IHME. 2014

Pneumonia is a type of respiratory disease in which the lungs are infected


by bacteria, viruses or fungi. It makes our lungs not to be able to function
properly and thus can cause many unwanted, severe problems such as
respiratory difficulties.
Besides that, is caused by the inflammation of lungs and it occurs
adjacently to the infected area

Pneumonia
- penyakit saluran nafas yg disebabkan oleh infeksi
bakteri, virus & fungi
- disertai inflamasi pd daerah terinfeksi
- fungsi paru2 tdk normal masalah berat krn
kesulitan bernafas
Ming, C.K., 2011

Pneumonia is a severe form of acute lower respiratory infection that


specifically affects the lungs.
When a person has pneumonia, pus and fluid fill the alveoli in one or both
lungs, which
interferes with oxygen absorption, making breathing difficult.

Pneumonia:
infeksi sal nafas akut yg berat effek spesifik pd
paru2
pd salah satu atau ke dua paru tertimbun cairan
& nanah mengganggu absorpsi oksigen susah
bernafas
Unicef-WHO, 2006

CAP in children in the United States, the focus of these guidelines, is defined
simply as the presence of signs and symptoms of pneumonia in a previously
healthy child caused by an infection that has been acquired outside of the
hospital. However, pneumonia definitions can also be designed to be very
sensitive for epidemiologic considerations (eg, fever and cough) or very specific,
as defined by government regulatory agencies for approval of antimicrobials to
treat pneumonia (eg, clinical symptoms and signs in combination with radiologic
documentation or microbiologic confirmation). Pneumonia, broadly defined asa
lower respiratory tract infection (LRTI), may also be defined in a way that is clinically oriented,
to assist practitioners with diagnosis and management.
Bradley, J.S., et al., 2011

B. ANATOMI & FISIOLOGI PARU-PARU


The lungs are composed of thousands of tubes (bronchi) that subdivide
into smaller airways (bronchioles), which end in small sacs (alveoli). The
alveoli contain capillaries where oxygen is added to the blood and carbon
dioxide is removed.
Unicef-WHO, 2006

C. KLASSIFIKASI

Basically, pneumonia can be classified as hospital-acquired pneumonia


(nosocomial) and community-acquired pneumonia. As the name suggests,
hospital-acquired pneumonia is acquired when someone is staying at
hospital while community-acquired pneumonia is acquired when someone
is staying outside the hospital.
Hospital-acquired pneumonia is more serious and dangerous than
community-acquired pneumonia as the germs in hospital are more
resistant to the drugs given.
There are several types of pneumonia which are bacterial pneumonia, viral
pneumonia, fungal pneumonia and also aspiration pneumonia. Pneumonia
is divided into these several types based on the agents causing this
disease.

Ming, C.K., 2011

D. EPIDEMIOLOGI
a common disorder that is potentially life threatening, older adults and
those with comorbid disease.
File Jr, T.M 2003
Pneumonia is a very common disease among children less than 5 years old in developing nations as it
cause up to 5 million deaths among them each year.

In higher-income countries, pneumonia is a disease that most frequently strikes


the elderly or people who are already sick. Elsewhere, children under 5 are the
main victims of pneumonia. In 2013, a child died from pneumonia every 35
seconds.
IHME. 2014

Pneumonia is a very common disease among children less than 5 years


old in developing nations as it cause up to 5 million deaths among them
each year.
Ming, C.K., 2011

It is estimated that more than 150 million episodes of pneumonia occur


every year among children under five in developing countries, accounting
for more than 95 per cent of all new cases worldwide. Between 11 million
and 20 million children with pneumonia will require hospitalization, and
more than 2 million will die from the disease. It is also important to note
that incidence of pneumonia among children decreases with age.
South Asia and sub-Saharan Africa combined bear the burden of more
than half of the total number of pneumonia episodes worldwide among
children under five.
Three quarters of all pneumonia episodes worldwide among children under
five occur in just 15 countries.

FIGURE 4
15 COUNTRIES ACCOUNT FOR THREE QUARTERS OF CHILDHOOD
PNEUMONIA CASES WORLDWIDE
India 44 million
China 18 million
Nigeria 7 million
Pakistan 7 million
Bangladesh 6 million
Indonesia 6 million
Brazil 4 million
Ethiopia 4 million
Congo, Democratic Republic of the 3 million
Philippines 3 million
Afghanistan 2 million
Egypt 2 million
Mexico 2 million
Sudan 2 million
Viet Nam 2 million
Total 113 million

COUNTING UNDER-FIVE DEATHS FROM PNEUMONIA

Neonatal diarrhoeal diseases 1% Diarrhoeal diseases 17%


Neonatal other 2%
Neonatal tetanus 2% Others 10%

Congenital anomalies 3% Malaria 8%


Birth asphyxia 8%
Preterm birth 10% Measles 4%

Injuries 3%

Neonatal severe infections AIDS 3%


(mainly pneumonia/sepsis) 10%
Pneumonia 19%
Undernutrition is implicated in 53% of all deaths among children under five.

Figure 1 presents the global distribution of the primary causes of all under-
five deaths and shows that pneumonia kills more children than any other
illness accounting for 19 per cent of all under-five deaths (see the
Appendix for more detailed information on these estimates of cause-
specific mortality ).
This figure, however, does not include deaths due to pneumonia during
the first four weeks of life, the neonatal period. It has been estimated that
26 per cent of neonatal deaths, or 10 per cent of all under-five deaths, are
caused by severe infections during the neonatal period. And a significant
proportion of these infections is caused by pneumonia/sepsis (sepsis is a
serious blood-borne bacterial infection that is also treated with antibiotics).
If these deaths were included in the overall estimate, pneumonia would
account for up to 3 million, or as many as one third (29 per cent), of under-
five deaths each year

Unicef-WHO, 2006

According to the latest estimates of child mortality issued by the United


Nations Childrens Fund (UNICEF), pneumonia and diarrhea continue to be
the leading killers of children under the age of five worldwide. Pneumonia
and diarrhea, respectively, are responsible for 17% and 9% of global child
deaths, together claiming the lives of more than 1.7 million under-five
children in 2012 alone. These diseases predominantly affect developing
countries and are highly concentrated in just a few countries. Despite
having roughly half of the worlds under-five population, these 15
countries account for 75% of global pneumonia and diarrhea deaths.

IVACS., 2013

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. Although difficult to quantify,
it is believed that up to 155 million cases of pneumonia occur in children every
year worldwide.
In the developed world, the annual incidence of pneumonia is 34 cases per 100
children 5 years old In the United States, outpatient visit rates for CAP between
19941995 and 20022003 were defined using International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes and
reported in the National Ambulatory Medical Care Survey and the National
Hospital Ambulatory Medical Care Survey and identified rates ranging from 74 to
92 per 1000 children 2 years old to 3552 per 1000 children 36 years old. In
2006, the rate of hospitalization for CAP in children through age 18 years, using
data from the Healthcare Cost Utilization Projects Kids Inpatient Database, also
based on ICD-9-CM discharge diagnosis codes, was 201.1 per 100 000.
Infants,1 year old had the highest rate of hospitalization (912.9 per 100 000)
whereas children 1318 years had the lowest rate (62.8 per 100 000). Data from
the Centers for Disease Control and Prevention (CDC) document that in 2006,
525 infants and children,15 years old died in the United States as a result of
pneumonia and other lower respiratory tract infections. The reported incidence
of pneumonia in children, both pathogen specific and as a general diagnosis,
varies across published studies based on definitions used, tests performed, and
the goals of the investigators
Bradley, J.S., et al., 2011

E. PENYEBAB
Although many pathogens have been associated with CAP, it is a small
range of key pathogens that cause most cases. The emergence of newly
recognised pathogens,
such as the novel coronavirus associated with (SARS), increases the
challenge for appropriate management of these infections.
The predominant pathogen in CAP is Streptococcus pneumoniae
(pneumococcus), which accounts for about two-thirds of all cases of
bacteraemic pneumonia.
Cigarette smoking is the strongest independent risk factor for invasive
pneumococcal disease in immunocompetent, non-elderly adults.
Other causative agents include, but are not limited to Haemophilus influenzae,
Mycoplasma pneumoniae, Chlamydophila pneumoniae (Chlamydia pneumoniae),
Legionella spp, Chlamydophila psittaci (Chlamydia psittaci), Coxiella burnetii,
enteric gram-negative bacteria (enterobacteriaceae), Pseudomonas aeruginosa,
Staphylococcus aureus, anaerobes (aspiration pneumonia), and respiratory
viruses (influenza virus, adenovirus, respiratory syncytial virus, parainfluenza
virus, coronavirus. Gram-negative cause of CAP in some patients (those who
have had previous antimicrobial treatment or who have pulmonary
comorbidities). The frequency of other causes, such as Mycobacterium
tuberculosis, C psittaci (psittacosis), C burnetii (Q fever), Francisella tularensis
(tularaemia), and endemic fungi (histoplasmosis, coccidioidomycosis,
blastomycosis) vary between epidemiological settings.
Table 118, shows the causes of CAP in adults in hospital as reported by workers
from several prospective studies in several worldwide locations who used
comprehensive diagnostic approaches. The incidence of specific pathogens
varied in accordance with the completeness of testing and specificity of
diagnostic criteria (ie, definite vs presumptive diagnosis [table 1]).
Collectively, S pneumoniae was the most frequently isolated organism, with the
highest incidence of this pathogen reported in studies that included detection by
a urinary antigen test. Relative to other pathogens, M pneumoniae, C
pneumoniae, and L pneumophila were also common. These organisms (along
with other Chlamydia spp and C burnetii) are often referred to as atypicals, a
label of contended scientific merit. Nevertheless, the term remains popular with
clinicians and is in widespread use in recent scientific reports. These atypical
pathogens are not often identified in clinical practice, however, because (with
the exception of L pneumophila) there is not a specific, rapid, or standardised
test for their detection; as such, the frequency of these pathogens is probably
underreported

The proportion of cases in recent studies with a defined cause ranged from 52 to
83%. By contrast, in an observational study that assessed the real-world
practice from several centres in the USA, only 6% of outpatients and a quarter of
inpatients with CAP had the cause of their disease defined. In a study of
consecutive patients with CAP, Ruiz-Gonzales and colleagues used
microbiological
analysis and PCR to test for respiratory pathogens in lung aspirate specimens
obtained by transthoracic needle aspiration. Their results showed that use of
these tests increased the proportion of cases of CAP for which a cause could be
established to 83%, from 50% reported when
conventional testsie, sputum and blood cultures and serological testswere
used. Their results also changed the ranking of pathogens established by
conventional testing from M pneumoniae (35%), C pneumoniae (17%), S
pneumoniae (17%) to S pneumoniae (30%), M pneumonia (22%), C pneumoniae
(13%). Importantly, S pneumonia represented one third of all causes not
documented by conventional testing.
Legionella spp are still a common cause of severe CAP. A review of nine studies
of CAP that resulted in admission to an intensive care unit (seven from Europe
and one each from USA and South Africa) noted that Legionella spp were the
second most commonly identified pathogens, with S pneumoniae being most
often detected. Aerobic gramnegative bacilli, H influenzae, and S aureus were
also identified, although few of these cases could be judged as definite (ie,
confirmed bacteraemia or isolation from pleural fluid or lung tissue). In an
international collaborative survey of 508 patients with culture-positive
legionellosis, 92% of the isolates with serogroup 1 were L pneumophila,
accounting for 84% of the total. L pneumophila serogroup 1 accounted for 88%
of isolates in America and Europe but for only 46% in Australia and New Zealand
where L longbeachae accounted for 30% of cases.
The most common pathogens identified from recent studies of mild (ie, in
ambulatory patients) CAP were S pneumoniae, M pneumoniae, Chlamydia spp,
and viruses (mostly influenza virus). Mycoplasma spp were most common in
patients younger than 50 years and without important comorbid conditions or
abnormality of vital signs, whereas S pneumoniae was the most common
pathogen for older patients or those with significant underlying disease.
An awareness of the likely cause of CAP in different settings is important to allow
the start of appropriate antimicrobial treatment. Table 2 shows the most common
pathogens associated with CAP as derived from collective results of various
studies. Severity of illness is judged by site of care (outpatient vs inpatient).
Although objective confirmation is often difficult, multiple organisms that infect a
patient concurrently or sequentially can cause CAP. For example, influenza A or
C pneumoniae infection might be followed by a secondary infection with S
pneumoniae. In one study of patients admitted with serologically diagnosed C
pneumonia pneumonia, 45% of patients were infected with other pathogens, the
most common copathogen being S pneumoniae.
The incidence of mixed infection varied from 2 to 11% (table 1). The importance
of treating multiple infecting organisms has not been established; however,
identification of one pathogen should not preclude tests for other causes when a
patient is not responding to treatment.
File Jr, T.M 2003
Many pathogens are responsible for CAP in children, most prominently viruses
and bacteria. Investigators have used a variety of laboratory tests to establish a
microbial etiology of CAP.
Furthermore, unique to pediatrics, the developing immune system and age-
related exposures result in infection caused by different bacterial and viral
pathogens, requiring that the incidence of CAP and potential pathogens be
defined separately for each age group.
Reports of epidemiologic investigations on the etiology of CAP before the
widespread use of these vaccines cited S. pneumoniae as the most common
documented bacterial pathogen, occurring in 4%44% of all children
investigated.
In some studies, viral etiologies of CAP have been documented in up to 80%of
children younger than 2 years; in contrast, investigations of older children, 1016
years, who had both clinical and radiographic evidence of pneumonia,
documented a much lower percentage of viral pathogens.
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. Less frequently detected are
adenoviruses, bocavirus, human metapneumovirus, influenza A and B viruses,
parainfluenza viruses, coronaviruses and rhinovirus.
Epidemiologic investigations of hospitalized children with CAP document that
2%33% are simultaneously infected by 2 or more viruses.
Epidemiologic studies that have assessed both viral and bacterial pathogens
have reported bacterial pathogens isolated in 2%50% of children with CAP;
inpatient studies that enroll more seriously ill children often document higher
rates of bacterial infection compared with outpatient studies.
Pathogens responsible for atypical pneumonia have been identified in 3%23%
of children studied, with M. pneumonia most often identified in older children and
C. pneumoniae in infants. Atypical pneumonia caused by Mycoplasma is
characteristically slowly progressing, with malaise, sore throat, low-grade fever,
and cough developing over 35 days. In contrast to adults with pneumonia,
Legionella sp. has only rarely been identified in children.
Although CAP caused by Mycobacterium tuberculosis and the nontuberculous
mycobacteria have been well-documented, the incidence of these serious
infections in the United States is far less than that of viral or bacterial CAP and is
often linked to high-risk exposures. Likewise, fungal pneumonia in normal hosts
caused by Histoplasma, Coccidioides, Blastomyces, and Cryptococcus is
uncommon, and in most epidemiologic studies, children with fungal pneumonia
are not identified. Mycobacterial and fungal pneumonia are not addressed in
these guidelines
Bradley, J.S., et al., 2011

Bacterial pneumonia is a type of pneumonia caused by bacteria.


