Pediatrics Pneumonia and

Meningitis and comprehensive

Management for both cases
Pediatric Pneumonia
Introduction
• Pneumonia is inflammation of the lung with
consolidation(fluid in the lung)
• The cause of the inflammation is infection which
can be caused by a wide range of organisms
• There are four classifications of pneumonia:
• Community-acquired
• Aspiration
• Hospital-acquired and
• Ventilator-associated
Cont.
• Community acquired pneumonia-
Patients who develop pneumonia in the
outpatient setting and have not been in
any health care facilities.
• Hospital acquired pneumonia (HAP)- is
defined as pneumonia that occurs 48
hours or more after admission.
• Ventilator associated pneumonia-
requires endotracheal intubation for at
least 48 hours before the onset of
pneumonia.
• Aspiration pneumonia- is caused by
aspiration of either oropharyngeal or
gastrointestinal contents
Epidemiology
• Approximately one-half of children
younger than 5 years of age with
community-acquired pneumonia
require hospitalization
• In developing countries, respiratory
tract infections are not only more
prevalent but more severe,
Cont.
• Accounting for more than 4 million
deaths annually.
• pneumonia is the number one killer of
children in these societies.
• The mortality rate in developed
countries is comparatively low (<1 per
1000 per year)
Etiology
Community-Acquired Pneumonia is caused by:
• S. pneumoniae (pneumococcus) 75%
• Others (atypical pathogens) : M. pneumoniae,
Legionella, C. pneumoniae
• Staphylococcus aureus and gram-negative rods (H.
Influenza---- especially in COPD)
Cont.
Hospital-Acquired Pneumonia is caused by:
Gram-negative aerobic bacilli (Pseudomonas,
H. Influenzae, Moraxella catarrhalis,
acinetobacter spp, and S.aureus)

