Turkish Thoracic Society

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1 Türk Toraks Derneği Turkish Thoracic Society Pocket Books Series Diagnosis and Treatment of Community Acquired Pneumonia in Children Short Version (Handbook) in English

2 This report was prepared and written by Emine Kocabas, Deniz Dogru Ersoz, Fazilet Karakoc, Gonul Tanir, Ali Bulent Cengiz, Deniz Gur, Ayten Pamukcu Uyan, Nermin Guler, Mithat Haliloglu, Derya Alabaz. The full text of the report is published in Turkish in Turkish Thoracic Journal 2009;10 (Supplement 3): 6-9 Türk Toraks Derneği Turan Güneş Boulevard, No: 175/19 Oran-Ankara-Turkey Telephone Number: Fax Number: address: Website:

3 Pneumonia is a clinical entity of fever, respiratory symptoms and physical examination and/or chest radiography findings of parenchymal involvement. - In children, it is difficult to identify pathogens of pneumonia. With available methods, the pathogens can be determined only in 24-85% of cases - Pathogens vary according to groups. - History can assist to determine the etiology (Age, season, vaccination history, the frequency of diseases in the community). - If pre-school children have accompanying wheezing, the disease is unlikely to be bacterial pneumonia. - The main findings of physical examination consist of fever, tachypnea, respiratory distress symptoms (chest retractions and cyanosis) and the presence of abnormal breath sounds. - In primary health care facilities, diagnosis is often determined by history and physical examination findings. - Except for cases of severe and very severe pneumonia, radiographic examination is not necessary. - Radiological follow-up examination should be considered for patients with evidence of respiratory distress, lobar collapse and round pneumonia. - Oxygen saturation should be determined in all children with pneumonia who are hospitalized. - Acute phase reactants (CRP, sedimentation rate, leukocyte count, etc.) are not useful to distinguish bacterial and viral pneumonia and should not be used as a routine. - Blood culture should be taken before antibiotic treatment from all hospitalized children who have febrile and severe disease. - If the patient has a history of contact with pulmonary tuberculosis and/or has suspected pulmonary tuberculosis, tuberculin skin test should be applied. The main objectives of treatment are 1. Ensuring oxygenation (If on room air, transcutaneous oxygen saturation by pulse oxymetry is %92, oxygen therapy should be applied) 2. Cleaning the microorganism - Mucolytic, expectorant and decongestant nts are not recommended. - In uncomplicated pneumonia, the duration of treatment is 7-10 days or at least 5 days after the fever resolves. - The general principles of disease prevention are training, emphasizing the importance of breastfeeding, healthy nutrition, prevention of malnutrition, vitamin and mineral support, hygiene, hand-washing training, the prevention of cigarette exposure, correction of crowded living conditions. - Routine immunization with BCG, measles, pertussis, pneumococcal, HIB conjugate vaccine and specific immunization in high-risk groups (pneumococcal polysaccharide vaccine, influenza vaccine) are the basic principles of prevention. 4 5

4 Table 1. Frequent factors as per groups in Community- Acquired Pneumonia (CAP) in children Birth 3 weeks Group B streptococcus, Gram negative bacteria, Listeria monocytogenes, S. aureus, CMV, HSV 3 weeks 3 months S. pneumoniae, H. influenzae, C. trachomatis, Bordatella pertussis, Moraxella catarrhatis, S. aureus, Adenovirus, Influenza virus, PIV, RSV 4 months 5 years of Respiratory viruses, S. pneumoniae, H. influenzae, C. pneumoniae, M. pneumoniae, S. aureus, S. pyogenes, M. tuberclosis, 5 years of 9 years of S. pneumoniae, M. pneumoniae, C. pneumoniae, Respiratory viruses, M. tuberclosis, 10 years of M. pneumoniae, C. pneumoniae, S. pneumoniae, Respiratory viruses, M. tuberclosis, Table 2. Respiration Rates and Tachypnea Criteria As Per Age (WHO) Age Tachypnea Normal Respiration Rate Limit (breathing rate/minute) (breath/minute) 0-2 months months years of years of Table 3. Clinical Classification in Pneumonia Pneumonia Severe Pneumonia Very Severe Pneumonia State of Consciousness Normal Propensity to sleep is possible Lethargy / confusion / non-response to the painful stimulus Groaning None Possible Exist Color Normal Breath Cyanotic Breathing Rate Tachypneic Tachypneic Tachypneic Apneic Chest contraction None Exist Exist Nutrition Normal Decrease in oral intake nourished Cannot be Dehydration None Possible Exist (shock findings) Table 4. Radiological Evaluation Indications in Pneumonia Diagnosis Uncertainty in clinical findings, Severe and very severe pneumonia findings, Development of the complication (pleural effusion, etc.), Non-response to standard outpatient treatment and prolonged clinical course, If the patient is below 5 years of, has > 39 C fever, the focus of which is not certain, and whose white blood cell count is above /mm 3, Presence of recurrence pneumonia, Lung TB doubt, Doubt of foreign body aspiration, In the exclusion of other causes which cause to respiratory distress, radiological evaluation should be made. 6 7

