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The Management of Community-Acquired
Transcript of The Management of Community-Acquired
Routine chest radiographs are not necessary for the confirmation of suspected CAP
- suspected or documented hypoxemia
- significant respiratory distress
- failed initial antibiotic therapy
verify the presence or absence of complications of pneumonia (parapneumonic effusions, necrotizing pneumonia, and pneumothorax).
document the presence, size, and character of parenchymal infiltrates
identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy
Sputum Gram Stain and Culture
should be obtained in hospitalized children who can produce sputum
not routinely performed in nontoxic, fully immunized children
should be obtained after initiation of antibiotic therapy:
- No clinical improvement
- Progressive symptoms - Clinical deterioration
moderate to severe CAP particularly complicated pneumonia
It should be used in the evaluation of children with CAP
A positive influenza test result may:
decrease the need for additional diagnostic studies
decrease antibiotic use, while guiding appropriate use of antiviral agents
Antibacterial therapy is not necessary in the absence of bacterial coinfection.
Testing For Viral Pathogens
outpatient and inpatient
Testing for Atypical Bacteria
Diagnostic testing for
is not recommended as reliable, and readily available diagnostic tests do not currently exist.
Children with signs and symptoms suspicious for
should be tested to help guide antibiotic selection.
cannot be used as
the sole determinant to distinguish between viral and bacterial causes of CAP
Should be performed in all children with pneumonia and suspected hypoxemia.
The presence of hypoxia should guide decisions regarding site of care and further diagnostic testing.
Limiting exposure to any antibiotic, whenever possible
Limiting the spectrum of activity of antimicrobials
Using the proper dosage of antimicrobial to achieve a minimal effective concentration at the site of infection
Treatment for the shortest effective duration
Shorter courses may be just as effective, particularly for outpatients with mild disease.
Certain pathogens, notably CA-MRSA, may require longer treatment.
10 days courses have been best studied
Children on adequate therapy should demonstrate clinical and laboratory signs of improvement within 48–72 hours
Children whose condition deteriorates after admission and initiation of antimicrobial therapy or who show no improvement within 48–72 hours, further investigation should be performed.
ADJUNCTIVE SURGICAL AND NON–ANTI-INFECTIVE THERAPY FOR PEDIATRIC CAP
How Should a Parapneumonic Effusion Be Identified?
History and physical examination
Chest ultrasound or computed tomography (CT)
What Laboratory Testing Should Be Performed on Pleural Fluid?
Analysis of pleural fluid parameters
Gram stain and bacterial culture of pleural fluid
Pleural fluid WBC count, with cell differential analysis
Antigen testing or nucleic acid amplification through PCR
Children and infants :
- with moderate to severe CAP as defined (respiratory distress and hypoxemia)
- with CAP caused by a pathogen with increased virulence, such a CA-MRSA
- who need careful observation at home or who are unable to be followed up
Infants less than 3–6 months of age with suspected bacterial CAP
if the child :
- requires invasive ventilation via a nonpermanent artificial airway (eg, endotracheal tube).
- requires use of noninvasive positive pressure ventilation (eg, continuous positive airway pressure or bilevel positive airway pressure)
- has impending respiratory failure
- has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion
- has altered mental status, whether due to hypercarbia or hypoxemia as a result of pneumonia
if the pulse oximetry measurement is ≤92% on inspired oxygen of ≥0.50
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
school aged and adolescent
responsible for the majority of disease
antimicrobial therapy not routinely required
mild to moderate CAP suspected to be bacterial
- moderate allergy:
cefpodoxim, cefuroxim, cefprozil
- severe allergy:
levofloxacin, linezolid,macrolide, clindamycin
fully immunized with no penicillin resistance to S. pneumonia
ampicillin or penicillin G
not fully immunized in region with high level of resistance
life threatening infection (empyema)
cephalosporin 3 G IV
suspected C. pneumonia, M. pneumonia:
+ macrolide(oral or IV)
+ vanco or clinda
or linezolid( renal dysfunction
or nephrotoxique agents or B-lactam , vanco, clinda allergy)
type B eliminated by vaccin
non typeable chronic lung disease
if resistance: cephalo 2 or 3G
if allergy: fluoroquinolone
cephalo 2 or 3 G
not frequent BUT may cause severe necrotizing pneumonia
B-lactam + clindamycin
afebrile LRTI in very young infants 2–12 weeks of age, born to
mothers with genital infection
atypical pneumonia in school-aged children and adolescent
Management of the child not responding to treatment
Relative weight of these factors:
-Severity of the presentation
-Rate of clinical deterioration or duration of lack of improvement
Patient = Non responder if:
Lack of improvement within 48-72 hours
Significant worsening at anytime after initiating therapy
Frequency: 5% - 15% (estimate)
Decision to consider a patient a non responder
Outpatient parenteral therapy for CAP can be used due to :
No further need for skilled nursing care
The creation of an outpatient management team
Who may require ongoing parenteral therapy?
