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Morning Report

September 7, 2011 Annie Powers

Case Presentation
Chief HPI:


3 year old female with cough and fever for 6 days Initial mild cough and fever; diagnosed with a viral respiratory illness Cough worsened and fever persisted; diagnosed with acute otitis media and started on amoxicillin

Case Presentation


Cough continued to worsen and she was still febrile, now with increased work of breathing Oxygen sats at PCPs 88% on room air, so she was referred to PCMC

Case Presentation
PMHx: Healthy term infant. No hospitalizations or surgeries. SocHx:

Lives with parents and older brother, who was recently ill. Attends pre-school twice a week. No recent travel. No tobacco exposure. No pets.

FamHx: Negative for asthma, congenital heart disease, autoimmune diseases, immunodeficiencies.

Case Presentation
Meds: None regularly All: NKDA Imms: Up to date

Case Presentation

Physical Exam

VS: Temp 37.8, P 129, RR 53, BP 102/59, O2 95% on 0.5 L NC

GENERAL: NAD, appears uncomfortable. HEENT: Conjunctivae clear, TMs clear without erythema, MMM, NP clear, OP w/o exudates. NECK: Supple, no LAD. LUNGS: No grunting or nasal flaring, minimal subcostal retractions, left lung clear to auscultation, right lung with crackles and decreased aeration. CV: Tachycardic, normal rhythm, no M/G, nl perfusion and pulses. ABD: Soft, NT/ND, no HSM, nl BS, no masses EXTREMITIES: No C/C/E. SKIN: No rashes, jaundice, cyanosis or pallor.

Differential Diagnosis

3 year old female with cough, fever, hypoxia

Laboratory and Imaging


349 BMP: Na 138, K 4.3, Cl 106, CO2 21, BUN 14, Cr 0.36, Glu 113, Ca 8.9 ESR 101, CRP 21.7 VRP: pending Blood cx: pending CXR

WBC 9.6 (1B/57N/35L), Hct 31.1, Plts

Community Acquired Pneumonia


greatest cause of death in children worldwide Definition:

Presence of signs and symptoms of pneumonia in a previously healthy child due to an infection acquired outside of the hospital Signs and Symptoms: Best positive predictive value: nasal flaring <12 mo, oxygen saturation, tachypnea Best negative predictive value: absence of tachypnea or other respiratory signs

Community Acquired Pneumonia Common Pathogens

< 3 months 3 mo 5 years Viral Pathogen RSV Influenza Parainfluenza hMPV RSV Influenza Parainfluenza hMPV Bacterial Pathogens GBS GM- bacilli S. pneumoniae B. Pertussis C. Tachomatis L. monocytogenes S. pneumoniae M. pneuoniae C. Pneumoniae S. Aureus GAS H. influenza S. pneumoniae M. pneumoniae C. pneumoniae S. Aureus GAS H. influenza Influenza Adenovirus >5 years

PIDS and IDSA Clinical Practice Guidelines Diagnostic Laboratory Tests

Blood cultures: Should not be obtained in a nontoxic, fully immunized child with CAP managed in the outpatient setting Should be obtained for patients requiring inpatient admission

Positive blood cultures ranged from 1.4% to 3.4% In Utah, 11.4% had positive cultures In pneumonia complicated by parapneumonic effusion, 13% to 26.5% had bacteremia

PIDS and IDSA Clinical Practice Guidelines Diagnostic Laboratory Tests

Testing for atypical pneumonia

Recommended if signs/symptoms consistent Culture and cold agglutinin testing not recommended Recommend using PCR, combined IgG-IgM assays or IgM assay

No widely used available and timely test exists for the diagnosis of C. pneumoniae
Not recommended as false positives are common and may reflect colonization

Urinary antigens testing for S. pneumoniae:

PIDS and IDSA Clinical Practice Guidelines Diagnostic Laboratory Tests

Viral Testing:

Should be part of the evaluation of pediatric CAP

Low risk of serious bacterial infection in children with laboratory-confirmed viral infection Viral and bacterial co-infections occurred in 23% of children hospitalized with CAP Positive viral testing leads to significantly decreased rate of antibiotic prescribing and appropriate antiviral therapy In one study of children with a documented viral illness and respiratory failure, 39% had a concomitant bacterial infection

PIDS and IDSA Clinical Practice Guidelines Diagnostic Laboratory Tests

CBC Degree of WBC elevation does not distinguish bacterial from viral infection ESR, CRP, procalcitonin Cannot be used as a sole determinant to distinguish bacterial from viral pneumonia May be helpful in monitoring clinical response in patients with serious or complicated disease