Pneumonia-causing bacteria can be divided into typical bacteria and
atypical bacteria. Typical bacteria include Streptococcus pneumonia,
Staphylococcus pneumonia and Haemophilus influenza while atypical
bacteria include Mycoplasma pneumonia, Legionella pneumonia and
Chlamydia pneumonia. All of them can cause pneumonia.
Viral pneumonia
Besides bacteria, viruses may also cause pneumonia among human being.
In fact, viruses are believed to cause about 50% of the pneumonia cases
although viruses-causing pneumonia is less serious than bacteria-causing
pneumonia. Viral pneumonia causes most of the pneumonia infection in
very young people.
Different type of viruses such as flu virus, herpes simplex virus, rhinovirus,
cytomegalovirus, etc can cause pneumonia. Cytomegalovirus-causing
pneumonia is very common among immune-suppressed patients such as
those undergoing transplant processes and AIDS patients.
Fungal Pneumonia
Other than bacteria and viruses, fungi may also cause pneumonia which is
a very rare case. Fungal infections such as actinomycosis, cryptococcosis,
aspergillosis, histoplasmosis, coccidiomycosis, blastomycosis and
nocardiosis may lead to pneumonia.
The most common pneumonia-causing fungus is Pneumocytosis carinii.
Pneumocytosis carinni is generally present in our surroundings and is very
common among immune-suppressed patients such as AIDS patients and
cancer patients. AIDS patients are more often to be infected by this type of
fungus.
Ming, C.K., 2011

Data on the pathogen-specific causes of pneumonia are limited, and


available information is often difficult to interpret. It is known that the
bacterial pathogen Streptococcus pneumoniae is the leading cause of
severe pneumonia among children across the developing world. Bacteria
also contribute to non-severe pneumonia cases, but to a lesser extent,
and more cases are probably of viral origin. Another major cause is the
bacterial pathogen Haemophilus influenzae type b (Hib). Other pathogens
include important viruses, less common bacteria and fungi. However,
more specific information for the aetiology of childhood pneumonia is not
available. Research is urgently needed to better describe the distribution
of pneumonia by its causes. Knowing which pathogens lead to pneumonia
is
critical for guiding treatment and policie

PATHOGEN-SPECIFIC CAUSES OF SEVERE PNEUMONIA CASES

Pathogen Distribution of Discussion


severe
pneumonia
cases by
cause
Streptococcu Leading cause S. pneumoniae is the leading pathogen in almost all
s studies from around the world. Recent vaccine trial data
pneumoniae indicate that in Africa it may be responsible for over 50%
of severe pneumonia cases, and probably a higher
proportion of fatal cases. This proportion may vary in
different parts of the world.
Haemophilus Major cause Most disease is caused by type b (Hib). Vaccine studies
influenzae from Bangladesh, Chile and the
Gambia suggest that Hib causes around 20% of severe
pneumonia cases, although
the proportion may vary in different parts of the world.
Other Less common These pathogens include important viruses such as
important respiratory synctial virus (RSV) and influenza; other
pathogens bacteria, such as Staphylococcus aureaus and Klebsiella
pneumoniae; and the fungus Pneumocystis jiroveci (PCP),
which is particularly important in young children with AIDS

Unicef-WHO, 2006

F. PENULARAN
Pathogens causing pneumonia may reach the childs lungs through
different routes. Although information on the pathogenesis of childhood
pneumonia is limited, it is widely believed that common bacterial
pathogens causing pneumonia are often already present in a childs nose
or throat and are then inhaled into the lungs, causing infection. Pathogens
may also be spread through contaminated air droplets or may result from
blood-borne infections. During or shortly after birth, babies are at higher
risk of developing pneumonia from coming into contact with organisms in
the birth canal or from contaminated substances contacted during
delivery.
Unicef-WHO, 2006

VIRUS: most frequently involved pathogens in the first 2 years of


life
Pathogens involved according to childs age or severity of illness:

1-3 1-24 2-5 years 6-18 years All ages


months months
Afebrile Respiratory Respiratory Mycoplasma Severe pneumonia
pneumonitis syncytial viruses pneumoniae requiring
syndrome: virus and hospitalization in
intensive care unit:
Chlamydia other Streptococcus Streptococcus
Streptococcus
trachomatis respiratory pneumoniae pneumoniae
pneumoniae
viruses Nontypeable
Staphylococcus
Respiratory Haemophilus Chlamydophil aureus
syncytial Streptococcus influenzae a Streptococcus
virus and pneumoniae Haemophilus pneumoniae pyogenes (group A)
other Haemophilus influenzae Influenza Haemophilus
respiratory influenzae type b* viruses A or B influenzae type b*
viruses type b* Mycoplasma Adenovirus Mycoplasma
Bordetella Nontypeable pneumoniae and other pneumoniae
Adenovirus
pertussis Haemophilus respiratory
influenzae Chlamydophila viruses
Chlamydia
trachomatis pneumoniae

INESSS. 2009

G. PATOMEKANISME
Most acute respiratory infections result in mild illnesses, such as the
common cold. But in vulnerable children, infections that begin with mild
symptoms may sometimes lead to more severe illnesses, such as
pneumonia especially when they coincide with other illnesses like
diarrhoea or malaria.

A healthy child has many natural defences that protect its lungs from the
invading pathogens that cause pneumonia. However, children and infants
with compromised immune systems have weakened defences.
Undernourished children, particularly those not exclusively breastfed or
with inadequate zinc intake, are at higher risk of developing pneumonia.
Similarly, children and infants suffering from other illnesses, such as AIDS
or measles, are more likely to develop pneumonia. Environmental factors,
such as living in crowded homes and exposure to parental smoking or
indoor air pollution, may also have a role to play in increasing childrens
susceptibility to pneumonia and its severe consequences
Unicef-WHO, 2006

H. FAKTOR RESIKO
compromised immune systems
Comorbid: diarrhoea or malaria.
Environmental factors, such as living in crowded homes and exposure to
parental smoking or indoor air pollution
Undernourished children particularly those not exclusively breastfed or
with inadequate zinc intake,
children and infants suffering from other illnesses, such as AIDS or
measles,
Unicef-WHO, 2006

older adults and those with comorbid disease.


Cigarette smoking risk factor for invasive pneumococcal disease in
immunocompetent patient
File Jr, T.M 2003
.

I. GAMBARAN KLINIK

Different types of pneumonia might show some specific signs and


symptoms. This is can be seen by the pneumonia caused by different
microorganisms which show different signs and symptoms.
Despite those specific signs and symptoms, all types of pneumonia do
share the common symptoms such as chest pain, shortness of breath,
shaking chills, and cough. Chest pain experienced by pneumonia patients is
caused by the inflammation of lungs and it occurs adjacently to the
infected area.
Normally, a pneumonia patient will experience shortness of breath when he
is doing some light exercise or climbing a stair. In other words, a
pneumonia patient feel tired easily and is lack of breath as compared to
usual people. However, different symptoms appear in different ages of
patients. For instances, cough usually occur in older children and adults
and dry occurs in infants, young children and the elderly. A pneumonia
patient may show signs such as fever, dullness to percussion[1],
egophony[2], tachycardia[3], tachypnea[4] and are fairly sensitive for
pneumoniapatient.
Often, the elderly does not develop fever while the infants commonly will
have nasal flaring and cyanosis. A pneumonia patient may have some rare
signs of pneumonia such as asymmetric breath sounds and pleural rubs
Viral pneumonia shares some similar signs and symptoms with bacterial
pneumonia which are fever, lethargy and rapid heartbeat or breathing.
On the other hand, fungal pneumonia is a rare disease.
Fungal pneumonia has the same sign as bacterial pneumonia which may
include fever and increase in heartbeat.
Aspiration pneumonia is a result of inhalation of foreign materials.
Sometimes it may take a few days for symptoms of aspiration pneumonia
to begin. Common signs and symptoms include frequent coughing, fever,
chest pain, dizzy or trouble in wallowing.
[1] The act of striking a part with short, sharp blows as an aid in diagnosing
the condition of the underlying parts by the sound obtained
[2] Increased resonance of voice sounds, with a
high-pitched bleating quality, heard especially over lung tissue compressed
by pleural effusion
[3] Abnormal rapid heart beat
[4] Very rapid respiration
[5] The enlargement of the opening nostrils during breathing
[6] A bluish discoloration of skin and mucous
membranes due to excessive concentration of
reduced hemoglobin in the blood
Ming, C.K. 2011.

Breathing can become very difficult, especially for young children. Other
symptoms can include intense coughing, a high fever, and chills. As
pneumonia progresses, children can experience convulsions,
unconsciousness, feeding problems, and without timely treatment, often
death.
IHME. 2014

Normally, a pneumonia patient will experience shortness of breath when


he is doing some light exercise or climbing a stair. In other words, a
pneumonia patient feel tired easily and is lack of breath as compared to
usual people. However, different symptoms appear in different ages of
patients. For instances, cough usually occur in older children and adults
and dry occurs in infants, young children and the elderly.
A pneumonia patient may show signs such as fever, dullness to
percussion[1], egophony[2], tachycardia[3], tachypnea[4] and are fairly
sensitive for pneumonia patient.
Often, the elderly does not develop fever while the infants commonly will
have nasal flaring[5] and cyanosis [6]. A pneumonia patient may have
some rare signs of pneumonia such as asymmetric breath sounds and
pleural rubs.
Viral pneumonia shares some similar signs and symptoms with bacterial
pneumonia which are fever, lethargy and rapid heartbeat or breathing.
On the other hand, fungal pneumonia is a rare disease. Fungal pneumonia
has the same sign as bacterial pneumonia which may include fever and
increase in heartbeat.
Aspiration pneumonia is a result of inhalation of foreign materials.
Sometimes it may take a few days for symptoms of aspiration pneumonia
to begin. Common signs and symptoms include frequent coughing, fever,
chest pain, dizzy or trouble in swallowing. (Is pneumonia contagious n.d.)
[1] The act of striking a part with short, sharp blows as an aid in
diagnosing the condition of the underlying parts by the sound obtained.
[2] Increased resonance of voice sounds, with ahigh-pitched bleating
quality, heard especially over lung tissue compressed by pleural effusion.
[3] Abnormal rapid heart beat [4] Very rapid respiration. [5] The
enlargement of the opening nostrils during breathing. [6] A bluish
discoloration of skin and mucous membranes due to excessive
concentration of reduced hemoglobin in the blood.
Ming, C.K., 2011

Children with pneumonia may have a range of symptoms depending on


their age and the cause of the infection. Bacterial pneumonia usually
causes children to become severely ill with high fever and rapid breathing.
Viral infections, however, often come on gradually and may worsen over
time. Some common symptoms of pneumonia in children and infants
include rapid or difficult breathing, cough, fever, chills, headaches, loss of
appetite and wheezing. Children under five with severe cases of
pneumonia may struggle to breathe, with their chests moving in or
retracting during inhalation (known as lower chest wall indrawing). Young
infants may suffer convulsions, unconsciousness, hypothermia, lethargy
and feeding problems.
Unicef-WHO, 2006

In a study of ambulatory patients with CAP, median time to resolution of


fever was 3 days; 5 days for myalgia, 6 days for dyspnoea, and 14 days
for both cough and fatigue.
Symptoms can last even longer in seriously ill patients. Fine and
colleagues have noted that 86% of patients had at least one persisting
pneumonia-related symptom at 30 days. Patients should be informed that
symptoms can last for this long to allow them a better awareness of their
illness and expected clinical course.
Death rates associated with CAP have not changed greatly over the past
two decadesin part because of the increased number of patients at risk
of the disease, such as
elderly people and patients with multiple comorbid conditions. In a
prospective study40 of prognostic factors of CAP caused by bacteraemic
pneumococcal disease in five countries, death rates ranged from 6% in
Canada to 20% in the USA and Spain (13% in the UK and 8% in Sweden).
Independent predictors of death were age greater than 65 years,
residence in a nursing home, presence of chronic lung disease, high acute
physiology and chronic health evaluation (APACHE) score, and need for
mechanical ventilation. Disease severity and frequency of underlying
conditions were factors that affected outcome. Mortensen and
colleagues41 noted that about half of deaths in patients with CAP were
attributable to the worsening of pre-existing conditions.