5 Table 5. Antibiotic Treatment in Community-Acquired Pneumonia Age OUTPATIENT TREATMENT IN-PATIENT TREATMENT 0 2 months To hospitalize 3 weeks 3 months 2 months 5 years of > 5 years of Pneumonia Severe Pneumonia ** (for C. trachomatis) Oral macrolide (azithromycin, clarithromycin, erythromycin) *** Penicillin or Amoxicillin *** Penicillin / Amoxicillin and/or Macrolide Ampicilline IV + Aminoglycoside Cefotaxime/Ceftriaxone *** Penicillin G / Ampicilline-sulbactam/ Amoxicillin-clavulanate/ Sefurocycim # Penicillin G / Ampicilline and/or Macrolide * Very Severe Pneumonia Ampicilline IV + Cefotaxime ± Aminoglycoside Cefotaxime/ Ceftriaxone ± Macrolide (for C. trachomatis) Cefotaxime/ Ceftriaxone # Cefotaxime/ Ceftriaxone ± Macrolide * If the patient is in toxic manifestation and sepsis findings are available and/or if pleural empyema, pneumatocele or pyopneumothorax are present ** If afebrile, hypoxemia and toxicity findings are nonexistent, but the patient is coughing as if he was choking *** If probable factor is S.pneumoniae, if lobar consolidation has been detected in the chest radiography In very severe cases followed-up in intensive care unit, add Vancomycin or Linezolid in case of betalactam resistance in S.pneumoniae strains or in case of treatment insufficiency depending on MRSA # Add macrolide if response to treatment is not good Table 6. Hospitalization Criteria Every babies received pneumonia diagnosis when they are below 2 months Children received pneumonia diagnosis when they are above 2 months Presence of hypoxemia (SpO 2 92 %) Respiratory distress findings Presence of tachypnea (BR > 70/min, infant; BR > 50/min, child) Deterioration of consciousness level Oral feeding is impossible Dehydration / vomiting substantially Toxic manifestation Non-response to oral antibiotics (clinical improvement during outpatient treatment) Multi-lobar involvement in chest radiography, wide atelectasis, abscess, pneumatocele, pleural effusion Rapid radiological improvement Disobedience to treatment (parents disobeying to treatment) Social indication (inadequacy of home care conditions provided by the family) 8 9

6 Diagnosis and Treatment Approach to the Child Considered Getting Community-Acquired Pneumonia Clinical Findings Leading to Consider CAP If contact history exists, perform tuberculin skin test EVALUATE Tachypnea Fever 38 C O2 saturation Inclusion of vibrissa in respiration Abnormal auscultation findings Increase in respiratory labor Not pneumonia Uncomplicated bacterial pneumonia Suspicious clinical findings or < 5 years of, high fever of unknown origin CAP Doubt of complication or Not response to antibiotics Perform white blood cell count and peripheral smear: If WBC is > /mm3, consider a bacterial cause Chest radiography Antibiotic Treatment for 7-10 days: < 5 years of, amoxicillin for S.pneumonia 5 years of : Mycopasma, Chlamydiae, macrolide for S.pneumonia in outpatient treatment or Yes No Bacterial CAP Complication doubt for other antibiotic alternatives, see Table 11 CAP Consensus Report No Follow-up without antibiotics Reevaluate the patient if findings are noncompliant Yes Follow-up according to the clinical table If necessary, arrange antibiotic treatment Treat complication Evaluate the patient s condition by consultation with infectious disease specialist and/or chest disease specialist 10 11

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