PIDS and IDSA Clinical Practice Guidelines Diagnostic Imaging Tests

CXR: Rarely affected decisions regarding hospitalization For experienced physicians, CXR supported the diagnosis of PNA in 92% of cases Should be obtained when empyema or effusion is suspected Follow up CXR not indicated in children who have fully recovered

PIDS and IDSA Clinical Practice Guidelines Anti-Infective Therapy


Outpatient Antibiotics
Presumed Bacterial Amoxicillin (90mg/kg/d divided BIDTID) Alt: Augmentin Amoxicillin (90mg/kg/d divided BIDTID) Alt: Augmentin Presumed Atypical Azithromycin Presumed Influenza Oseltamivir

Age <5 years

>5 years


Oseltamivir or zanamivir

PIDS and IDSA Clinical Practice Guidelines Anti-Infective Therapy


Inpatient Antibiotics
Presumed Bacterial Presumed Atypical Presumed Influenza

Fully Immunized

Ampicillin or Penicillin Alt: Ceftriaxone, Cefotaxime Add clinda/vanc

Azithromycin Oseltamivir or zanamivir

Not fully immunized

Ceftriaxone, Cefotaxime Add clinda/vanc

Azithromycin Oseltamivir or zanamivir

PIDS and IDSA Clinical Practice Guidelines Anti-Infective Therapy

Treatment Duration

Most studies have used a standard 10 day treatment course Shorter courses (3-7 days) are being tested CA-MRSA may require longer require longer treatment courses Complicated pneumonias may require 4-6 weeks of therapy

PIDS and IDSA Clinical Practice Guidelines Adjunctive Surgical Therapy

Management of Pneumonia with Parapneumonic Effusion

Size of Effusion Small: <10mm Bacteriology Bacterial culture and Gram stain unknown or neg. Bacterial culture an/or Gram stain positive or negative Bacterial culture and/or Gram stain results positive Risk of Poor Outcome Low Tube drainage +/fibrinolysis or VATS No

Moderate: >10mm rim on fluid Large: opacifies more than half of the hemithorax

Low to moderate

No unless resp compromise or consistent with empyema Yes in most cases


Management of pneumonia with parapneumonic effusion; abx, antibiotics; CT, computed tomography; dx, diagnosis; IV, intravenous; US, ultrasound; VATS, video-assisted thoracoscopic surgery.

Bradley J S et al. Clin Infect Dis. 2011;53:e25-e76

Case Presentation Continued

Effusion progressed, did not qualify for VATS Pigtail catheter placed by IR on hospital day #2 Continued to have fevers, hypoxia and stalled CRP CT scan done hospital day #4 revealed complicated right-sided pneumonia with areas of necrosis and pneumatocele formation and complicated moderate sized empyema VATS procedure on hospital day #5 with placement of two chest tubes Discharged home on IV abx on hospital day #10 Transitioned to oral abx for another 2 weeks (total 6 weeks of abx)

Pneumococcal Necrotizing Pneumonia in Utah

Utah saw a modest decrease in invasice pneumococcal disease after PCV7 introduction PNP has been increasing in Utah since 2001 Cases were associated with nonvaccine pneumococcal serotypes, especially type 3

Pneumococcal Vaccine Recommendations

PCV13 (S. pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F )

4 dose series at 2, 4, 6 and 12-15 months Healthy children 7-59 months (not previously vaccinated with PCV7 or PCV13) should receive 1-3 doses Children 24-71 months with underlying medical conditions should receive 2 doses of PCV 13 Healthy children 24-59 months should receive 1 dose

PPSV23 (S. pneumoniae: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F)

Children aged 2 and above with chronic heart disease, chronic lung disease, DM, CSF leaks, cochlear implants, sickle cell and other hemoglobinopathies, congenital or acquired asplenia, HIV, chronic renal failure or nephrotic syndrome, immunosuppression, congenital immunodeficiencies


Bradley et al. The management of communityacquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Clin Infect Dis. 2011;53:617-30. Michelow et al. Epidemiology and clinical characteristics of community acquired pneumonia in hospitalized children. Pediatrics. 2004;113:701-7. Bender et al. Pneumococcal Necrotizing Pneumonia in Utah: Does Serotype Matter? Clin Infect Dis. 2008;46:1346-1352.