File Jr, T.M 2003

J. DIAGNOSIS
Once caregivers have recognized the danger signs of pneumonia (cough
and fast or difficult breathing) and taken their children to appropriate
medical care, health personnel including trained community health
workers should then diagnose and treat pneumonia in children
according to the following Integrated Management of Childhood Illness
(IMCI) guidelines:
Diagnosis: Children aged 2 months to 5 years are diagnosed with
pneumonia if they exhibit a cough and fast or difficult breathing.
Thresholds for fast breathing depend on the childs age (see What is
fast breathing?,
below). Severe pneumonia in children is diagnosed if they exhibit lower
chest wall
indrawing (when the childs chest moves in or retracts during inhalation)
or stridor (a harsh noise made during inhalation). Respiratory rate timers
should be available to help health personnel count breathing rates.

Unicef-WHO, 2006

Knowing the signs and symptoms only is not enough to treat the
pneumonia. Diagnosis should be done in further to choose the right and
more effective treatment. Understanding the patients medical and
personal history is important before making a pneumonia diagnosis. It is
because pneumonia may be caused by chronic diseases such as lung
disease and the treatment will be totally different from those who have no
chronic diseases or any medical history.

Diagnosis of pneumonia is typically based on chest x-ray, consideration of


pulmonary embolism and sometimes identification of pathogen.
Chest radiography or chest x-ray is the most common way to diagnose
pneumonia. It is used to check which part of lungs is infected and it can
show the abnormal fluid collection in the lungs which leads to pneumonia.
Chest x-ray is recommended to the patients showing complicated signs
and symptoms. However, the x-ray findings may be different for different
types of pneumonia. (John G. Bartlett, MD. 2008)
Besides that, tests such as laboratory tests and listening to heart and
lungs through stethoscope are also some common diagnosis for
pneumonia patients. Laboratory testing such as white blood cells count,
serum electrolytes, blood tests and creatinine testing are recommended
for hospitalized-acquired pneumonia patients to test the severity of
disease. Blood test is carried out to see whether the patients immune
system is working to fight against the pneumonia or not. The tests are
conducted to see how severe the pneumonia is.
However, for aspiration pneumonia patient, tests such as swallowing
studies or special tests of throat or esophagus might work better. Other
than that, sputum cultures can also be carried out to identify the
microorganism that causes pneumonia. It is advisable to identify a
pathogen in patients who are showing therapeutic failure or are critically
ill.
Pathogen identification is important as different pathogen-causing
pneumonia needs different treatment. For example, antibiotics are
prescribed for bacterial pneumonia but not viral pneumonia. Besides the
type of pneumonia, different type of bacteria-causing pneumonia may
need different antibiotics.
Other investigations like urea and electrolytes examination and liver
function tests are also recommended for patients with non-severe
community acquired pneumonia.

Ming, C.K.. 2011.

Diagnosis of pneumococcal pneumonia has been based on positive


cultures of blood, antibody responses, antigen detection, and nucleic acid
detection.
Each test has different sensitivity, specificity, and positive and negative
predictive values that are dependent on the prevalence of the pathogen at
the time of testing. Therefore, comparing etiologies of pneumonia
between published studies is challenging.
More recent investigations have used a variety of sensitive molecular
techniques including nucleic acid detection, particularly for viral
identification. 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.

Identification of the causative agent


The use of diagnostic studies to establish the causative agents of CAP is
controversial because there is not a rapid, easily done, accurate, cost-
effective method to allow immediate results for most patients at the point
of service (ie, the initial assessment by a clinician in an office or acute-
care setting). Nevertheless, there is a good rationale for establishing the
causative agent in the disease to allow the selection of antibiotics that
permit optimum selection of agents against a specific pathogen and limit
the misuse of antibiotics and its consequences, and to identify pathogens
associated with notifiable diseases such as Legionnaires disease or
tuberculosis. Despite these good reasons, there is an absence of solid,
documented benefit with respect to establishing the causative agent.
Routine microbiological tests are not recommended by most guidelines for
patients managed in the community.
However, if a patient has purulent sputum, it is reasonable to send a
sample to the laboratory for gram stain and culture on the basis that the
information could be of use in directing specific treatment if the patient
fails to respond to initial empirical treatment.6
Investigations that are recommended for patients who require admission
include: blood cultures, sputum gram stain and culture, and thoracentesis
if pleural fluid is present. About 11% of patients with CAP will have positive
blood cultures, more commonly associated with severe illness. Although
the usefulness of blood cultures for all patients admitted to hospital is
questioned, investigators in one study noted that if results of blood
cultures were obtained within 24 h of admission, survival rates were
improved. The yield of clinically useful information is greater if the culture
specimen is collected before antibiotics are administered. The value of
routinely doing a sputum gram stain and culture has long been debated.
These tests are limited by the fact that many patients cannot produce a
good specimen, patients often receive antimicrobial agents before
assessment, and many specimens yield inconclusive results. The validity
of the gram stain is related directly to the experience of the interpreter.
Indeed, some discrepant findings about the sputum gram stain are
presumably explained by the quality of specimens and technical expertise;
and when stringent criteria are applied, although the sensitivity drops, the
specificity for pneumococcal pneumonia can approach 90%. Sputum
culture for other pathogens (ie, Legionella spp, fungi, viruses,
Mycobacterium spp) should be considered to identify unusual pathogens
or notifiable diseases. However, because the early administration of
treatment is important for the outcome of CAP, an attempt to obtain
expectorated sputum should never delay the prompt start of antimicrobial
treatment.
Other tests that might be useful in patients admitted to hospital include
the urinary antigen assays for Legionella spp and S pneumoniae and a
direct stain (ie, acid-fast) for detection of mycobacterial infections in
patients who are in high-risk categories for tuberculosis. The urine antigen
assays for L pneumophila serogroup 1 (LgUA) and for pneumococcus
(SpUA) can be done easily and rapidly.
The LgUA has a sensitivity of 70% and a specificity greater than 90% for
infections caused by serogroup 1 and should be especially useful in the
USA and Europe since about 85% of isolates are serogroup 1. Since
Legionella spp are a common cause of severe CAP, this test should be
routinely considered for patients requiring admission to an intensive care
unit. An assay approved by the Food and Drug Administration (FDA) for
pneumococcal urinary antigen has been assessed in several studies. The
sensitivity in defining invasive pneumococcal disease in adults is 6090%
with a specificity close to 100%. In one of the largest published studies to
date, Gutierrez and colleagues used this assay on concentrated urine
samples obtained from 452 adults with CAP. Pneumococcal antigen was
detected in 19
(70%) of 27 patients with proven pneumococcal pneumonia. Of the 269
patients who had pneumonia with no pathogen identified, antigen was
detected in 69 (26%), which suggests that an important proportion of
cases that are presently undiagnosed by standard tests can be identified
with this assay. However, 16 (10%) of 156 samples from patients with
pneumonia caused by other agents were positive, indicating potential
problems with specificity.
Other tests that might be useful in patients admitted to hospital include
the urinary antigen assays for Legionella spp and S pneumoniae and a
direct stain (ie, acid-fast) for detection of mycobacterial infections in
patients who are in high-risk categories for tuberculosis. The urine antigen
assays for L pneumophila serogroup 1 (LgUA) and for pneumococcus
(SpUA) can be done easily and rapidly.
The LgUA has a sensitivity of 70% and a specificity greater than 90% for
infections caused by serogroup 1 and should be especially useful in the
USA and Europe since about 85% of isolates are serogroup 1. Since
Legionella spp are a common cause of severe CAP, this test should be
routinely considered for patients requiring admission to an intensive care
unit. An assay approved by the Food and Drug Administration (FDA) for
pneumococcal urinary antigen has been assessed in several studies. The
sensitivity in defining invasive pneumococcal disease in adults is 6090%
with a specificity close to 100%. In one of the largest published studies to
date, Gutierrez and colleagues used this assay on concentrated urine
samples obtained from 452 adults with CAP. Pneumococcal antigen was
detected in 19 (70%) of 27 patients with proven pneumococcal
pneumonia. Of the 269 patients who had pneumonia with no pathogen
identified, antigen was detected in 69 (26%), which suggests that an
important proportion of cases that are presently undiagnosed by standard
tests can be identified with this assay. However, 16 (10%) of 56 samples
from patients with pneumonia caused by other agents were positive,
indicating potential problems with specificity.
Many rapid diagnostic tests such as nucleic acid amplification tests (ie,
PCR) assays are still in early stages of development, or are not commonly
available, or are not sufficiently accurate. The role of these new tools is
under investigation and they are not yet in routine use; however, they
could offer the potential for rapid diagnosis and have been shown to be
useful in clinical situations. Serological tests are not usually helpful in the
early management of CAP since acute and convalescent concentrations
are needed before ascribing the cause of the disease to a specific
pathogen.
Percutaneous transthoracic needle aspiration (PTNA) has been advocated
as a valuable, safe method to increase the chance of establishing the
causative agent in the disease. Nevertheless, PTNA or other invasive
testing (including bronchoscopy and biopsy) are not routinely
recommended for the assessment of patients with CAP.6 Clinical settings
that might warrant the use of such tests include pneumonia in
immunocompromised hosts, suspected tuberculosis in the absence of
productive cough, selected cases of chronic pneumonia, pneumonia
associated with suspected neoplasm or foreign body, suspected
Pneumocystis carinii pneumonia, some cases in which intubation is
required, and suspected conditions which necessitate lung biopsy.

Accurate diagnosis of CAP


Adult patients who are immunocompetent should be assessed for
pneumonia if they present with symptoms that include cough, sputum
production, laboured breathing (including altered breath sounds and
rales), or fever. These symptoms are non-specific and might also be
present in patients with upper respiratory-tract infections, other lower
respiratory-tract infections such as acute bronchitis and chronic bronchitis,
and non-infectious diseaseseg, reactive airways disease, atelectasis,
congestive heart failure, vasculitis, pulmonary embolism, and malignant
disease. Although guidelines vary with respect to the emphasis placed on
obtaining a chest radiograph for ambulatory patients, this study is usually
necessary to establish the diagnosis of CAP and to differentiate it from
other respiratory illnesses. A CAP diagnosis is important to ensure
appropriate use of antimicrobial agents, especially since most cases of
upper respiratory-tract infection and acute bronchitis are of viral origin and
do not merit treatment with antibacterial agents. Spiral CT scans are much
more sensitive in detecting pulmonary infiltrates in patients admitted with
CAP, but the clinical significance of this finding is unclear.

File Jr, T.M 2003


[1] The act of striking a part with short, sharp blows as an aid in
diagnosing the condition of the underlying parts by the sound obtained.
[2] Increased resonance of voice sounds, with ahigh-pitched bleating
quality, heard especially over lung tissue compressed by pleural effusion.
[3] Abnormal rapid heart beat [4] Very rapid respiration. [5] The
enlargement of the opening nostrils during breathing. [6] A bluish
discoloration of skin and mucous membranes due to excessive
concentration of reduced hemoglobin in the blood.

Knowing the signs and symptoms only is not enough to treat the
pneumonia. Diagnosis should be done further to choose the right and
more effective treatment.
Understanding the patients medical and personal history is important
before making a pneumonia diagnosis. It is because pneumonia may be
caused by chronic diseases such as lung disease and the treatment will be
totally different from those who have no chronic diseases or any medical
history.
Diagnosis of pneumonia is typically based on chest x-ray, consideration of
pulmonary embolism and sometimes identification of patho Chest
radiography or chest x-ray is the most common way to diagnose
pneumonia. It is used to check which part of lungs is infected and it can
show the abnormal fluid collection in the lungs which leads to pneumonia.
Chest x-ray is recommended to the patients showing complicated signs and
symptoms. However, the x-ray findings may be different for different types
of pneumonia.
Besides that, tests such as laboratory tests and listening to heart and lungs
through stethoscope are also some common diagnosis for pneumonia
patients. Laboratory testing such as white blood cells count, serum
electrolytes, blood tests and creatinine testing are recommended for
hospitalized-acquired pneumonia patients to test the severity of disease.
Blood test is carried out to see whether the patients immune system is
working to fight against the pneumonia or not. The tests are conducted to
see how severe the pneumonia is.
However, for aspiration pneumonia patient, tests such as swallowing
studies or special tests of throat or esophagus might work better.
Other than that, sputum cultures can also be carried out to identify the
microorganism that causes pneumonia. It is advisable to identify a
pathogen in patients who are showing therapeutic failure or are critically ill.
Pathogen identification is important as different pathogen-causing
pneumonia needs different treatment. For example, antibiotics are
prescribed for bacterial pneumonia but not viral pneumonia. Besides the
type of pneumonia, different type of bacteria-causing pneumonia may need
different antibiotics.
Other investigations like urea and electrolytes examination and liver
function tests are also recommended for patients with non-severe
community acquired pneumonia.
Ming, C.K., 2011

For example, diagnosis of pneumococcal pneumonia has been based on


positive cultures of blood, antibody responses, antigen detection, and
nucleic acid detection.
Each test has different sensitivity, specificity, and positive and negative
predictive values that are dependent on the prevalence of the pathogen at
the time of testing. Therefore, comparing etiologies of pneumonia between
published studies is challenging.
More recent investigations have used a variety of sensitive molecular
techniques including nucleic acid detection, particularly for viral
identification. 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.

