The McMaster at night Pediatric Curriculum

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Alexandrina Sutton
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1 The McMaster at night Pediatric Curriculum Community Acquired Pneumonia Based on CPS Practice Point Pneumonia in healthy Canadian children and youth and the British Thoracic Society Guidelines on CAP

2 Objectives To describe the clinical signs and symptoms of communityassociated pneumonia (CAP) To outline appropriate diagnostic investigations for CAP based current evidence and guidelines To discuss the most responsible microorganisms for CAP, and develop an approach to empiric antimicrobial therapy in the outpatient and inpatient setting To outline management, including reasons for admission, for CAP based on clinical severity To discuss complications of CAP

3 Background Acute inflammation of parenchyma of LRT caused by microbial pathogen CAP = clinical signs/symptoms of pneumonia in previously healthy children due to infection acquired outside of hospital In developed countries, often verified by CXR Common! One in 20 children <5 years old will contract pneumonia each year Single largest cause of death worldwide as per WHO

4 Background This presentation does not address persistent (chronic) pneumonia syndromes, aspiration pneumonia, or recurrent pneumonias, or those associated with chronic medical problems such as immunodeficiency

5 The Case 4 year old Lila presents to the ER with a three day history of cough. She has been persistently febrile over the past 1 day. In triage, her vitals are: T39 C (oral), HR 130, RR40, SpO2 94% on RA

6 History What would you ask?

7 History Constitutional Level of activity and energy Fever* Chills and rigours Respiratory symptoms Shortness of breath Cough Work of breathing Chest pain Feeding Poor feeding and vomiting common Always assess for level of hydration (i.e. ask about amount of voids/wet diapers)! Abdominal pain Common in lower lobe pneumonias, can mimic appendicitis

8 Physical Exam What would you look for?

9 Physical Exam Vitals Tachypnea** Highest sensitivity + specificity for radiographically proven pneumonia Oxygen saturation and need for supplemental O 2

10 Physical Exam Inspection Level of activity and mental status Work of breathing Level of hydration Respiratory ê Vesicular breath sounds é Bronchial breath sounds Dullness to percussion Crackles All of the above are specific, NOT sensitive Absence might help you rule out pneumonia! **Wheezing is unlikely in pneumonia; indicates atelectasis and mucus plugging from asthma or bronchiolitis

11 Physical Exam Cardiovascular Assess perfusion and cardiovascular status Look for signs of sepsis! Ask yourself: do they look toxic or unwell?

12 Physical Exam The Bottom Line Consider pneumonia in any child with persistent or repetitive fever >38.5 C with tachypnea or retractions

13 Test your Knowledge What is the most common cause of pneumonia in infants and preschool children? A. Streptococcus pneumoniae B. Mycoplasma pneumoniae C. Viruses D. Haemophilus influenzae non-typeable

14 Test your Knowledge What is the most common cause of pneumonia in infants and preschool children? A. Streptococcus pneumoniae B. Mycoplasma pneumoniae C. Viruses D. Haemophilus influenzae non-typeable

15 The Answer In preschool children, viruses (i.e. RSV, influenza, parainfluenza) that circulate in winter are the most common cause Viruses as the sole cause of pneumonia are less common in older children, except for influenza Name some bacterial causes!?

16 Bacterial Etiologies Streptococcus pneumoniae** (most common) Group A strep Staphylococcus aureus Haemophilus influenza non-typeable Mycoplasma pneumoniae Seen in children >3-4 years of age Chlamydophila pneumoniae There is no reliable way of clinically distinguishing between viral and bacterial etiologies

17 Workup What would you order?

18 Workup Chest X-ray Pneumonia is over-diagnosed in the absence of radiological confirmation. It is encouraged whenever possible to support the clinical diagnosis (CPS Statement) BTS suggests that CXR should not be routinely done in a child with clinical signs and symptoms of pneumonia who is not admitted to hospital Obtain PA view Sensitivity & specificity 100% of frontal x-ray alone Lateral view is not routinely performed in CAP (BTS guideline)

19 Workup Lobar pneumonia (S pneumoniae) Viral pneumonia Images from: h8p://emedicine.medscape.com/ar<cle/ overview

Workup Atypical pneumonia Patchy re<culnodular

org/ar<cles/atypical- pneumonia h8p://osp.mans.

