CAP

Question 1

Risk factors for pediatric CAP

Answer 1

Recent history of URTI- viral respiratory prodrome
Lower socioeconomic status
Crowded living environment
Exposure to cigarette smoking
Comorbidities

Question 2

Comorbidities for CAP

Answer 2

ASTHMA
Bronchopulmonary dysplasia
CF
Sickle cell disease
Congenital heart disease

Question 3

Bacterial causes of CAP

Answer 3

Strep. pneumoniae- MOST COMMON PATHOGEN
H. influenzae
S. aureus
Group A Strep

Atypical (3-23%, mostly in older children):
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella (rare)

Question 4

Viral causes of CAP

Answer 4

Influenza virus
RSV
PIV
Adenovirus
Rhinovirus

Question 5

Viral agents are more common in what age group?

Answer 5

<2 years old, makes up ~80% of CAP cases in this population

Question 6

Best predictor of cause via identification of likely pathogen and exposure

Answer 6

AGE

Question 7

Suspected CAP pathogens: birth-20 days

Answer 7

GBS
Gram-negative enteric bacteria
L. monocytogenes

Question 8

Suspected CAP pathogens: 3 weeks-3 months

Answer 8

S. pneumoniae
S. aureus
RSV
PIV
B. pertussis
C. trachomatis

Question 9

Suspected CAP pathogens: 4 months-4 years

Answer 9

S. pneumoniae
H. influenzae
M. pneumoniae
Viruses
M. tuberculosis

Question 10

Suspected pathogens: 5 years-15 years

Answer 10

S. pneumoniae
H. influenzae
M. pneumoniae
C. pneumoniae
Influenza A or B, adenovirus
M. tuberculosis

Question 11

Outpatient CAP: <5 years old, presumed bacterial pneumonia, 1st-line option

Answer 11

Amoxicillin 90mg/kg/d PO div. BID or TID, MDD 3-4g/day

Question 12

Reason a high dose of amoxicillin is used

Answer 12

Overcome S. pneumonia’s mechanism of resistance (production of PCN-binding protein)

Question 13

Outpatient CAP: <5 years old, presumed bacterial pneumonia, alternative

Answer 13

Amox/clav 90mg/kg/day div. BID or TID, MDD= 875-1000mg/dose

Question 14

What is the clavulanate there to do in amox/clav?

Answer 14

Cover the beta-lactamase producing organisms

Question 15

ES formulations of amox/clav do what?

Answer 15

Increase the amoxicillin component without increasing the clav. component, which may increase diarrhea

Question 16

Outpatient CAP: <5 years old, presumed atypical pneumonia, 1st-line option

Answer 16

Azithromycin 10mg/kg/day PO on day 1 (MDD=500mg), then Azithromycin 5mg/kg/day PO on days 2-5 (MDD=250mg)

Question 17

Reason azithromycin course is only 5 days

Answer 17

Long half-life with post-ABX effect

Question 18

Outpatient CAP: <5 years old, presumed atypical pneumonia, alternative

Answer 18

Clarithromycin 15mg/kg/day in 2 doses x7-14 days OR erythromycin 40mg/kg/day in 4 doses

Question 19

Outpatient CAP: <5 years old, presumed influenza pneumonia, 1st-line option

Answer 19

oseltamivir x5 days, but only effective if initiated within 48 hours of symptoms

Question 20

Outpatient CAP: ≥5 years old, presumed bacterial pneumonia, 1st-line option

Answer 20

Amoxicillin 90mg/kg/day (like in patients <5 years old)

Can add macrolide to beta-lactam ABX for empiric therapy if there’s not enough evidence to distinguish between this and atypical CAP

Question 21

Outpatient CAP: ≥5 years old, presumed bacterial pneumonia, alternate

Answer 21

Amox/clav (like in patients <5 years old)

Question 22

Outpatient CAP: ≥5 years old, presumed atypical pneumonia, 1st-line option

Answer 22

Amox/clav, like in patients <5

Question 23

Outpatient CAP: ≥5 years old, presumed atypical pneumonia, alternates

Answer 23

erythromycin, doxycycline in kids >7

Question 24

Outpatient CAP: ≥5 years old, presumed influenza pneumonia

Answer 24

oseltamivir or zanamivir for children ≥7

Question 25

Inpatient CAP, fully immunized, MIC ≤2: presumed bacterial pneumonia

Answer 25

Ampicillin (or PCN G) 150-200mg/kg/day IV div. q6h, MDD=2g/dose ^empiric dose or S. pneumonia, H. influenzae Group A Strep: 200mg/kg/day IV div. q6h S. pneumoniae when PCN MIC is ≥4: 300-400mg/kg/day IV div q6h, MDD= 12g/day

Question 26

Ampicillin ADEs

Answer 26

diarrhea, rash, eosinophilia

Question 27

Ampicillin alternatives

Answer 27

ceftriaxone, cefotaxime, adding vanco or clindamycin for suspected CA-MRSA

Question 28

Inpatient CAP, fully immunized, MIC ≤2: presumed atypical pneumonia

Answer 28

Azithromycin (in addition to beta-lactam if diagnosis of atypical pneumonia is in doubt)

Question 29

Azithromycin alternatives

Answer 29

clarithromycin or erythromycin; doxycycline for children >7 years old; levofloxacin for children who have reached growth maturity or can't tolerate macrolides

Question 30

Inpatient CAP, fully immunized, MIC ≤2: presumed influenza pneumonia

Answer 30

oseltamivir or zanamivir for children ≥7 years old

Question 31

Inpatient CAP: not fully immunized, MIC ≥2: presumed bacterial pneumonia

Answer 31

Ceftriaxone 50mg/kg/dose q24h, or cefotaxime; adding vanco or clindamycin for suspected CA-MRSA

Question 32

CTX ADEs

Answer 32

diarrhea, rash, eosinophilia, pain at injection site with IM formulation

Question 33

Reason CTX is used in un-immunized children

Answer 33

Concern for H. influenzae beta-lactamase producing

Question 34

Alternatives to CTX/cefotaxime

Answer 34

levofloxacin, add vanco or clindamycin

Question 35

Inpatient CAP: not fully immunized, MIC ≥2: presumed atypical pneumonia

Answer 35

Same treatment as fully immunized Azithromycin

Question 36

Inpatient CAP: not fully immunized, MIC ≥2: presumed influenza pneumonia

Answer 36

same as fully immunized

Question 37

CAP treatment: what to do with a non-serious allergy

Answer 37

Trial under medical supervision Use of cephalosporins: cefpodoxime, cefprozil, cefuroxime

Question 38

CAP treatment: anaphylactic allergy

Answer 38

Respiratory fluoroquinolone Linezolid Macrolide Clindamycin Bactrim

Question 39

Duration of CAP treatment

Answer 39

10 days total of treatment, but CA-MRSA may require more 5 days only for azithromycin and oseltamivir

Question 40

When to discharge a patient with CAP

Answer 40

Clinical improvement, increased O2 sat, baseline mental status, can take PO meds

Question 41

CAP: vaccine prevention

Answer 41

PCV13, Hib, DTaP, influenza, RSV in high-risk infants

Question 42

Hallmark signs and symptoms of CAP

Answer 42

Fever, cough

Question 43

Other signs/symptoms of CAP

Answer 43

Pleuritic chest pain d/t inflammation Purulent expectorant Tachypnea for age (Infants: >70 breaths/min, children: >50 breaths/min) Respiratory distress- severe CAP, severity increases as disease progresses Retractions (suprasternal, intercostal, subcostal) Grunting Nasal flaring Apnea Wheezing Crackles/rales Pulse ox <90% on room air Altered mental status

Question 44

Gold standard for diagnosing CAP

Answer 44

chest x-ray

Question 45

How to distinguish viral vs. bacterial pneumonia

Answer 45

Viral on a chest-x-ray is general haziness Bacterial on a chest x-ray is consolidated in a specific area

Question 46

Who should be hospitalized for CAP?

Answer 46

Moderate-severe CAP Significant respiratory distress: SPO2 <90% All infants <3 months Infants <6 months with suspected bacterial CAP Suspicion/documentation of community-acquired MRSA infections Concern for caretaker capabilities