Chest X-rays and laboratory tests are used to confirm the presence of
pneumonia, including the extent and location of the infection and its cause.
But in resource-poor settings without access to these technologies,
suspected cases of pneumonia are diagnosed by their clinical symptoms.
Children and infants are presumed to have pneumonia if they exhibit a
cough and fast or difficult breathing (see detailed guidelines in Box 5, page
24).
Caregivers, therefore, have an important role to play in recognizing the
symptoms of pneumonia in children and seeking appropriate medical care
as necessary.
Unicef-WHO, 2006

Patients may present the following signs and symptoms:


Cough
Fever
Tachypnea with:
s >60 breaths/minute in infants aged <2 months
s >50 breaths/minute in infants aged between 2 and 12 Higher
monthspositive
predictive
s >40 breaths/minute in toddlers aged 12 months to 5 years value
s >20 breaths/minute in children aged >5 years if more than one
Intercostal, subcostal or supracostal retractions sign is present
Presence of crackles
Decreased vesicular breath sounds
When combinations of the above signs and
When combinations of the above signs and symptoms are absent,
diagnosis of pneumonia is unlikely (very high negative predictive value).
Chest radiography recommended to confirm the diagnosis.
INESSS. 2009

DIAGNOSTIC TESTING FOR PEDIATRIC CAP

What Diagnostic Laboratory and Imaging Tests Should Be Used in a Child


With Suspected CAP in an Outpatient or Inpatient Setting?

Recommendations

Microbiologic Testing
Blood Cultures: Outpatient
12. Blood cultures should not be routinely performed in nontoxic, fully
immunized children with CAP managed in the outpatient setting.
(strong recommendation; moderate-quality evidence)
13. 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 (strong
recommendation; moderate-quality evidence).

Blood Cultures: Inpatient


14. Blood cultures should be obtained in children requiring hospitalization
for presumed bacterial CAP that is moderate to severe, particularly
those with complicated pneumonia. (strong recommendation; low-
quality evidence)
15. In improving patients who otherwise meet criteria for discharge, a
positive blood culture with identification or susceptibility results
pending should not routinely preclude discharge of that patient with
appropriate oral or intravenous antimicrobial therapy. The patient can
be discharged if close follow-up is assured. (weak recommendation;
low-quality evidence)

Follow-up Blood Cultures


16. Repeated blood cultures in children with clear clinical improvement are
not necessary to document resolution of pneumococcal bacteremia.
(weak recommendation; low-quality evidence)
17. Repeated blood cultures to document resolution of bacteremia should
be obtained in children with bacteremia caused by S. aureus,
regardless of clinical status. (strong recommendation; low-quality
evidence)

Sputum Gram Stain and Culture


18. Sputum samples for culture and Gram stain should be obtained in
hospitalized children who can produce sputum. (weak
recommendation; low-quality evidence)

Urinary Antigen Detection Tests


19. Urinary antigen detection tests are not recommended for the diagnosis
of pneumococcal pneumonia in children; false-positive tests are
common. (strong recommendation; highquality evidence)

Testing For Viral Pathogens


20. Sensitive and specific tests for the rapid diagnosis of influenza virus
and other respiratory viruses should be used in the evaluation of
children with CAP. A positive influenza test may decrease both the
need for additional diagnostic studies and antibiotic use, while guiding
appropriate use of antiviral agents in both outpatient and inpatient
settings. (strong recommendation; high-quality evidence).
21. Antibacterial therapy is not necessary for children, either outpatients
or inpatients, with a positive test for influenza virus in the absence of
clinical, laboratory, or radiographic findings that suggest bacterial co-
intection. (strong recommendation; high-quality evidence).
22. Testing for respiratory viruses other than influenza virus can modify
clinical decision making in children with suspected pneumonia,
because antibacterial therapy will not routinely be required for these
children in the absence of clinical, laboratory, or radiographic findings
that suggest bacterial coinfection. (weak recommendation; low-quality
evidence).

Testing for Atypical Bacteria


23. Children with signs and symptoms suspicious for Mycoplasma
pneumoniae should be tested to help guide antibiotic selection. (weak
recommendation; moderate-quality evidence)
24. Diagnostic testing for Chlamydophila pneumoniae is not recommended
as reliable and readily available diagnostic tests do not currently exist.
(strong recommendation; high-quality evidence)

Ancillary Diagnostic Testing

Complete Blood Cell Count


25. Routine measurement of the complete blood cell count is not
necessary in all children with suspected CAP managed in the outpatient
setting, but in those with more serious disease it may provide useful
information for clinical management in the context of the clinical
examination and other laboratory and imaging studies. (weak
recommendation; low-quality evidence)
26. A complete blood cell count should be obtained for patients with
severe pneumonia, to be interpreted in the context of the clinical
examination and other laboratory and imaging studies. (weak
recommendation; low-quality evidence)

Acute-Phase Reactants
27. Acute-phase reactants, such as the erythrocyte sedimentation rate
(ESR), C-reactive protein (CRP) concentration, or serum procalcitonin
concentration, cannot be used as the sole determinant to distinguish
between viral and bacterial causes of CAP. (strong recommendation;
high-quality evidence)
28. Acute-phase reactants need not be routinely measured in fully
immunized children with CAP who are managed as outpatients,
although for more serious disease, acute-phase reactants may provide
useful information for clinical management. (strong recommendation;
low-quality evidence)
29. In patients with more serious disease, such as those requiring
hospitalization or those with pneumonia-associated complications,
acute-phase reactants may be used in conjunction with clinical findings
to assess response to therapy. (weak recommendation; low-quality
evidence)

Pulse Oximetry
30. Pulse oximetry should be performed in all children with pneumonia and
suspected hypoxemia. The presence of hypoxemia should guide decisions
regarding site of care and
further diagnostic testing. (strong recommendation; moderatequality
evidence)

Chest Radiography
Initial Chest Radiographs: Outpatient
31. Routine chest radiographs are not necessary for the confirmation of
suspected CAP in patients well enough to be treated in the outpatient
setting (after evaluation in the office, clinic, or emergency department
setting). (strong recommendation; high-quality evidence)
32. Chest radiographs, postero-anterior and lateral, should be obtained in
patients with suspected or documented hypoxemia or significant
respiratory distress and in those with failed initial antibiotic therapy to
verify the presence or absence of complications of pneumonia,
including parapneumonic effusions, necrotizing pneumonia, and
pneumothorax. (strong recommendation; moderate-quality evidence)

Initial Chest Radiographs: Inpatient


33. Chest radiographs (posteroanterior and lateral) should be obtained in
all patients hospitalized for management of CAP to document the
presence, size, and character of parenchymal infiltrates and identify
complications of pneumonia that may lead to interventions beyond
antimicrobial agents and supportive medical therapy. (strong
recommendation; moderate-quality evidence)

Follow-up Chest Radiograph


34. Repeated chest radiographs are not routinely required in children who
recover uneventfully from an episode of CAP. (strong recommendation;
moderate-quality evidence)
35. Repeated chest radiographs should be obtained in children who fail to
demonstrate clinical improvement and in those who have progressive
symptoms or clinical deterioration within 4872 hours after initiation of
antibiotic therapy. (strong recommendation; moderate-quality
evidence)
36. Routine daily chest radiography is not recommended in children with
pneumonia complicated by parapneumonic effusion after chest tube
placement or after videoassisted thoracoscopic surgery (VATS), if they
remain clinically stable. (strong recommendation; low-quality
evidence).
37. Follow-up chest radiographs should be obtained in patients with
complicated pneumonia with worsening respiratory distress or clinical
instability, or in those with persistent fever that is not responding to
therapy over 48-72 hours. (strong recommendation; low-quality
evidence)
38. Repeated chest radiographs 46 weeks after the diagnosis of CAP
should be obtained in patients with recurrent pneumonia involving the
same lobe and in patients with lobar collapse at initial chest
radiography with suspicion of an anatomic anomaly, chest mass, or
foreign body aspiration. (strong recommendation; moderatequality
evidence)

IV. What Additional Diagnostic Tests Should Be Used in a


Child With Severe or Life-Threatening CAP?
Recommendations

39. The clinician should obtain tracheal aspirates for Gram stain and
culture, as well as clinically and epidemiologically guided testing for
viral pathogens, including influenza virus, at the time of initial
endotracheal tube placement in children requiring mechanical
ventilation. (strong recommendation; lowquality evidence)
40. Bronchoscopic or blind protected specimen brush sampling,
bronchoalveolar lavage (BAL), percutaneous lung aspiration, or open
lung biopsy should be reserved for the immunocompetent child with
severe CAP if initial diagnostic tests are not positive. (weak
recommendation; low-quality evidence)
Bradley, J.S., et al., 2011

K. MANAGEMEN

Factors affecting treatment choice Antimicrobials are the mainstay of


treatment for most
patients with CAP.6 Decisions about antimicrobial treatment are guided by
factors such as spectrum of activity, pharmacokinetics, efficacy, safety
profile, cost, and whether or not a specific pathogen is identified (ie,
empirical vs pathogen-directed treatment). The emergence of resistant
respiratory pathogens, especially drug-resistant strains of S pneumoniae,
is becoming an important concern that has complicated initial empirical
management of CAP.

Drug resistant S pneumoniae


Surveillance studies indicate that the prevalence of drug resistant S
pneumoniae continues to increase worldwide.
In two recent multinational studies, the worldwide prevalence of penicillin-
resistant and macrolide-resistant S pneumoniae ranged from 182 to
221% and from 246% to 318%, respectively. The dominant factor in the
emergence of drug resistant S pneumoniae in one US study has been
human-to-human spread of only a few clonal groups that harbour
resistance determinants to multiple classes of antibiotics (including
cephalosporins, macrolides, doxycycline, trimethoprim/sulfamethoxazole).
Despite the rapid increase in the prevalence of drug resistant S
pneumoniae, its clinical relevance in the outcome of CAP remains
controversial and depends on the class of antimicrobial agent being
considered. Most studies suggest that current levels of _ lactam resistance
do not usually result in treatment failures for patients with CAP. While the
present breakpoints for S pneumonia susceptibility to penicillin (_006
_g/mL, susceptible;
0110 _g/mL, intermediate susceptibility; _20 _g/mL, resistant) are
relevant for meninigitis, they do not reliably predict clinical outcome for
CAP. On the basis of established pharmacokinetic and pharmacodynamic
principles, adequate drug concentrations in serum and tissue should be
achieved with appropriate doses of parenteral _ lactams or oral amoxicillin
to treat effectively many pneumococcal strains that are thought to be
nonsusceptible to penicillin by the present criteria
Furthermore, an analysis of nine controlled trials of a high-dose oral
formulation of amoxicillin-clavulanate noted a good clinical response for
respiratory infections (mostly outpatients) caused by S pneumoniae with
penicillin minimal inhibitory concentrations (MIC) up to 8 _g/mL.90
Although most studies have not shown an adverse effect of _ lactam
resistance on the outcome of pneumococcal pneumonia, most clinicians
remain concerned that clinical failures will become more frequent if the
proportion of resistance strains and their MICs increase.
Moreover, in controlled studies of pneumococcal bacteraemia, Feikin and
colleagues91 noted an increased risk of death in patients with high-level
resistance (penicillin MIC _4 _g/mL) and Metlay and colleagues showed an
increase risk of suppurative complications for
non-susceptible infections. Risk factors for penicillin resistant S
pneumoniae have been identified (ie, age <2 years or >65 years, _ lactam
treatment within 3 months, alcoholism, medical comorbidities,
immunosuppressive illness or treatment, and exposure to a child in
a day-care centre.
The clinical relevance of macrolide resistant S pneumoniae might be
dependent on the type of resistance expressed by a particular strain. The
most common mechanisms of resistance include methylation of a
ribosomal target encoded by erm gene and efflux of the macrolides by cell
membrane protein transporter, encoded by mef gene. S pneumoniae
strains with mef are resistant at a lower level (with MICs usually 116
_g/mL) than erm-resistant strains; and it is possible that such strains
(especially with MIC<8 _g/mL) might be inhibited if sufficiently high
concentrations of macrolide can be obtained within infected tissue (such
as could arise with newer macrolides-clarithromycin or azithromycin).
However, there is recent evidence that the MICs of these strains are
increasing and this could affect the effectiveness of these macrolides. The
mef-resistant strains are usually susceptible to clindamycin. Most
ermresistant isolates have an MIC greater than 32 _g/mL for erythromycin
and are thought to be highly resistant to all macrolides and clindamycin.
Until recently, reports of failure of CAP treated with macrolides have been
rare, particularly for patients at low risk of drug-resistant strains. However,
since 2000, anecdotal reports and one controlled study have documented
failures attributable to macrolide-resistant S pneumoniae in patients
treated with an oral macrolide who have subsequently required admission
with S pneumoniae bacteraemia. Currently, mef-associated resistance
predominates in North America. erm-associated resistance predominates
in Europe and is
common in Japan.
Although the worldwide prevalence of pneumococcal resistance to the
newer fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin) remains
low (fewer than 2% of cases), in some countries resistance has increased
substantially. The overall prevalence of fluoroquinolone resistance
(levofloxacin >4 _g/mL) in Hong Kong in 2000 had increased to 133%
because of the dissemination of a fluoroquinolone-resistant clone.
Treatment failures have already been reported, most often in patients who
have previously been treated with fluoroquinolones. Risk factors for
levofloxacin resistance were identified as previous exposure to a
fluoroquinolone, residence in a nursing home, nosocomial infection, and
chronic obstructive pulmonary disease.
In view of the emerging resistance of the pneumococcus to existing drugs,
alternative agents need to be considered. Although glycopeptides (ie,
vancomycin, teicoplanin) are almost certain to provide antibiotic coverage
for drug resistant S pneumoniae, they are not active against other key
respiratory pathogens (ie, atypicals, H influenzae) and there is a strong
reason not to use these drugs until needed because of fear of emergence
of other resistant organisms such as vancomycin-resistant enterococci,
vancomycin resistant S aureus. Other agents effective against drug-
resistant S pneumoniae include quinupristin/dalfopristin, linezolid, and the
ketolides. The focus of treatment of quinupristin/dalfopristin and linezolid
is more for nosocomial infections (and especially for vancomycin-resistant
enterococci or macrolideresistant S pneumoniae). The ketolides
(telithromycin is the first to be marketed) are a novel addition to the
macrolide group of antibacterials and have an efficacy against key
respiratory pathogens (including penicillin-resistant and erythromycin-
resistant strains)

Empirical antimicrobial treatment


Until rapid diagnostic methods improve, most patients will be treated
empirically. Although some authorities propose a syndromic approach to
treatment (ie, counting on the predictability of a causative agent based on
the presenting clinical manifestations), most data indicate that the
presenting clinical features are not specific enough to predict reliably the
causative agent of CAP.
Thus, unless there is a specific epidemiological factor (such as an influenza
epidemic), the empirical approach to initial therapy is usually based on the
likelihood that one of the key pathogens is responsible for disease.
Specific recommendations for empirical therapy for CAP as included in
recently published guidelines from North America, UK, and Japan are
shown in table 3.
Several observational studies have assessed the effect of empirical
antimicrobial regimens on patients outcomes.
Although limited by their retrospective design, these studies show that use
of macrolides as part of an initial combination treatment (usually with a
cephalosporin agent) or monotherapy with a fluoroquinolone for patients
who require admission seems to be associated with decreased risk of
death or a shorter hospital stay than with a cephalosporin alone. The
specific causative agent of infection was not estalished in these studies;
however, it is possible that the added coverage for atypical pathogens
might, in part, explain this observation. Results of additional retrospective
studies suggest that the benefit of combination therapy that includes a
macrolide applies not only to CAP in general but also to CAP specifically
associated with S pneumonia bacteraemia. The possible coexistence of
atypical pathogens or the immunomodulating effect of the macrolides
might, in part, be responsible for this finding.
However, interpretation of these studies is subject to limitations inherent
in their retrospective study design; and, since they only assessed
empirical treatment, the findings are not necessarily applicable for
pathogendirected treatment that usually is started 2448 h after initial
therapy.

Recommendations for empirical therapy of outpatients


North American guidelines variably recommend macrolides, doxycycline,
an antipneumococcal fluoroquinolone (eg, levofloxacin, gatifloxacin,
moxifloxacin), or the combination of a _ lactam plus macrolide as
treatment options for patients who are mildly ill and can be treated as
outpatients. In general, the North American guidelines recommend a
macrolide as first-line treatment for outpatients with no comorbidity or risk
factors for drugresistant S pneumoniae. The rationale is that the
macrolides provide effective therapy for the most common bacterial
pathogens for such patients, primarily S pneumoniae (that
has, until now, been mostly responsive to macrolide in North America) as
well as the atypical organisms (especially M pneumoniae and C
pneumoniae, which are common in outpatients). The positioning of the
macrolides as prominent first-line agents in the North American guidelines
is partly based on the presumption that the newer macrolides
(azithromycin or
clarithromycin) can be effective against macrolide-resistant S pneumoniae
strains in which lower-level resistance results from increased drug efflux
with resulting MIC often less than 8 _g/mL. However, because recent data
indicate that mef-mediated resistance is becoming associated with higher
MICs (from a median of 4 g/mL to 8 g/mL), it is reasonable to consider
alternative treatment (ie, respiratory fluoroquinolone, or high dose
amoxicillin
plus macrolide) if risk factors for drug-resistant S pneumoniae are present.
The Centers for Disease Control and Prevention (CDC) statement
emphasises that the fluoroquinolones should be reserved for cases
associated with failure, or allergy to other agents, or documented drug-
resistant S pneumoniae. The rationale is that widespread use would lead
to the development of fluoroquinolone resistance in the respiratory
pathogens (as well as other pathogens colonising the treated patients).
By contrast, the primary agents recommended in the recently published
British Thoracic Society guidelines are lactamsmostly penicillinsand
not macrolides. The rationale is that these agents are effective against S
pneumoniae, and when given in high doses they are even effective for
most strains with decreased sensitivity to penicillin. Since most of the
macrolide resistance in Europe is erm-mediated, high-level resistance, the
macrolides are not regarded as optimum first line empirical agents to treat
this pathogen if S pneumoniae is likely. Additionally, the British statement
places less importance on the need to treat the atypical pathogens
empirically in ambulatory patients (mild disease). Rather, the statement
suggests that since M pneumoniae exhibits epidemic periodicity every 45
years and chiefly affects younger people, a policy for initial empirical
treatment that aims always to cover this pathogen was unnecessary.
The two approaches represented by the North American and the British
Thoracic Society statements differ because of the greater emphasis in
North America to treat routinely the atypical pathogens and the fact that
macrolide-resistant S pneumoniae in Europe is of higher
level resistance than in North America. Future studies are needed to
address the issue of whether routine treatment should be able to treat
atypical pathogens. The Japanese statement advocates initial therapy
based on a syndromic approach (ie, macrolides or tetracycline for likely
atypical pneumonia and a penicillin-type agent for bacterial pneumonia).

Recommendations for empirical therapy of inpatients


North American guidelines recommend treatment with a _ lactam plus a
macrolide or monotherapy with a fluoroquinolone for patients admitted to
the general ward (in part, because of results showing that these regimens
are associated with a substantial reduction in deaths compared with that
noted with cephalosporin alone). Recommendations in the British Thoracic
Society guidelines are similar to those from North America. Workers from
two recent studies in Europe noted that most patients who were admitted
with CAP were successfully treated with penicillin alone. The Japanese
statement stratifies patients on the basis of age and the presence of
underlying illness, with an injected fluoroquinolone being recommended
for the first category and a combination regimen for the second category.
For patients with severe CAP who require admission to an intensive care
unit, all guidelines recommend comprehensive antimicrobial therapy to
cover S pneumoniae (including drug-resistant S pneumoniae), Legionella
spp and the possibility of Pseudomonas spp.
Australian guidelines advocate empirical therapy for Burkholderia
pseudomallei for patients in tropical areas, acknowledging the relevant
local pathogens.

Pathogen-directed therapy
Treatment options are obviously simplified if the causative agent is
established or strongly suspectedDiagnostic procedures that provide
identification of a specific cause within 2472 h can still be useful for
guiding continued treatment. If, for example, an appropriate culture shows
the isolation of penicillinsusceptible S pneumoniae, treatment can be
specified by selecting a narrow spectrum agent (such as penicillin or
amoxicillin), which will hopefully reduce the selective pressure for
resistance. This information is often available at the time for consideration
when the patient is switched from parenteral to oral therapy. Length and
route of antimicrobial treatment
There are no controlled trials that have specifically assessed the optimum
duration of antimicrobial treatment in CAP. The decision is usually based
on the causative pathogen, response to treatment, comorbid illness, and
complications. Until further data are available, it seems reasonable to treat
bacterial infections such as those caused by S pneumoniae until a patient
is afebrile for 72 h.
Most randomised clinical trials for the new fluoroquinolones or newer
macrolides have shown good outcomes with 710 days of treatment, and
shorter courses could even be possible with the use of these agents
(azithromycin could be used for shorter courses of treatment in
ambulatory patients because of its longer half-life in tissue).
For many pathogens, there is no clear advantage of intravenous therapy
over oral therapy; however, for most patients admitted to hospital the
common practice is to begin therapy with intravenous drugs. Changing
from intravenous to oral therapy when the patient is clinically stable or
improving and is able to ingest drug is associated with several economic,
care, and social benefits. This approach has been shown to be
appropriate, even for patients with pneumococcal bacteraemia. Most
patients can be safely discharged without inhospital observation after
switch to oral treatment. Ideally, parenteral drugs should be given in an
oral formulation with adequate bioavailability; if no oral formulation is
available, then an oral agent with a similar spectrum of activity should be
selected on the basis of in vitro or predicted susceptibility patterns of the
established or probable pathogen.

Processes of care (quality indicators)


Many studies have assessed processes of careie, interventions
undertaken to assess, diagnose, or treat with the clinical outcome of
patients. In a metaanalysis from a structured review of 4531 published
reports, Rhew identified several quality indicators thatwere judged to be
valid on the basis of published evidence or professional consensus and
that were associated with a beneficial effect on outcome in elderly
patients with CAP.
These indicators were: use of pneumococcal and influenza vaccines (for
prevention of CAP); administration of antimicrobials in a timely matter
(within 8 h of arrival at the hospital); advice to cease smoking for patients
who smoke; drainage of a pleural empyema; conversion from parenteral to
oral antimicrobial treatment when the patient is improving,
haemodynamically stable, and able to take oral medications; and use of
appropriate discharge criteria (ensuring that patients are clinically stable
at the time of release from hospital). Whereas the studies reviewed by
Rhew supported 8 h as the target time for appropriate initiation of
antimicrobial agents, more recent data have shown that starting therapy
within 4 h was associated with better outcomes for patients who needed
to be admitted. Although one study of CAP patients who were admitted to
academic medical centers did not show a benefit of many of these
indicators, implementation of a pneumonia practice guideline that
promote some or all of these quality indicators has been shown in
many other studies to be associated with better outcomes (including a
reduced risk of death).