Those who may have ongoing disease requiring a high serum antibiotic concentration in order to achieve sufficient exposure in infected tissues
Although studies have demonstrated the safety and effectiveness of oral outpatient therapy for serious bacterial infection
The risks of adverse events from oral therapy are less than those of intravenous therapy
S. pneumonia and H. influenza type b :
The most common causes of pediatric CAP
Infection preventable through immunization
The 13-valent pneumococcal conjugate vaccine: 13 serotypes
Influenza virus LRTIs
Inactivated trivalent vaccine (efficacy 86%)
Attenuated vaccine (live, cold adapted): better efficacy in young children 6-59 months of age
Bacterial pneumonia (pneumococcal pneumonia and CA-MRSA pneumonia)
Associated with preceding seasonal influenza virus infection
Universal influenza immunization in patients aged ≥ 6 month
Respiratory syncitial virus (RSV)
Most common viral etiology
Palivizumab: monoclonal antibody produced by recombinant DNA technology
recommended for infants that are high-risk because of prematurity or other medical problems such as congenital heart disease.
documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12–24 hours
consistent pulse oximetry measurements .90% in room air for at least 12–24 hours
stable and/or baseline mental status
substantially increased work of breathing or sustained tachypnea or tachycardia
documentation that they can tolerate their home anti-infective regimen, whether oral or intravenous, and home oxygen regimen, if applicable, before hospital discharge
parents able to administer and children are able to adequately comply with taking those antibiotics before discharge
children with chest tube:discharge is appropriate after the chest tube has been removed for 12–24 hours, with no evidence of deterioration since removal
children with barriers to care, including
concern about careful observation at home, inability to comply with therapy, or inability to be followed up, these issues should be identified and addressed before discharge.
Parenteral Outpatient Therapy vs. Oral Step-Down Therapy
Outpatient parenteral antibiotic therapy should be offered
to families of children no longer requiring skilled
nursing care in an acute care facility but having a demonstrated need for ongoing parenteral therapy
through a skilled pediatric home nursing program or through daily intramuscular injections at an appropriate pediatric outpatient facility.
Conversion to oral outpatient step-down therapy, when
possible, is preferred to parenteral outpatient therapy
Children should be immunized with vaccines for
bacterial pathogens including S. pneumoniae, H. influenzae type b and pertussis to prevent CAP.
All children and adolescents >6 months of age should
be immunized annually with vaccines for influenza virus to prevent CAP
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
Pneumococcal CAP after influenza virus infection is
decreased by immunization against influenza virus.
High-risk infants should be provided immune
prophylaxis with RSV-specific monoclonal antibody to decrease the risk of severe pneumonia
caused by RSV
Resistance to Antimicrobials
slow progressing developing over 3 to 5 days
low grade fever
Anti infective treatment
Adjunctive surgical therapy
Methicillin-susceptible Staphylococcus aureus
most often treated initially in the inpatient setting
IV b-lactamase–stable penicillin:oxacillin or nafcillin
cephalosporin 1G: cefazolin
severe infections: combination therapy with aminoglycoside:gentamicin