20 Workup Atypical pneumonia Patchy re<culnodular opaci<es + atelectasis More extensive than clinical ﬁndings suggest Staph aureus pneumonia Pneumatocele Images from: h8p://radiopaedia.org/ar<cles/atypical- pneumonia h8p://osp.mans.edu.eg/tmahdy/students/x- Ray/CHEST/pages/STAPH%20PNEUMONIA2.htm

21 Workup Microbiological samples NPS for viruses only if admitted Assists with cohorting patients Most children cannot provide a sputum sample If available, send for Gram staining & culture Pursue additional invasive testing if child fails to improve or worsens on therapy Blood culture <5 10% positive in pneumonia, obtain in admitted patients

22 Workup CBC Higher WBC in bacterial pneumonia versus viral/atypical Indicated only in admitted patients Acute Phase Reactants i.e. CRP Not helpful in distinguishing viral versus bacterial causes Not useful for management of uncomplicated CAP

23 Management Most children can be managed as outpatients Indications for admission: Unable to eat or drink, vomiting Inability to comply with oral therapy Dehydration Sepsis Hypotension SpO2<92% Increased WOB (chest retractions) Any evidence of empyema or abscess There should be a low threshold for admitting children <6 months because it can be difficult for caregivers to recognize deterioration

24 Test Your Knowledge In a 3 year old child with CAP who does not require oxygen or admission, what is the suggested first line antimicrobial treatment? A. Cefuroxime po 150 mg/g/day B. Azithromycin 10 mg/kg x 1 day then 5 mg/kg/day x 2 5 days C. Amoxicillin mg/kg/day D. Amoxicillin mg/kg/day

25 Test Your Knowledge In a 3 year old child with CAP who does not require oxygen or admission, what is the suggested first line antimicrobial treatment? A. Cefuroxime po 150 mg/g/day B. Azithromycin 10 mg/kg x 1 day then 5 mg/kg/day x 2 5 days C. Amoxicillin mg/kg/day D. Amoxicillin mg/kg/day

26 Antimicrobial Therapy Viruses: supportive care Bacterial CAP: Non-severe* pneumonia: high dose amoxicillin or ampicillin IV Non-severe pneumonia with features of atypical pneumonia: clarithromycin or azithromycin po *Non-severe pneumonia = does not require hospital admission or requires admission and requires minimal supplemental O2 (<30%) and is in minimal respiratory distress

27 Antimicrobial Therapy Bacterial CAP: Severe* pneumonia: Ceftriaxone IM/IV or Cefotaxime IV plus clarithromycin PO or azithromycin PO/IV *Severe pneumonia = requires significant supplemental oxygen, patient in moderate respiratory distress, or may require ICU CTX offers better coverage for penicillin-resistant pneumococcus Clarithromycin/azithromycin do NOT always cover pneumococcus but covers atypicals well

28 Antimicrobial Therapy Penicillin-allergic patients: Non-severe pneumonia: Clarithromycin PO or azithromycin PO/IV Severe pneumonia: if not IgE mediated allergy, cephalosporins (i.e. cefuroxime) can be used If IgE-mediated, consult with ID

29 Complications Pleural effusion or empyema Consider if patient still febrile after >48 h antibiotics Assess with chest U/S If moderate or large effusion, consider pleural tap (with surgical & ID consultation!) Ceftriaxone/cefotaxime + azithromycin +/- cloxacillin Requires longer duration of therapy as determined by clinical course Abscess Assess with CT scan

30 Further Management Repeat CXR Not recommended in uncomplicated CAP Children with lung abscess or pleural effusion require repeat CXRs and follow-up until complete resolution

31 Summary Community-acquired pneumonia is common in healthy children Consider in any child with tachypnea & fever CXR should be used to confirm diagnosis Viruses are the most common cause, and Strep pneumoniae is the most common bacterial cause Investigate with NPS, blood culture, CBC only if admitted High dose amoxicillin for non-severe pneumonia, and third generation cephalosporin + macrolide for severe pneumonia Repeat CXRs are generally not necessary to follow-up for resolution (clinical exam is enough!)

32 Fin

33 References Le Saux N, Robinson JL. Pneumonia in healthy Canadian children and youth: Practice points for management. (2011). Paediatr Child Health; 16(7): Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, Thomson A, on behalf of the British Thoracic Society Standards of Care Committee. British Thoracic Society Guidelines for management of communityacquired pneumonia: update (2011). Thorax; 66(2): ii1-ii23 Gereige RS and Laufer PL. Pneumonia. (2013). Pediatrics in Review. 34(10):

Community Acquired Pneumonia. Abdullah Alharbi, MD, FCCP

Community Acquired Pneumonia. Abdullah Alharbi, MD, FCCP Community Acquired Pneumonia Abdullah Alharbi, MD, FCCP A 68 y/ male presented to the ED with SOB and productive coughing for 2 days. Reports poor oral intake since onset due to nausea and intermittent