File Jr, T.M 2003

The treatments for pneumonia depend on the type of pneumonia and the
severity of the condition.
The most common type of pneumonia is community-acquired pneumonia.
Normally, people who have community-acquired pneumonia will be
treated at home provided his condition is not very serious.
Most people can be treated at home by following these steps:
Drinking plenty of fluids to help loosen secretions and bring up the
phlegm.
Resting alone.
Cough medicines may make it harder for your body to cough up the extra
sputum. Thus, do not take cough medicines without consulting the doctor
first.
Controlling fever with acetaminophen, aspirin or non-steroidal anti-
inflammatory drugs. But never give aspirin to children.
Bacterial Pneumonia
In order to cure this type of pneumonia, antibiotics will be a wise choice to
kill the bacteria.
Streptococcus pneumonia
Antibiotics including penicillin such as amoxicillin in combination with
clavulanic acid and macrolide antibiotics such as erythromycin,
azithromycin and clarithromycin are used to treat this type of pneumonia.
Macrolide is used for penicillin-resistant Streptococcus pneumonia.
oral fluoroquinolones is used in the treatment of mild to moderate
community-acquired pneumonia.
However, overuse of fluoroquinolones as a single agent may promote
quinolone resistance.
Besides that, for elderly patient, combination therapy with a beta-lactam
and macrolide may give a better outcome in hospitalised patients.
Klebsiella pneumonia
The antibiotics that can be used are second and third generation
cephalosporins, amoxicillin in combination with clavulanic acid,
fluoroquinolones (levofloxacin), oral moxifloxacin, and trimethoprim in
combination with sulfamethoxazole.
Besides that, tigecycline can be used too but its significance side effect
(empyema recurrence) should be considered first before giving the
treatment.
Mycoplasma pneumonia
Macrolides such as erythromycin, clarithromycin and azithromycin is the
first line of therapy use in the treatment of community-acquired
pneumonia that is not responsive to beta-lactam antibiotics alone.
Tetracycline and fluoroquinolone are groups of antimicrobials that can be
used to treat this disease too.
However, both tetracyclines and fluoroquinolones are not recommended for
use in children. Fluoroquinolones are not recommended for use in children
younger than 18 years of age due to their potential for damaging cartilage
whereas tetracyclines is limited to children older than 8 years due to their
liability to cause permanent dental discolouration.
Legionella pneumophila pneumonia
Macrolides and fluoroquinolones are the monotherapy in the treatment of L.
pneumophila pneumonia whereas rifampin-based combination therapy is
used for severe community-acquired Legionella pneumophila pneumonia.
However, rifampin therapy should be considered only for patients with
severe disease or significant comorbid conditions such as uncontrolled
diabetes, smoking, or obstructive lung disease, immunocompromised hosts
and those patients who are refractory to conventional monotherapy
regimens. It is due to its significant adverse drug events and drug-drug
interactions
Chlamydia pneumonia
Most Chlamydia Pneumonia infections in children and young adults are
generally quite mild and do not require hospitalization. Severe cases of
Chlamydia Pneumonia most probably will happen in elderly people with
other pre-existing health complications. Chlamydia Pneumonia treatment
includes tetracyclines (eg. doxycycline) which is usually not for pregnant
women, macrolides( eg. trythromycin) and in some cases fluoroquinolones
are used.
Staphylococcus aureus pneumonia
Vancomycin and linezolid can be used to treat this type of pneumonia.
Besides that, ?-cyclodextrin
derivative (IB201) is use to treat Staphylococcus aureus pneumonia too. It
provides a high level of protection against lethal disease caused by both
methicillin-sensitive and methicillin-resistant clinical isolates. Early
treatment with IB201 is required to prevent mortality from Staphylococcus
aureus pneumonia.
Treatment of multidrug-resistant pneumonia
A patient will usually get multidrug-resistant pneumonia from a hospital
and thus multidrug resistant pneumonia is always related to hospital-
acquired pneumonia. Several drugs can be used to treat this type of
pneumonia.
Penicillin-resistant and cephalosporin-resistant pneumococcal pneumonia
Patients with mild/moderate pneumococcal pneumonia may be treated with
oral amoxicillin whereas patient with severe pneumonia may be
successfully treated with intravenous ceftriaxone, cefotaxime, or
amoxicillin-clavulanic acid. Imipenem and vancomycin should not be widely
used for the treatment of pneumococcal pneumonia except for well-
selected patients.
Methicillin- resistant staphylococcus aureus (MRSA) pneumonia
MRSA is resistant to all classes of beta-lactam antibiotics. Vancomycin is
the only antibiotic that consistently shows activity against MRSA. Besides
that, ceftaroline, teicoplanin and linezolid are the alternative therapy to
treat MRSA. Linezolid shows a better efficacy than vancomycin because of
its better pharmacokinetics and pharmacodynamics index.
Teicoplanin is another glycopeptide antibiotic available in Europe for the
treatment of MRSA. (Linezolid is
superior treatment for drug-resistant pneumonia n.d.) Other than that,
tigecycline is useful in the salvage therapy after linezolid failure.
Macrolide-resistant pneumonia
The ketolides represent a new class of macrolide-like antibacterials that are
highly effective in vitro against macrolide-resistant pneumococci.
Alternative therapy for pediatric pneumonia including tetracyclines and
fluoroquinolones should be considered in children experiencing treatment
failure although they are currently not approved for this indication.
Fluoroquinolone (levofloxacin)-resistant pneumonia
Cephalosporins can be used with or without the co-drug to treat this
disease. Combinations of potent parenteral cephalosporins (cefepime and
ceftriaxone) and some newer fluoroquinolones (gatifloxacin, gemifloxacin,
and moxifloxacin) have the greatest initial empiric coverage. These
treatments are less effective than vancomycin or quinupristin and
dalfopristin, but these latter agents possess narrower spectrums of overall
activity and higher associated toxicity.
Trimethoprim-sulfamethoxazole (TMP-SMX) resistant pneumonia
The combination of clindamycin and primaquine is use to treat this disease.
It is likely to be more effective than intravenous pentamidine.
Viral Pneumonia
Pneumonia caused by virus can be treated with antiviral agent which
inhibits DNA synthesis and viral replication by competing for viral DNA
polymerase with deoxyguanosine triphosphate. For example amantadine,
rimantadine, zanamivir, oseltamivir, ribavirin, acyclovir, ganciclovir, and
foscarnet are used as antiviral agent.
Amantadine and Rimantadine prevent penetration of the virus into the host
by inhibiting uncoating of influenza A. However during influenza season in
2005-2006, resistance to Rimantadine has emerged. Zanamivir and
Oseltamivir inhibit a glycoprotein on the surface of the influenza virus
called neuraminidase that destroys the infected cell's receptor for viral
hemagglutinin. The release of viruses from infected cells is reduced and the
spreading of virus is controlled through the inhibition of neuraminidase.
Similarly to Rimantadine, resistant strains of seasonal influenza and H1N1
to Oseltamivir have been reported.
Ribavirin inhibits DNA and RNA synthesis and thus preventing viral
replication. It has shown in vitro antiviral properties against RSV,
parainfluenza, hantavirus, measles, and many other. Acyclovir has affinity
for viral thymidine kinase and it causes DNA chain termination when
phosporylated when acted on by DNA polymerase. Thus it has inhibitory
activity of both HSV-1 and HSV-2 when it is used within 24-48 hours of rash
onset, patients experience less pain and faster resolution of HSV or VZV
lesions.
Ganciclovir is an acyclic nucleoside analog of 2'-deoxyguanosine and is a
synthetic guanine derivative. It inhibits replication of herpesviruses both in
vitro and in vivo and is active against CMV, HSV, H H V - 6 , and H H V - 8 .
The level of ganciclovir-triphosphate could reach 100-fold greater In CMV-
infected cells than in uninfected cells, possibly due to preferential
phosphorylation of ganciclovir in virus-infected cells.
Valganciclovir is an oral prodrug of Ganciclovir that is available now. For the
treatment of CMV pneumonia, high-dose intravenous immunoglobulin has
been used successfully in conjunction with ganciclovir. Through anti-
idiotypic antibodies, immune globulin IV neutralizes circulating myelin
antibodies. It down-regulates proinflammatory cytokines; blocks Fc
receptors on macrophages suppresses inducer T cells and B cells; amplify
suppressor T cells; stops the complement cascade, encourages
remyelination, and may increase CSF IgG levels (10%).
Foscarnet is an organic analog of inorganic pyrophosphate that inhibits viral
replication at pyrophosphate-binding sites on virus-specific DNA
polymerases of known herpesviruses, including CMV, HSV-1, and HSV-2.
Viral resistance may occur and this is shown if there is poor clinical
response or persistent viral excretion during therapy.
Fungal pneumonia
Pneumonia caused by fungi is treated using antifungal agent.Against
Cryptococcus neoformans, it is recommended that a regimen for induction
therapy is Amphotericin B plus flucytosine for at least 2 weeks followed by
consolidation therapy with fluconazole (400 mg daily) for 8 weeks, and
then maintenance therapy with fluconazole (200 mg daily) for life or until
the CD4 cell count rises above 200 cells/?L for at least 6 months as a result
of antiretroviral therapy.
Amphotericin B (liposomal) is also recommended as first-line treatment for
disseminated histoplasmosis caused by Histoplasma capsulatumand,
disseminated coccidioidomycosis caused by Coccidioides immitis and
Coccidioides posadasii and for cases of diffuse pneumonia.
Patients with histoplasmosis and coccidioidomycosis should be treated with
Amphotericin B until clinical improvement (usually at least 2 weeks). This is
followed by itraconazole (200 mg three times daily for 3 days, then 200 mg
twice daily) for a total of at least 12 months. Persons with severe
disseminated histoplasmosis or CNS involvement and those who relapse
despite appropriate therapy should receive itraconazole (200 mg daily)
probably for life.
Ming, C.K., 2011

Initial treatment is always empirical. At the present time, no test provides


rapid information on the etiology of pneumonia. Treatment suggestions are
adapted to the probability of a pathogen in the particular epidemiological
context (outpatient or inpatient), underlying comorbidities or severity of
the pneumonia.

General care:
- Adequate hydration - Routine use of antitussives not
recommended
- Analgesic/antipyretic if necessary - Oxygen therapy if hypoxemia

Potential indications for hospitalization

Age <6 months Complicated pneumonia


Toxic or lethargic appearance Dehydration, inability to feed
Immunodeficiency Vomiting
Severe respiratory distress Failure to respond to oral antibiotics
Oxygen requirement Low parental involvement
Underlying cardiac or pulmonary to ensure treatment compliance
disease

Factors associated with Streptococcus pneumoniae resistance:


- Age <2 years - Use of antibiotics in previous 3 months
- Day care attendance - Hospitalization in previous 3 months
If fever persists more than 48 to 72 hours after initiating therapy or if
clinical deterioration: reassess the patient and search for complications
(empyema).

Treatment of community-acquired pneumonia in children according


to age

Age First-line oral Maximum Second-line oral Maximum dosage of


th/ dosage of th/ second-line oral
first-line oral therapy
therapy
1-3 months Clarithromyci 500 mg BID Hospitalize
Afebrile n (Biaxin) children
pneumoniti 15 mg/kg/day who are febrile
s
BID x 10 or hypoxic
syndrome
days 500 mg DIE
Azithromycin day 1 then
(Zithromax) 250 mg DIE x
10 mg/kg DIE 4 days
on 1st day
then 5
mg/kg/day DIE
x 4 days
4 months- Amoxicillin 1 500 mg BID Amoxicillin- 1 000 mg BID
4 years 90 mg/kg/day clavulanate
TID x 7-10 potassium
days (Clavulin)
90 mg/kg/day
BID or TID x 7-
10 days 500 mg BID
Clarithromyci
n (Biaxin)
15 mg/kg/day
BID x 7-10 days 500 mg DIE day 1
Azithromycin then
(Zithromax) 250 mg DIE x 4
10 mg/kg DIE days
on 1st day
then 5
mg/kg/day DIE
x 4 days
Cefuroxime 500 mg BID
axetil
(Ceftin)
30 mg/kg/day
BID x 7-10 days
5-15 years Clarithromyci 500 mg BID Amoxicillin 500 mg BID
n (Biaxin) 90 mg/kg/day
15 mg/kg/day TID x 7-10 days
BID x 7-10 Amoxicillin- 1 000 mg BID
days 500 mg DIE clavulanate
Azithromycin day 1 then potassium
(Zithromax) 250 mg DIE x (Clavulin)
10 mg/kg DIE 4 days 90 mg/kg/day
on 1st day BID or TID x 7-
then 5 10 days 500 mg BID
mg/kg/day DIE Cefuroxime
x 4 days axetil
(Ceftin)
30 mg/kg/day
BID x 7-10 days

INESSS. 2009

Site-of-Care Management Decisions

Treatment: Children aged 2 months to 5 years with severe pneumonia should be


referred to the nearest health facility immediately. Those diagnosed with
pneumonia may be treated at home with a full course of effective
antibiotics. Infants less than 2 months old
with signs of pneumonia should be referred promptly to the nearest
health facility because they are at high risk of suffering severe illness or
death.
.
Unicef-WHO, 2006

Illness severity and site of care


A key decision for a clinician is whether to admit a patient with CAP to
hospital. The general consensus is that most patients can be safely
treated as outpatients.
However, selected patients should be admitted if they have special
requirements such as the need for close observation, respiratory support,
intravenous antibiotics, or other concerns. This decision about whether or
not a patient should be admitted might have an effect on the
extent of diagnostic testing as well as the choice of empirical antimicrobial
treament. The advantages of not admitting patients for CAP are great and
include decreased cost, patient preference, and avoidance of iatrogenic
complications in hospital. For elderly patients in particular, a reduction in
immobilisation time (ie, time in a hospital bed) can facilitate better
convalescence.
The decision to admit a patient with CAP depends on many variables,
including the severity of illness, associated disease, adequacy of home
support, and probability of adherence to treatment. Recognised risk
factors for increased mortality of patients with CAP include extremes of
age, comorbid illnesses such as malignant disease, congestive heart
failure, coronary artery disease, alcoholism, abnormality of vital signs, and
several laboratory and radiographic findings. The admission decision relies
on a clinicians judgment; however, prognostic scoring rules have been
developed that provide support for this decision.
A pneumonia severity of index score, the pneumonia prediction rule, has
been developed from studies of the pneumonia Patient Outcomes
Research Team (PORT).
The prediction rule stratifies patients to one of five categories with a point
system based on several variables after an initial evaluation of three
factors: age, presence of comorbid conditions, and vital signs and mental
status.
This process has been validated as a method for identifying patients at
risk of death, which is low for risk classes IIII (0128%), intermediate for
class IV (8293%), and high for class V (2731%). It is also an effective
method for triaging patients and, in particular, for identifying low-risk
patients who can be safely treated as outpatients. Subsequent
recommendations by the pneumonia PORT are that, before calculation of
the severity of index score, patients should first be assessed for any pre-
existing condition that might compromise the safety of home care,
including haemodynamic instability, active co-existing conditions that
would necessitate admission, acute hypoxaemia, social or psychiatric
problems compromising home care, or the inability to take oral
medication.
By contrast, the British Thoracic Society guidelines recommend an
assessment of severity based on the presence of adverse prognostic
features. Such adverse features include, age greater than 50 years,
coexisting disease, and four additional specific core features, remembered
by the acronym CURB: mental Confusion, elevated Urea nitrogen,
Respiratory rate greater or equal to 30 breaths per min, and low Blood
pressure. Additional adverse prognostic features include hypoxaemia and
bilateral or multilobar pulmonary infiltrates on chest radiographs. Patients
who have none of the features listed are at low risk of death and do not
usually require inpatient care, whereas those who display two or more
core adverse prognostic features should be admitted. A scoring method
based on this British Thoracic Society assessment has been developed;
this system was assessed with use of a compilation of data from three
prospective studies of CAP done in the UK, New Zealand, and the
Netherlands. A six point score (one point for any of confusion, urea >7
mmol/L, respiratory rate >30, low blood pressure, and age >65 years)
enabled patients to be stratified in accordance with risk of death (score
0=07% increase in risk of death; 1=21%; 2=92%; 3=145%; 4=40%).
This simple scoring system can be used to stratify patients with CAP into
different groups for management purposes.
Prediction rules might oversimplify the interpretation of important
variables, and, therefore, these scoring systemsand guidelines are meant
to contribute to, rather than supersede, clinicians judgment. Additional
limitations of the severity of illness scoring systems include a potential
overemphasis on age and the perception by some healthcare workers that
the systems are not practical for everyday routine patient management.
There are no universally accepted criteria for severe CAP requiring
admission to an intensive care unit. One set of variables that has been
proposed as a reliable predictor defines severe CAP as the presence of two
out of three possible minor criteria (systolic BP <90 mm Hg, multilobar
disease, PaO2/FiO2 <250), or one of two major criteria (need for
mechanical ventilation or septic shock).
However, an assessment by the pneumonia PORT study group noted that
these criteria had only a modest predictive value.
File Jr, T.M 2003

I. When Does a Child or Infant With CAP Require Hospitalization?

Recommendations
1. 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) (Table 3)
should be hospitalized for management, including skilled pediatric
nursing care. (strong recommendation; high-quality evidence)
2. Infants less than 36 months of age with suspected bacterial CAP are
likely to benefit from hospitalization. (strong recommendation; low-
quality evidence)
3. 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. (strong recommendation; lowquality evidence)
4. Children and infants for whom there is concern about careful
observation at home or who are unable to comply with therapy or unable
to be followed up should be hospitalized. (strong recommendation; low-
quality evidence).
Bradley, J.S., et al., 2011

II. When Should a Child With CAP Be Admitted to an Intensive


Care Unit (ICU) or a Unit With Continuous Cardiorespiratory
Monitoring?

