Guidelines/Guidance/CAP/ Hospitalized Child. PHM Boot Camp 2014 Jay Tureen, MD June 19, 2014

Transcription

1 Guidelines/Guidance/CAP/ Hospitalized Child PHM Boot Camp 2014 Jay Tureen, MD June 19, 2014

2 CAP in Children: Epi Greatest cause of death in children worldwide Estimated > 2 M deaths in children In developed countries, 3 4/100 children < 5y Hospitalizations using ICD 9: 200/100,000 Infants < 1y: 912/100,000 Adolescents y: 62/100,000

3 CAP: Etiology Viral most common, especially < 2 y/o RSV, adenovirus, bocavirus, influenza A/B, parainfluenza virus, metapneumovirus, coronavirus, rhinovirus S. pneumoniae, S. aureus, S. pyogenes Atypical pathogens: M. pneumoniae, C. pneumoniae, C. trachomatis

4 CAP: Clinical Questions Diagnostic testing Site of care decisions Anti infective rx Adjunctive surgical/fibrinolysis for empyema Prevention Discharge criteria

5 CAP: Diagnostic testing microbiology Bacteria Blood cultures not recommended for outpts (1 2 %) ; +/ for inpts, mod to severe PNA ( %; 11.4% in one study) or complicated ( %) Sputum: yes if can produce; Tracheal aspirate/bal for intubated patients Urine antigen: no; not correlated with sputum cx in children and + may reflect colonization, not S.p. PNA

6 CAP: Diagnostic testing microbiology (2) Viral testing Yes, but recognize limitations of poor sensitivity. DFA 50 80% for pathogens; PCR 80 90% Advantage is ability to limit antibiotics if alternative dx, but recognize up to 10% have both a resp viral pathogen and bacterium Atypical organisms For M. pneumoniae, poor specificity of + cold agglutinins and delay in results of antibody testing; complement fixation rarely timely

7 CAP: Ancillary Diagnostic testing CBC +/ Inflammatory markers +/ acutely; value for followup of complicated cases CXR /+ (usually have had as outpt); f/u imaging not usually needed unless Parapneumonic effusion present or suspected U/S preferred over CT as initial additional imaging

8 CAP: Clinical Questions Diagnostic testing Site of care decisions Anti infective rx Adjunctive surgical/fibrinolysis for empyema Prevention Discharge criteria

9 CAP: Dx criteria World Health Organization definition Mild: tachypnea, fever Moderate: tachypnea, fever, retractions Severe: tachypnea, fever, retractions, cyanosis or inability to eat

10 CAP: Site of Care Mild: Outpatient management Moderate: Hospitalization Hypoxemia (< 90% O2 sat) on RA, resp distress*, age < 3 mos, +/ 3 6 mos with suspected bacterial CAP, suspected S. aureus, home considerations Severe: Intensive Care Hypoxemia with supplemental O2, BP or HR abnl. AMS, need for PP vent

11 CAP: Clinical Questions Diagnostic testing Site of care decisions Anti infective rx Adjunctive surgical/fibrinolysis for empyema Prevention Discharge criteria

12 CAP: Rx Lobar/no prior Rx Age Organisms Inpatient Discharge > 2 mo S. pneumoniae H. influenzae M. catarrhalis S. aureus Lobar/prior Rx > 2 mo S. pneumoniae H. influenzae M. catarrhalis S. aureus Complicated > 2 mo S. pneumoniae S. aureus Atypical > 5 yr Mycoplasma Chlamydia 1 st line: Amp Alternative: Cefttriaxone 1 st line: Ceftriaxone Alternative: Amp Sulbactam Vanco + Ceftraixone or Clindamycin Azithromycin or levofloxacin Amoxicillin Amoxicillinclavulanate or Cefdinir Based on culture and sensitivity Continue x 5d Influenza Any age Flu A, Flu B Oseltamivir Continue x 5d

13 CAP: Clinical Questions Diagnostic testing Site of care decisions Anti infective rx Parapneumonic effusions and Empyema/VATS/fibrinolysis Discharge criteria

14 CAP: Parapneumonic Effusions 2 12% Small (1 cm) can be managed conservatively with antibiotics alone Moderate (< ½ of hemithorax) 27% required drainage Large (> ½ hemithorax) usually require drainage Empyema fibrinolytic or VATS + drainage + antibiotics

15 PNA: PPE Empyema 3 Phases Exudative Free flowing, cytochemical changes minimal (normal glucose, ph, cell count low) Fibrinopurulent +/ loculated, U/S shows fibrin stranding, septations Light Criteria: ph < 7.2, glucose, 40, LDH > 1000, + GM stain, + U/S Organized, Loculated, pleural peel

16 PNA with PPE: Suggested approach Dx early Establish free flowing and differentiate exudative vs fibrinopurulent Diagnostic thoracentesis Pleural fluid analysis combined with U/S

17 Empyema: Med vs Surg When empyema diagnosed, earlier rx leads to shortened hospital stay. Intrapleural fibrinolytics (tpa, urokinase) + antibiotics Video assisted thorascopic surgery (VATS) + antibiotics Can be primary rx or follow fibrinolysis if rx fails (17%)

18 Empyema: VATS vs Fibrinolytic Rx St. Peter 2009 Sonappa 2006 Kurt 2006 VATS/CT + fibrinolytic (# pts) 18/18 30/30 10/8 LOS (days) 6.9/6.8 6/6 5.8/13/2 Cost ($) 11,700/ / ,714/21,947 Fever after intervention (days) 3.1/ / /6.2

19 Empyema: Approach

20 CAP: Clinical Questions Diagnostic testing Site of care decisions Anti infective rx Adjunctive surgical/fibrinolysis for empyema Prevention Discharge criteria

21 PNA: Discharge criteria Recommendations made by expert opinion, often with little or no clinical trial evidence No substantially incr WOB, incr RR, incr HR Overall clinical improvement >24h (decreased WOB, activity, appetite) Pulse ox >90% for >24h If CT placed, no air leak > 24h Able to tolerate home PO ABX regimen

22 References The management of Community Acquired Pneumonia in Infants and Children Older than 3 months of Age: Clinical Practice Guidelines by the PIDS and the IDSA. Bradley JS et al; Clin Infect Dis, 8/2011, Epub. Time to clinical stability in patients hospitalized with community acquired pneumonia; implications for practice guidelines. Halm EA et al. JAMA,1998:279:1452. Video Assisted Thoracoscopic Surgery vs Chest Drain with Fibrinolytics for the treatment of Pleural Empyema n Children: A systematic review of Randomized Controlled Trials. Mahant S et al. Arch Pediatr Adol Med., 2010; 164: Influenza associated pediatric mortality in the United States: increase of Staphylococcus aureus co infection. Finelli L et al. Pediatrics 2008; 122: The diagnosis and management of empyema in children: a comprehensive reviwe from the APSA Outcomes and Clinical Trials Committee Islam S et al. J Pediatr Surg 2012; 47: Decline in invasive pneumococcal disease after the introduction of proteinpolysaccharide conjugate vaccine. Whitney CG et al. N. Engl J. Med 2003; 348: