Flashcards in Uncomplicated pneumonia in healthy Canadian children and youth: Practice points for management Deck (23):
By what percentage has the pneumococcal conjugate vaccine decreased radiologically proven pneumonia admission rates in children <5yo?
What is pneumonia?
An acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen.
Uncomplicated pneumonia maybe accompanied by small parapneumonia effusions but cannot have empyema, lung abscess or necrotic lung
What is the etiology of pneumonia?
Viruses (e.g. RSV, influenza, parainflunza, HMPV) in infants and preschoolers
Haemophilus influenzae type b (rare since vaccine)
GAS (less common)
Staphylococcus aureus (less common)
What are symptoms of pneumonia?
3. Difficulty breathing
4. Poor feeeding
6. Decreased interest in normal activities
7. Chest or abdominal pain
9. Malaise and headache 7-10d before fever and cough (Mycoplasma)
10. Diffuse myalgias, fever, cough, sore throat prior (influenza)
What are signs of pneumonia?
2. Tachypnea (<2mo >60 2-12mo >50 1-5yo >40 >5yo >30)
3. Work of breathing
6. Dullness to percussion
7. Increased tactile fremitus
8. Reduced normal vesicular breath sounds
9. Increased bronchial breath sounds
What are the typical patterns of pneumonia on chest imaging?
Lobar consolidation with air bronchograms, nodular opacities = bacterial
Poorly defined patches of infiltrates or atelectasis = viral
Bilateral focal or interstitial infilitrates more extensive = atypical (Mycoplasma, Chlamydia)
When is US useful?
Diagnosis of complicated pneumonia
What investigations can be done to determine etiology?
1. Sputum C&S >10yo
2. Nasopharyngeal viral testing usu. not indicated
3, NP specimen for mycoplasma
What bloodwork is indicated for children who are hospitalized with pneumonia?
1. CBC + diff
2. Blood culture
What are some general indications for pneumonia?
1. Inadequate oral intake
2. Intolerant of oral therapy
3. Severe illness
4. Respiratory compromise
5. Complicated pneumonia
6. Lower threshold for <6mo
What is the treatment for pneumonia where influenza is detected?
Neuraminidase inhibitors e.g. oseltamivir, zanamivir
What is the treatment for other viral pneumonias?
Manage with supportive care (O2, hydration)
What is the first line therapy for outpatient treatment of community acquired pneumonia?
Amoxicillin 40-90mg/kg/day PO TID (max 4000mg/day) x 5d
What is the first line therapy for inpatient treatment of community acquired pneumonia?
Ampicillin 200mg/kg/day IV q6h (max 12g/day) x 7-10d
What is the first line therapy for children presenting with respiratory failure or septic shock associated with pneumonia?
Third generation cephalosporin x 7-10d
Ceftriaxone 50-100mg/kg/day IV q12-24h (max 4g/day)
What organisms do third generation cephalosporins provide better coverage for than ampicillin?
High level penicillin resistant pneumococcas
What is the first line empiric coverage for children with rapidly progressing multilobar disease or pneumatoceles?
Ceftriaxone/Cefotaxime and Vancomycin IV x 7-10d
- discontinue vanco if culture negative
What is the coverage for atypical pneumonia?
Azithromycin 10mg/kg on day 1, then 5mg/kg day 2-5 (max 500mg/day) PO/IV
Resistance consider Doxycycline in >8yo
What is the recommended duration of therapy?
Hospitalized uncomplicated 7-10d
Empyema or abscess 2-4w
What is the recommended therapy for penicillin allergic patients?
If patient experienced non-urticarial rash then give ampicillin/amoxicillin
If patient mild reaction give third generation cephalosporin
If rapid onset of urticaria, angioedema, hypotension, bronchospasm then observe for 30min with accessible epinephrine after first dose of cephalosporin
Clarithromycin or azithromycin are alternative but high resistance rates
If SJS or TEN then give another class of drugs
When should clinical improvement occur in uncomplicated pneumonia?
Within 48h of antibiotics
What are some reasons for lack of clinical resolution?
1. Complications e.g. empyema, abscess
2. Foreign body aspiration
3. Reactive airway disease with atelectasis
4. Congenital pulmonary anomaly
6. Unrecognized immunodeficiency