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The Management of Community-Acquired

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stef eid

on 4 March 2014

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Transcript of The Management of Community-Acquired

The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age

Routine chest radiographs are not necessary for the confirmation of suspected CAP
performed :
- 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

Blood Cultures

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
C. pneumoniae
is not recommended as reliable, and readily available diagnostic tests do not currently exist.
Children with signs and symptoms suspicious for
M. pneumoniae
should be tested to help guide antibiotic selection.
Acute-Phase Reactants
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.

Pulse Oximetry
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.

How Should a Parapneumonic Effusion Be Identified?
History and physical examination
Chest radiography
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


ICU admission
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
Anti-Infective Therapy
school aged and adolescent
viral pathogens
responsible for the majority of disease
antimicrobial therapy not routinely required
mild to moderate CAP suspected to be bacterial
S. pneumonia
- moderate allergy:
cefpodoxim, cefuroxim, cefprozil
- severe allergy:
levofloxacin, linezolid,macrolide, clindamycin

S. pneumonia
most prominent
atypical bacteria
M. pneumonia
macrolide: azithromycin
adolescent: levofloxacin
fully immunized with no penicillin resistance to S. pneumonia
ampicillin or penicillin G
- ceftriaxone
- cefotaxim
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)
suspected MRSA:
+ vanco or clinda
or linezolid( renal dysfunction
or nephrotoxique agents or B-lactam , vanco, clinda allergy)
H. influenza
type B eliminated by vaccin
non typeable chronic lung disease
chronic obstruction
if resistance: cephalo 2 or 3G
if allergy: fluoroquinolone
cephalo 2 or 3 G
Streptococcus A
not frequent BUT may cause severe necrotizing pneumonia
penicillin V
penicillin G
-toxin-mediated disease:
B-lactam + clindamycin
afebrile LRTI in very young infants 2–12 weeks of age, born to
mothers with genital infection
Chlamydia trachomatis
atypical pneumonia in school-aged children and adolescent
Chlamydia pneumoniae
macrolide: azithromycin
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

Clinical Judgment

Laboratory Results

Imaging Results

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.

discharge criteria
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
and hospitalization
caused by RSV
Resistance to Antimicrobials

Follow up
slow progressing developing over 3 to 5 days
low grade fever
sore throat
Management decision
Anti infective treatment
Adjunctive surgical therapy

Microbiologic Testing
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

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