Recommendations
5. A child should be admitted to an ICU if the child requires invasive
ventilation via nonpermanent artificial airway (eg, endotracheal tube).
(strong recommendation; high-quality evidence)
6. A child should be admitted to an ICU or a unit with continuous
cardiorespirator monitoring capabilities if the child acutely requires use
of noninvasive positive pressure ventilation (eg, continuous positive
airway pressure or bilevel positive airway pressure). (strong
recommendation; very lowquality evidence)
7. A child should be admitted to an ICU or a unit with continuous
cardiorespirator monitoring capabilities if the child has impending
respiratory failure. (strong recommendation; moderate-quality evidence)
8. A child should be admitted to an ICU or a unit with continuous
cardiorespiratory monitoring capabilities if the child has sustained
tachycardia, inadequate blood pressure, or need for pharmacologic
support of blood pressure or perfusion. (strong recommendation;
moderate-quality evidence)
9. A child should be admitted to an ICU if the pulse oximetry measurement
is ,92% on inspired oxygen of $0.50. (strong recommendation; low-
quality evidence)
10. A child should be admitted to an ICU or a unit with continuous
cardiorespiratory monitoring capabilities if the child has altered mental
status, whether due to hypercarbia or hypoxemia as a result of
pneumonia. (strong recommendation; low-quality evidence)
11. Severity of illness scores should not be used as the sole criteria for ICU
admission but should be used in the context of other clinical, laboratory,
and radiologic findings. (strong recommendation; low-quality evidence)
Bradley, J.S., et al., 2011

ANTI-INFECTIVE TREATMENT
V. Which Anti-Infective Therapy Should Be Provided to a
Child With Suspected CAP in Both Outpatient and Inpatient
Settings?
Recommendations
Outpatients

41. Antimicrobial therapy is not routinely required for preschool-aged


children with CAP, because viral pathogens are responsible for the
great majority of clinical disease. (strong recommendation; high-
quality evidence)
42. 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. Table 5 lists preferred
agents and alternative agents for children allergic to amoxicillin
(strong recommendation; moderate-quality evidence)
43. 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, the most
prominent invasive bacterial pathogen. Atypical bacterial pathogens
(eg, M. pneumoniae), and less common lower respiratory tract
bacterial pathogens, as discussed in the Evidence Summary, should
also be considered in management decisions. (strong
recommendation; moderatequality evidence)
44. Macrolide antibiotics should be prescribed for treatment of children
(primarily school-aged children and adolescents) evaluated in an
outpatient setting with findings compatibl with CAP caused by
atypical pathogens. Laboratory testing for M. pneumoniae should be
performed if available in a clinicall relevant time frame. Table 5 lists
preferred and alternative agent for atypical pathogens. (weak
recommendation; moderate-quality evidence)
45. Influenza antiviral therapy (Table 6) should administered as soon as
possible to children with moderate to severe CAP consistent with
influenza virus infection during widespread local circulation of
influenza viruses, particularly for those with clinically worsening
disease documented at the time of an outpatient visit. Because early
antiviral treatment has been shown to provide maximal benefit,
treatment should not be delayed until confirmation of positive
influenza test results.
Negative results of influenza diagnostic tests, especially rapid
antigen tests, do not conclusively exclude influenza disease.
Treatment after 48 hours of symptomatic infection may still provide
clinical benefit to those with more severe disease. (strong
recommendation; moderate-quality evidence).
Bradley, J.S., et al., 2011

Inpatients
46. Ampicillin or penicillin G should be administered to the fully
immunized infant or school-aged child admitted to a hospital ward
with CAP when local epidemiologic data document lack of substantial
high-level penicillin resistance for invasive S. pneumoniae. Other
antimicrobial agents for empiric therapy are provided in Table 7.
(strong recommendation; moderate-quality evidence)
47. Empiric therapy with a third-generation parenteral cephalosporin
(ceftriaxone or cefotaxime) should be prescribed for hospitalized
infants and children who are not fully immunized, in regions where
local epidemiology of invasive pneumococcal strains documents
high-level penicillin resistance, or for infants and children with
lifethreatening infection, including those with empyema. Nonb-
lactam agents, such as vancomycin, have not been shown to be
more effective than third-generation cephalosporins in the
treatment of pneumococcal pneumonia for the degree of resistance
noted currently in North America. (weak recommendation;
moderate-quality evidence)
48. 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. pneumonia and C. pneumoniae are
significant considerations; diagnostic testing should be performed if
available in a clinically relevant time frame (weak recommendation;
moderate-quality evidence)
49. Vancomycin or clindamycin (based on local susceptibility data)
should be provided in addition to b-lactam therapy if clinical,
laboratory, or imaging characteristics are consistent with infection
caused by S. aureus (strong recommendation; low-quality evidence)

Bradley, J.S., et al., 2011

VI. How Can Resistance to Antimicrobials Be Minimized?


Recommendations

50. Antibiotic exposure selects for antibiotic resistance; therefore,


limiting exposure to any antibiotic, whenever possible, is preferred.
(strong recommendation; moderate-quality evidence)
51. Limiting the spectrum of activity of antimicrobials to that specifically
required to treat the identified pathogen is preferred. (strong
recommendation; low-quality evidence)
52. Using the proper dosage of antimicrobial to be able to achieve a
minimal effective concentration at the site of infection is important
to decrease the development of resistance. (strong recommendation;
low-quality evidence)
53. Treatment for the shortest effective duration will minimize exposure
of both pathogens and normal microbiota to antimicrobials and
minimize the selection for resistance. (strong recommendation; low-
quality evidence)

Bradley, J.S., et al., 2011


VII. What Is the Appropriate Duration of Antimicrobial Therapy
for CAP?
Recommendations

54. Treatment courses of 10 days have been best studied,although


shorter courses may be just as effective, particularly for more mild
disease managed on an outpatient basis. (strong recommendation;
moderate-quality evidence)
55. Infections caused by certain pathogens, notably CAMRSA, may
require longer treatment than those caused by S. pneumoniae.
(strong recommendation; moderate-quality evidence)
Bradley, J.S., et al., 2011

VIII. How Should the Clinician Follow the Child With CAP for the
Expected Response to Therapy?

Recommendation
56. Children on adequate therapy should demonstrate clinical and
laboratory signs of improvement within 4872 hours. For children
whose condition deteriorates after admission and initiation of
antimicrobial therapy or who show no improvement within 4872
hours, further investigation should be performed. (strong
recommendation; moderate-quality evidence)
Bradley, J.S., et al., 2011

ADJUNCTIVE SURGICAL AND NONANTI-INFECTIVE THERAPY FOR


PEDIATRIC CAP

IX. How Should a Parapneumonic Effusion Be Identified?


Recommendation

57. History and physical examination may be suggestive of parapneumonic


effusion in children suspected of having CAP, but chest radiography
should be used to confirm the presence of pleural fluid. If the chest
radiograph is not conclusive, then further imaging with chest ultrasound
or computed tomography (CT) is recommended. (strong
recommendation;
high-quality evidence)
Bradley, J.S., et al., 2011

X. What Factors Are Important in Determining Whether Drainage


of the Parapneumonic Effusion Is Required?
Recommendations

58. The size of the effusion is an important factor that determines


management. (strongrecommendation; moderate-quality evidence)
59. The childs degree of respiratory compromise is an important factor
that determines management of parapneumonic effusions (strong
recommendation; moderatequality evidence)
Bradley, J.S., et al., 2011

XI. What Laboratory Testing Should Be Performed on


Pleural Fluid?
Recommendation

60. Gram stain and bacterial culture of pleural fluid should be


performed whenever a pleural fluid specimen is obtained.
(strong recommendation; high-quality evidence)
61. Antigen testing or nucleic acid amplification through
polymerase chain reaction (PCR) increase the detection of
pathogens in pleural fluid and may be useful for management.
(strong recommendation; moderate-quality evidence)
62. Analysis of pleural fluid parameters, such as pH and levels of
glucose, protein, and lactate dehydrogenase, rarely change
patient management and are not recommended. (weak
recommendation; very low-quality evidence)
63. Analysis of the pleural fluid white blood cell (WBC) count, with
cell differential analysis, is recommended primarily to help
differentiate bacterial from mycobacterial etiologies and from
malignancy. (weak recommendation; moderate-quality
evidence)
Bradley, J.S., et al., 2011

XII. What Are the Drainage Options for Parapneumonic


Effusions?
Recommendations

64. Small, uncomplicated parapneumonic effusions should not routinely


be drained and can be treated with antibiotic therapy alone. (strong
recommendation; moderate-quality evidence)
65. Moderate parapneumonic effusions associated with respiratory
distress, large parapneumonic effusions, or documented purulent
effusions should be drained. (strong recommendation; moderate-
quality evidence)
66. Both chest thoracostomy tube drainage with the addition of
fibrinolytic agents and VATS have been demonstrated to be effective
methods of treatment. The choice of drainage procedure depends on
local expertise. Both of these methods are associated with decreased
morbidity compared with chest tube drainage alone. However, in
patients with moderate-to-large effusions that are free flowing (no
loculations), placement of a chest tube without fibrinolytic agents is a
reasonable first option. (strong recommendation; high-quality
evidence)

Bradley, J.S., et al., 2011

XIII. When Should VATS or Open Decortication Be Considered in


Patients Who Have Had Chest Tube Drainage, With or
Without Fibrinolytic Therapy?
Recommendation

67. VATS should be performed when there is persistence of moderate-


large effusions and ongoing respiratory compromise despite _23
days of management with a chest tube and completion of fibrinolytic
therapy. Open chest debridement with decortication represents
another option for management of these children but is associated
with higher morbidity rates. (strong recommendation; low-quality
evidence)

XIV. When Should a Chest Tube Be Removed Either After Primary


Drainage or VATS?

68. A chest tube can be removed in the absence of an intrathoracic air


leak and when pleural fluid drainage is,1 mL/kg/24 h, usually
calculated over the last 12 hours. (strong recommendation; very low-
quality evidence)
Bradley, J.S., et al., 2011

XV. What Antibiotic Therapy and Duration Is Indicated for the


Treatment of Parapneumonic Effusion/Empyema?
Recommendations

69. When the blood or pleural fluid bacterial culture identifies a


pathogenic isolate, antibiotic susceptibility should be used to
determine the antibiotic regimen. (strong recommendation;
highquality evidence)
70. In the case of culture-negative parapneumonic effusions, antibiotic
selection should be based on the treatment recommendations for
patients hospitalized with CAP . (strong recommendation; moderate-
quality evidence)
71. The duration of antibiotic treatment depends on the adequacy of
drainage and on the clinical response demonstrated for each patient.
In most children, antibiotic treatment for 24 weeks is adequate.
(strong recommendation; low-quality evidence)

Bradley, J.S., et al., 2011

MANAGEMENT OF THE CHILD NOT RESPONDING TO


TREATMENT

XVI. What Is the Appropriate Management of a Child Who Is


Not Responding to Treatment for CAP?
Recommendation

72. Children who are not responding to initial therapy after 4872 hours
should bemanaged by one ormore of the following:
a. Clinical and laboratory assessment of the current severity of
illness and anticipated progression in order to determine whether
higher levels of care or support are required. (strong
recommendation; low-quality evidence)
b. Imaging evaluation to assess the extent and progression of the
pneumonic or parapneumonic process. (weak recommendation;
low-quality evidence)
c. Further investigation to identify whether the original pathogen
persists, the original pathogen has developed resistance to the
agent used, or there is a new secondary infecting agent. (weak
recommendation; low-quality evidence)
73. A BAL specimen should be obtained for Gram stain and culture for
the mechanically ventilated child. (strong recommendation;
moderate-quality evidence)
74. A percutaneous lung aspirate should be obtained for Gram stain and
culture in the persistently and seriously ill child for whom previous
investigations have not yielded a microbiologic diagnosis. (weak
recommendation; low-quality evidence)
75. An open lung biopsy for Gram stain and culture should be obtained
in the persistently and critically ill, mechanically ventilated child in
whom previous investigations have not yielded a microbiologic
diagnosis. (weak recommendation; low-quality evidence)

XVII. How Should Nonresponders With Pulmonary Abscess


or Necrotizing Pneumonia Be Managed?
Recommendation

76. A pulmonary abscess or necrotizing pneumonia identified in a


nonresponding patient can be initially treated with intravenous
antibiotics. Well-defined peripheral abscesses without connection to
the bronchial tree may be drained under imaging-guided procedures
either by aspiration or with a drainage catheter that remains in
place, but most abscesses will drain through the bronchial tree and
heal without surgical or invasive intervention. (weak
recommendation; very low-quality evidence)

DISCHARGE CRITERIA

XVIII. When Can a Hospitalized Child With CAP Be Safely


Discharged?
Recommendations

77. Patients are eligible for discharge when they have documented
overall clinical improvement, including level of activity, appetite, and
decreased fever for at least 1224 hours. (strong recommendation;
very low-quality evidence)
78. Patients are eligible for discharge when they demonstrate consistent
pulse oximetry measurements .90% in room air for at least 1224
hours. (strong recommendation; moderatequality evidence)
79. Patients are eligible for discharge only if they demonstrate stable
and/or baseline mental status. (strong recommendation; very low-
quality evidence)
80. Patients are not eligible for discharge if they have substantially
increased work of breathing or sustained tachypnea or tachycardia
(strong recommendation; high-quality evidence)
81. Patients should have documentation that they can tolerate their
home anti-infective regimen, whether oral or intravenous, and home
oxygen regimen, if applicable, before hospital discharge. (strong
recommendation; low-quality evidence)
82. For infants or young children requiring outpatient oral antibiotic
therapy, clinicians should demonstrate that parents are able to
administer and children are able to comply adequately with taking
those antibiotics before discharge. (weak recommendation; very low-
quality evidence)
83. For children who have had a chest tube and meet the requirements
listed above, hospital discharge is appropriate after the chest tube
has been removed for 1224 hours, either if there is no clinical
evidence of deterioration since removal or if a chest radiograph,
obtained for clinical concerns, shows no significant reaccumulation of
a parapneumonic effusion or pneumothorax. (strong
recommendation; very low-quality evidence)
84. In infants and children with barriers to care, including concern about
careful observation at home, inability to comply with therapy, or lack
of availability for follow-up, these issues should be identified and
addressed before discharge. (weak recommendation; very low-
quality evidence)

The treatment plan must be followed and all medicines must be taken as
prescribed and ongoing medical care should be seeked. The doctor may want to
have a chest x ray on the patient to make sure the pneumonia is gone thus
follow up is necessary. Fatigue can persist for up to a month or more though the
patients may start to feel better after a few days or weeks. People who are
treated in the hospital may need minimum 3 weeks before they resume normal
routines.