•
Aspiration pneumonia is caused by
Anaerobic bacteria (Bacteroides spp,
Fusobacterium spp., Prevotella spp,and
anaerobic gram-positive cocci)
•
Pathophysiology
Microorganisms gain access to LRT by three routes:
• Inhaled as aerosolized particles
• Enter the lung via bloodstream from an
extrapulmonary site of infection
• Aspiration of oropharyngeal contents may occur.
Cont.
• Local host defenses of the LRT include cough,
mucociliary antibodies, and alveolar macrophages
• Once breakdown of local host defenses occurs and
organisms invade lung tissue, an inflammatory
response is generated either by organisms causing
tissue damage or by immune response to the
presence of organisms
Risk factor
• Environmental crowding
• Underlying cardiopulmonary disorders
• Congenital and acquired immunodeficiency disorders
• Exposure to cigarette smoke, especially if the mother
smokes it increases the risk for pneumonia in infants
younger than 1 year of age.
• Malnutrition
• Trauma
• Anesthesia
• Aspiration
Clinical presentation
• Cough: chief symptom
• Increased respiratory rate
•
Cont.
• Tachypnea
• Retractions, and
• Hypoxemia
• They may have other constitutional symptoms,
such as
• headache,
• pleuritic chest pain, and
• nonspecific abdominal pain
Cont.
Severe pneumonia is manifested when
• Cough or difficulty in breathing with:
• Oxygen saturation < 90% or central cyanosis
• Severe respiratory distress (e.g. grunting, very
severe chest indrawing)
Signs of pneumonia with a general danger sign
• Inability to breastfeed or drink
• Lethargy or reduced level of consciousness
• Convulsions
• Vomiting everything
Complications
• Pneumothorax
• Septicaemia
• Pleural effussions
• Empyema
• Abscess
• Bronchiectasis
• Infective endocarditis
• Hem. Dissemination –sepsis, meningitis pericardtis
arthritis etc
Diagnosis
• Chest radiograph - A dense lobar or segmental
infiltrate or patchy consolidation
• fast breathing:
• age 2–11 months, ≥ 50/min
• age 1–5 years, ≥ 40/min
• lower chest wall indrawing
• Hypoxic or other clinical symptoms
 Treatment
The Goal of therapy is to:
• Eliminate the patient’s symptoms,
• Minimize or prevent complications, and
• Decrease mortality
• Alleviate symptoms
• Prevent respiratory failure
• Prevent complications
Non pharmacological treatment
• Soothe the throat; relieve the cough with a safe
remedy
Safe remedies to recommend include:
• Breast milk for exclusively breast-fed infant
• Home fluids such as tea with honey, fruit juices
• Give oxygen if SpO2 < 90% with nasal prongs and
monitor through pulse oximetry for those in
respiratory distress via nasal cannula.
Pharmacologic therapy
Antipyretic
• Paracetamol, 10-15mg /kg P.O., up to 4-6 times a
day for the relief of high fever
Alternative
• Ibuprofen, 5 – 10mg/kg/dose every 6-8hr P.O.
(max. 40mg/kg/24hours).
 Community acquired pneumonia
• The vast majority of children diagnosed with
pneumonia in the outpatient setting are treated
with oral antibiotics.
• The choice of an initial empiric agent is selected
according to the susceptibility and resistance
patterns of the likely pathogens.
 Non-severe pneumonia
• High-dose Amoxicillin is used as a first-line agent for
children with uncomplicated community-acquired
pneumonia, which provides coverage for
Streptococcus pneumoniae
• Give the first dose at the clinic and teach the
mother how to give the other doses at home.
Cont.
First-line
• Amoxicillin, 30-50mg/kg every 12hours P.O for 5
days
Alternatives
• Azithromycin, 10mg/kg P.O., once daily for 3 days
mainly on patients that have afebrile pneumonia
syndrome.
• Reassess child for progress after 3 days.
Severe Pneumonia
• Benzyl penicillin, 50,000units/kg/24hours IV QID
for at least 3 days
• When the child improves switch to oral
• Amoxicillin: 30-50mg/kg/24 hours 3 times a day.
• The total course of treatment is 5-7days.
Cont.
• If the child doesn’t improve within 48 hours, switch
to ceftriaxone 80mg/Kg/24 hours IM/IV for 5 days
• If staphylococcus is suspected (empyema,
pneumatocele at X ray), give gentamicin 5 mg/kg
once daily plus cloxacillin 50 mg/kg IV every 6-hour
• Zinc supplementation in children <5years with
severe pneumonia
Aspiration pneumonia
• Ceftriaxone 80mg/Kg/24 hours IM/IV +
Metronidazole 7.5mg/kg every 8 hours
• Refer the patient for possible removal
• Gentle suction of thick secretions from upper
airway maybe supplemental.
Hospital and ventilator-associated
pneumonia
For patients at lower risk of drug resistant organisms,
Ceftazidime Total daily dose 75 mg/kg IV (divided
into 2 doses per day)
• AND
• Gentamicin 3 – 5 mg/kg/day IV (given once daily)
for 7 days
Cont.
Patients at higher risk of drug resistant organisms
• Piperacillin-Tazobactam 100 mg/kg IV q 8 hours for
7 day
Pediatric Meningitis
Introduction
• Meningitis is acute inflammation of the meninges
(the membranes covering the brain).
• It is an acute and one of the most potentially
serious infections in infants and children that
affects the central nervous system
• Meningitis can be bacterial, viral or fungal,
although bacterial meningitis (caused by the
meningococcal bacteria) is more serious than viral
or fungal meningitis and requires rapid treatment.
Meninges are the three layers of membranes that
cover and protect the central nervous system (CNS).
They're known as:
• Dura mater: This is the outer layer, closest to the
skull.
• Arachnoid mater: This is the middle layer.
• Pia mater: This is the inner layer, closest to the
brain tissue.
• Acute Bacterial meningitis- Pediatric bacterial
meningitis is a life threatening illness that results
from bacterial infection of the meninges
• Aseptic meningitis- is an inflammation of the
meninges caused mainly by nonbacterial
organisms, specific agents, or other disease
processes.
Epidemiology
• An estimated 2.5 million cases of meningitis occur
globally each year, with approximately 250,000
deaths.
• Without treatment, the case-fatality rate can be as
high as 70%
• The mortality rate of untreated pediatric bacterial
meningitis approaches 100 percent.
• 1 in 5 survivors of bacterial meningitis may be left
with permanent sequelae including hearing loss,
neurologic disability/impairments, seizures, or loss of
a limb
Etiology
The Pathogen is influenced by :
• Age of the host
• Immune status of the host
• Epidemiology of the pathogen
From Birth upto 2 months
• Group B Streptococci (Streptococcus agalactiae)
• Gram negative enteric bacilli(E.coli,klebsiella)
• Listeria Monocytogenes
• Group D streptococci (Enterococcus)
From 2 month upto 12 years
• S. Pneumoniae
• N. Meningitidis
• H.. influenza type B ( 70% of cases of meningitis in
<5 yr of age )
Other less common pathogens
• P. aeruginosa
• S. aureus
• CONS
• Salmonella spp.
• L.monocytogenes
Risk Factors
• Lack of immunity to specific pathogens
associated with young age 95% of cases occur
between 1 mth – 5 yrs of age .
• Recent colonization with pathogenic bacteria
• Male sex
• Crowded living conditions
• Poverty
• Splenic dysfunction
• CSF leak
• T-lymphocyte defects
• CSF shunt infections
- Staphylococci (especially CONS)
- Low virulence bacteria that colonize the skin