PEDIATRICS COMMUNITY

ACQUIRED PNEUMONIA

ISIMIJOLA OPEYEMI

PNEUMONIA
• Its an inflammation of the lung
parenchyma
• Leading cause of death globally
among children younger than 5
years old
CAP
Defined as presence of signs and
symptoms of pneumonia in a
previously healthy child caused by an
infection that has been acquired
outside the hospital.
ETIOLOGY
INFECTIOUS VS NONINFECTIOUS
BACTERIA
• Streptococcus peneumoniae
• Haemophilus influenza
• Staphylococcus aureus
• Grp B streptococcus
• E coli
• Klebsiella
VIRUSES
• Respiratory syncytial virus
• Influenza virus A,B
• Parainfluenza virus 1-3
• Adenovirus
• Human metapneumovirus
ATYPICAL ORGANISM FUNGI

• Mycoplasma • Pneumocystis jiroveci

• Chlamydia
NON INFECTIOUS CAUSE

• Aspiration of food and gastric acid

• Foreign bodies
• Hydrocarbons
• Hypersensitivity reactions
• Drug or radiation induced
CLINICAL MANIFESTATIONS

• Pneumonia is most often preceded by several days of symptoms of an

URTI typically rhinitis and cough

• Viral pneumonia generally has low grade fever unlike bacteria

pneumonia

• Tachypnea is the most consistent clinical manifestation of pneumonia

• Increased work of breathing accompanied by intercostal,
subcostal, and suprasternal retractions, nasal flaring and use of
accessory muscles are other manifestations

• In older children, bacteria pneumonia typically begins suddenly

with high fever, cough and chest pain.
PREDICTORS OF CAP IN PATIENT WITH COUGH

• Ages 3mos-5 y/o: tachypnea and/ retractions.

• Ages 5-12 y/o: fever, tachypnea and crackles.
• >12 y/o: fever, tachypnea, tachycardia, at least one abnormal
chest findings of (rhonchi, crackles, wheezes decreased breath
sounds)
Age specific criteria for tachypnea
• 2-12 months: 50bpm
• 1-5 years:40bpm
• >5 years: 30bpm
Diagnosis of an adolescent suspected to have CAP:
Tachypnea (RR >20cpm)
Tachycardia:(HR>100bpm)
Fever: (temp>37.8)
At least one abnormal chest findings
Chest x-ray with infiltrates
CRITERIA FOR ADMISSION
DIAGNOSTIC AIDS
• PCAP A and PCAP B: chest x-ray, CBC, CRP, ESR,
Procalcitonin, Blood Culture.
• PCAP C: gram stain of sputum, culture and sensitivity of pleural
fluid, ABG, oximetry, chest x-ray, CBC, CRP, electrolytes and
glucose.
• PCAP D: refer to specialist
ANTIBIOTIC RECOMMENDATION

• For patient classified as PCAP A or B and is:

Beyond 2 years of age

Having high grade fever without wheeze
• For patient classified as PCAP C and is:

Beyond 2 years of age

Having high grade fever without wheeze
Having alveolar consolidation on chest x-ray
Having WBC count > 15,000
ANTIBIOTIC RECOMMENDATION

• For patient classified as PCAP D

FEATURES SUGGESTIVE OF BACTERIA AND VIRAL PATHOGENS
• Demonstration of either alveolar infiltrates on chest x-ray or
elevated WBC favors bacteria Pathogen.

Features Bacterial Viral

Fever >38.5 <38.5
Wheezes Absent Present
WBC Count Elevated (15,000 – Normal or elevated (not
40,000/mm3, higher than
Granulocytes 20,000/mm3,
predominance Lymphocyte
predominance
EMPIRIC TREATMENT
PCAP- A/B PCAP-C w/o previous antibiotic PCAP-D
w/o previous
antibiotic
Oral Amoxicillin (40- Complete Hib Penicillin G (100,000 Refer to Specialist
50 mg/kg/day TID) immunization u/kg/day QID)
x 7 days Hib immunization not IV Ampicillin (100
completed mg/kg/day QID
ALTERNATIVE DRUGS
PCAP- A/B PCAP-C w/o previous antibiotic PCAP-D
w/o previous
antibiotic

Cotrimoxazole Cefuroxime and Refer to specialist

Ampicillin-Sulbactam
INITIAL TREATMENT WITH VIRAL ETIOLOGY

• Oseltamivir :

30mg twice a day for <15kg body weight

45mg twice a day for > 15-23kg body weight
60mg twice a day for >23-40kg body weight
75mg twice a day for >40kg body weight.
• For influenza A and B infection: oseltamivir 2mg/kg/dose BID
can be given for 5 days.
• For influenza A Infection: amantadine 4.4-4.8mg/kg/day can be
given for 3 to 5 days
• Discontinue drug within 24 to 48 hours of resolution of
symptoms.
WHEN IS A PATIENT CONSIDERED RESPONDING
TO TREATMENT

• Decrease in respiratory signs (tachypnea) and defervescence

within 72 hours after initiation of antibiotics.
• Persistence of symptoms after 72 hours of antibiotic initiation
requires reevaluation.
• Out patient classified as PCAP A or B and not responding to
treatment:
- Change initial antibiotics
- Start oral macrolides
- Reevaluate diagnosis
• For possibility of penicillin resistant S.pneumoniae

Change amoxicillin to any of the following: cefuroxime, co-

amoxiclav, cepfodoxime.
• For possibility of mycoplasma or chlamydia specie:

Start oral macrolide

• In patient classified as PCAP C and not responding to current
antibiotics within 72 hours:
consider consultation with a specialist following possibilities of
penicillin resistant S.pneumoniae or presence of complications.
• In patient with PCAP D not responding within 72 hours:

Re-consultation with specialist

WHEN CAN SWITCH THERAPY IN PNEUMONIA BE
STARTED

For PCAP C:
• Responsive to current antibiotics
• Tolerance to feeding and without vomiting and diarrhea
• Without any current pulmonary or exra pulmonary complication
• Without oxygen support

For PCAP D
• Consider referral to specialist
PREVENTION
Vaccine against:
• Streptococcus pneumonia
• Influenza
• Diphtheria ,Pertussis, Rubeola, Varicella, Hemophilus Influenza
type B.
Micronutrients:
• Elemental zinc for age 2 to 59 months to be given for 4 to
6months.
• Vitamin d3 supplementation

Note that Vit A should not be given to prevent pneumonia.

COMPLICATIONS

• Pleural effusion
• Empyema
• Pericarditis
• Meningitis
• Suppurative arthritis
• osteomyelitis
THANK YOU!