Bradley, J.S., et al., 2011

XIX. When Is Parenteral Outpatient Therapy Indicated, In


Contrast to Oral Step-Down Therapy?
Recommendations

85. Outpatient parenteral antibiotic therapy should be offered to


families of children no longer requiring skilled nursing care in an
acute care facility but with a demonstrated need for ongoing
parenteral therapy. (weak recommendation; moderate-quality
evidence)
86. Outpatient parenteral antibiotic therapy should be offered through a
skilled pediatric home nursing program or through daily
intramuscular injections at an appropriate pediatric outpatient
facility. (weak recommendation; low-quality evidence)
87. Conversion to oral outpatient step-down therapy when possible, is
preferred to parenteral outpatient therapy. (strong recommendation;
low-quality evidence)

Bradley, J.S., et al., 2011

L. KOMPLJKASI
pneumonia may lead to other diseases such as meningitis, etc.
Ming, C.K., 2011

705 928 patients were admitted to the hospital with community acquired
pneumonia (incidence: 3.5 cases per 1000 adults per year). The in-hospital
mortality of these patients was 13.1% (92 227 persons).
Strau, R., e al, 2014.
M. PROGNOSIS
Respiratory rate is an independent risk marker for in-hospital mortality in
community acquired pneumonia. It should be measured when patients are
admitted to the hospital with pneumonia and other acute conditions..
The plot of mortality as a function of respiratory rate on admission was U-
shaped and slanted to the right, with the lowest mortality at a respiratory
rate of 20/min on admission. If patients with a respiratory rate of 12
20/min are used as a baseline for comparison, patients with a respiratory
rate of 2733/min had an odds ratio (OR) of 1.72 for in-hospital death, and
those with a respiratory rate above 33/min had an OR of 2.55. Further
independent risk factors for in-hospital death were age, admission from a
nursing home, hospital, or rehabilitation facility, chronic bedridden state,
disorientation, systolic blood pressure, and pulse pressure.

Strau, R., e al, 2014.

N. PENGENDALIAN
PREVENTING PNEUMONIA IS KEY
Reducing pneumonia deaths also requires implementing effective
prevention measures so that children are healthier and less likely to
develop pneumonia in the first place. The prevention measures listed
below all show at least some evidence of reducing pneumonia mortality
among under-fives.a Some research has also suggested that hand
washing and lowering indoor air pollution play a role in reducing
pneumonia deaths among children in the developing world. For HIV-
infected children, preventing pneumonia (PCP) through cotrimoxazole
prophylaxis is essential (see Box 3, page 8 ).

IMMUNIZATION
Immunizations help reduce childhood deaths from pneumonia in two
ways.
First, vaccinations help prevent children from developing infections that
directly cause pneumonia, such as Haemophilus influenzae type b (Hib).
Second, immunizations may prevent infections that can lead to
pneumonia as a complication (e.g., measles and pertussis). Three
vaccines have the potential to significantly reduce child deaths from
pneumonia. These vaccines include the measles, Hib and pneumococcal
conjugate vaccines. Their ability to reduce pneumonia deaths is detailed
in Box 8, page 27.

ADEQUATE NUTRITION
Undernourished children are at a substantially higher risk of suffering
childhood death or disability. It has been estimated that child
undernutrition contributes to more than half of all child deaths in
developing countries, and that undernutrition in children aged 0-4 years
contributes to more than 1 million pneumonia deaths each year.e
Undernutrition may place children at an increased risk of developing
pneumonia in two ways. First malnutrition weakens a childs overall
immune system, as an adequate amount of protein and energy is
needed for proper immune system functioning. Second, undernourish
children have weakened respiratory muscles, which inhibits them from
adequately clearing secretions found in their respiratory tract.

EXCLUSIVE BREASTFEEDING
It is widely recognized that children who are exclusively breastfed
develop fewer infections and have less severe illnesses than those who
are not.
Breast milk contains the nutrients, antioxidants, hormones and
antibodies needed by the child to survive and develop, and specifically
for a childs immune system to function properly. Yet only about one third
of infants in the developing world are exclusively breastfed for the first
six months of life. Infants under six months old who are not breastfed are
at five times the risk of dying from pneumonia as infants who are
exclusively breastfed for the first six months of life. Furthermore, infants
6 - 11 months old who are not breastfed are also at an increased risk of
dying from pneumonia compared to those who are breastfed.

ZINC
Children who lack sufficient amounts of specific micronutrients,
particularly zinc, face additional risks of developing and dying from
pneumonia. A growing body of research highlights the importance of zinc
to child survival and to specifically reducing deaths from pneumonia.
intake helps reduce the incidence of pneumonia and the severity of the
disease.
Specifically, research has shown that zinc intake during the acute phase
of severe pneumonia decreased the duration and severity of pneumonia
and reduced treatment failure rates when compared with a placebo
intervention. Improving the zinc status of children is currently being
considered by public health and nutrition experts

Unicef-WHO, 2006

VACCINES HOLD PROMISE OF SAVING MILLION OF CHILDREN FROM


DYING OF PNEUMONIA
Three vaccines have the potential to save millions of childrens lives by reducing
deaths from pneumonia. These vaccines work to reduce the incidence of
pneumonia caused by the bacterial pathogens Streptococcus pneumoniae
(pneumococcal conjugate vaccine) and Haemophilus influenzae type b (Hib
vaccine), as well as pneumonia caused by serious complications from measles
(mea
Unicef-WHO, 2006

sles vaccine).

As idiom goes prevention is better than cure, prevention of pneumonia is


always important before someone suffering painfully from it and it may
lead to death at the end if proper treatment is no undertaken.The best
way to prevent pneumonia is to practice healthy lifestyle.
Avoid and stop smoking.
As smoking can seriously damage our lungs natural defence against
infection, we will have a higher chance to get pneumonia if we smoke. So,
dont smoke and stop smoking today to have healthier lungs and to have
lower chance to get pneumonia.
Get enough rest and stay fit
There are some types of pneumonia that invade immunosuppressed
patients. In other words, they attack people who have low immune
system. So, in order to prevent this type of pneumonia, strengthening of
immune system is a must. Getting enough rest, doing exercise frequently
and eating healthy diet including plenty of fat-free dairy products, fruits,
vegetables and whole grains can help to boost up our immune system.
Hygiene.
Since pneumonia is an infectious disease that can be transmitted from one
to another especially during hot weather, maintaining good personal
hygiene is a must to prevent someone from getting the transmitted
pneumonia. Usually, pneumonia is caused by flu and cough that are
transmitted from one to another through shaking hands. Thus, washing
hands frequently after coming back from outside and before meals with
soaps or to be more effective by antibacterial soaps can prevent the
transmission of
pneumonia.
As an infectious disease, pneumonia can also be transmitted through the
wounds. Hence, proper handling and care of wounds are needed. A wound
should be cleaned and covered with dry plasters or clothing. Besides that,
sharing of personal items such as toothbrush, towel and razor should be
strictly
restricted.
Hospital settings.
The best way to prevent someone from getting hospital-acquired
pneumonia is to stay away from hospital. As hospitals are full of bacteria,
children and the elderly are advised not to go to hospital as they have
weaker immune system than usual people.
However, it is impossible for people working at hospital such as doctor,
physician, nurses, hospital pharmacist and the hospitalised patients from
staying away from the hospitals. Hence, education should be given to
those who cannot stay away from hospital on how to reduce the
transmission of bacteria. For example, sharing of personal items among
the hospitalised patients is strictly forbidden. Besides that, the shared
medical equipments and patients bed-sheets should be cleaned
frequently. The proper of handling patients wound should also be given to
the hospitals staff so that the chance for them to get the transmitted
disease from the patients is reduced to a safe level.
Vaccines
Another way to prevent pneumonia is to get vaccination. Vaccine helps
someone to get immuned to pneumonia by stimulating the body to make
antibodies against pneumonia and hence the chance for him to get
pneumonia is greatly reduced.
Generally, there are two types of pneumonia vaccines which are for the
children and the adults respectively. The vaccine for children is called the
7-valent pneumococcal conjugate vaccine.
More than one dose is given to the children younger than 2 years old but
the children older than 2 years old just need 1 dose of the vaccine.
Similarly, there is vaccine for adults called the 23-valent pneumococcal
polysaccharide vaccine (Pneumovax, Pnu-Immune). Only one dose of
vaccine is needed for this type of vaccination.
Vaccination is recommended for the people of this following:
People aged 65 and over
People who smoke
People who have serious chronic diseases such as lung disease which may
lead to pneumonia eventually.
People who have weaker immune system including those receiving organ
transplant, AIDS patients and cancer patients
The young children
People staying at hospital for long period of time
Besides vaccines for pneumonia, other vaccine which can prevent
common diseases that may lead to pneumonia is also available such as
viral flu vaccine.
Ming, C.K., 2011

- Smoke-free home
- Vaccination: Haemophilus influenzae type b (Pediacel) vaccine;
pneumococcal conjugate vaccine (Prevnar, Synflorix)

INESSS. 2009

The advent of polysaccharide-protein conjugate vaccines for H. influenzae type b


and 7 serotypes of S. pneumonia (7-valent pneumococcal conjugate vaccine
[PCV7]) dramatically decreased the incidence of infection, including CAP, caused
by these bacteria. Newer vaccines that protect against a greater number of
pneumococcal serotypes are in various stages of clinical development, with a
newly licensed 13-valent pneumococcal conjugate vaccine (PCV13) available in
the United States.
Bradley, J.S., et al., 2011

Processes of care (quality indicators)


Many studies have assessed processes of careie, interventions
undertaken to assess, diagnose, or treatwith the clinical outcome of
patients (table 5). In a metaanalysis
from a structured review of 4531 published reports, Rhew identified
several quality indicators that were judged to be valid on the basis of
published evidence or professional consensus and that were associated
with a beneficial effect on outcome in elderly patients with CAP.
These indicators were: use of pneumococcal and influenza vaccines (for
prevention of CAP); administration of antimicrobials in a timely matter
(within 8 h of arrival at the hospital); advice to cease smoking for patients
who smoke; drainage of a pleural empyema; conversion from parenteral to
oral antimicrobial treatment when the patient is improving,
haemodynamically stable, and able to take oral medications; and use of
appropriate discharge criteria (ensuring that patients are clinically stable
at the time of release from hospital). Whereas the studies reviewed by
Rhew supported 8 h as the target time for appropriate initiation of
antimicrobial agents, more recent data have shown that starting therapy
within 4 h was associated with better outcomes for patients who needed
to be admitted. Although one study of CAP patients who were admitted to
academic medical centers did not show a benefit of many of these
indicators, implementation
of a pneumonia practice guideline that promote some or all of these
quality indicators has been shown in many other studies to be associated
with better outcomes

File Jr, T.M 2003

PREVENTION

XX. Can Pediatric CAP Be Prevented?


Recommendations

88. Children should be immunized with vaccines for bacterial


pathogens, including S. pneumoniae, Haemophilus influenza type b,
and pertussis to prevent CAP. (strong recommendation; high-quality
evidence)
89. All infants $6 months of age and all children and adolescents
should be immunized annually with vaccines for influenza virus to
prevent CAP. (strong recommendation; highquality evidence)
90. Parents and caretakers of infants ,6 months of age, including
pregnant adolescents, should be immunized with vaccines for
influenza virus and pertussis to protect the infants from exposure.
(strong recommendation; weak-quality evidence).
91. Pneumococcal CAP after influenza virus infection is decreased by
immunization against influenza virus. (strong recommendation;
weak-quality evidence)
92. High-risk infants should be provided immune prophylaxis with
respiratory syncytial virus (RSV)specific monoclonal antibody to
decrease the risk of severe pneumonia and hospitalization caused
by RSV. (strong recommendation; high-quality evidence)

Bradley, J.S., et al., 2011


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