Pediatric Pneumonia

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Pediatric Pneumonia

• Pisespong Patamasucon,M.D
• Pediatric Infectious Diseases

2
Pediatric Pneumonia

• Serious human illness since history ever recorded
  Egyptian mummies( 1250 to 1000 BC ) also had
  lungs compatible with Pneumococcal pneumonia.

3
Important Landmarks-

• Approval of a heptavalent conjugate
  polysaccharide vaccine ( Prevnar, Wyeth-Lederle
  vaccines) by FDA in Feb,2000 in USA.
• A 14 valent Pneumococcal polysaccharides
  vaccine in 1977 and a 23- valent vaccine in 1983
  
• Approval of a conjugate polysaccharide vaccine
  for H.influenzae Type B in October 1990.

4
Microbiology

• Dr.Robert Austrian estimates that bacteria are
  response for 1/10 to 1/3 of acute pneumonia
• Finish study using antigen detection and antibody
  assays found bacteria in 45
• Lung punctures in developing countries found
  S.pneumonia, H.influnenzae and S.aureus as the
  leading pathogens.

5
Attack Rates

• Overall annual rate of pneumonia 12/1000 pop per
  yr.
• Highest at 0-4 yr age group 12-15/1000 pop per
  yr.

Etiology Frequency Frequency Frequency
Etiology 0-3 mo. 4 mo.- 5 yr 6 16 yr
-virus
RSV
Hmpneumovirus ?
Parainfluenzae
Type


6
Etiology Frequency Frequency Frequency
Etiology 0 -3 mo. 4 mo.- 5 yr 6 16 yr
virus
Influenzae
Type A
Type B
Adenovirus
Rhinovirus
HIV
VZV
CMV
Mycoplasma -
Ch.pneumonia -
Ch.trachomatis - -
P.carinii
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Age(years)
Incidence(cases/100,0000) of pneumococcal disease
by age group,Goteborg,Sweden,1970-1980.
8
Age(Years)
Incidence of lower respiratory disease by age
group,chapel Hill Corolina.
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Leading Etiologic Agents of Pneumonia Infants and
Children
Age Bacterial pathogens Viral Pathogens Other
Neonate Group B Streptocaccus Gram-negative bacilli( E.coli,K.pneumoniae,Proteus spp.,others) S.aureus RSV Herpes simplex virus CMV Adenovirus
1-3 mo. S.pneumoniae H.Infuenzae type b RSV C.trachomatis
4 mo.-5 yrs S.pneumoniae H.Influenzae type b Parainflenza virus1 and 3, Adenovirus Influenza viruses A and B
5 yrs and older S.pneumoniae M.pneumoniae C.pneumoniae
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Clues to The Etiology of Pneumonia Obtained
Through History - Taking
Type of Contact or Prodrome Disease or Organism
- Contact with an individual with a lung infection Tuberculosis M.pneumoniae RSV S.pneumoniae
- Infant/young child in day care H.Influenzae type B N.meningitis Respiratory viruses
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Clues to The Etiology of Pneumonia Obtained
Through History Taking
Type of Contact or Prodrome Disease or Organism
-Animal contact Psittacosis Tularemia Plaque, Q fever
Geographic regions Histoplasmosis Coccidioidomycosis Rickettsial infections
Building construction Aspergillus spp.
Air conditioning cooling towers Legionaires disease
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Clues to The Etiology of Pneumonia Obtained
Through History Taking ( cont)
Type of Contact or Prodrome Disease or Organism
-Outbreak/epidemic Group A Streptococcus Influenza RSV
- Smoker,smoking in household,wood-burning stove Increase in all lower respiratory infections
- Short prodrome Bacterial agents such as S.pneumoniae,H.influenzae type b, Group A Streptococcus
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Clues to The Etiology of Pneumonia Obtained
Through History Taking ( cont)
Type of Contact or Prodrome Disease or Organism
- Long prodrome M.pneumoniae C.pneumoniae or C.trachomitis RSV
- Preceding rash Measles N.meningitidis M.pneumoniae S.aureus
Preceding focal abscessintra-or extrapulmonary S.aureus
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Pneumonia - Epidemiology - Diagnosis - Treatment - Prevention
Diagnosis -- Signs and symptoms -- CXR -- Physical Examination -- Culture -- Lab -- Antigen Detection
Diagnosis Practice for Acute Lower Respiratory Tract Infection P.E. -- Transtracheal Aspirate CXR -- Lung tape Sputum -- Thoracocentesis CBC -- Antigen Detection Blood CIS
Gold standard for Diagnosis of Pneumonia is to Obtain Etiology agent from lung tissue Blood culture Detection of antigen from pleural fluid
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Respiratory Rates (Breaths/minute) of Normal
children
Age Normal Rate- sleeping Normal Rate- sleeping Normal Rate-Awake Normal Rate-Awake
Age Mean Range Mean Range
6-12 mo. 27 22-31 64 58-75
1-2 yr. 19 17-23 35 30-40
2-4 yr. 19 16-25 31 23-42
4-6 yr. 18 14-23 26 19-36
6-8 yr. 17 13-23 23 15-30
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Diagnostic Tools for pneumonia

• CXR
• Sputum culture
• Blood culture
• Urine antigen test CIE or latex agglutination
• Lung tap
• Pleural fluid culture

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Three Types of Pediatric Pneumonia

• The pediatrician can see when looking at the
  film.
• The pediatrician can not see when looking at the
  film until pointed out by radiologist.
• The pediatrician can not see when looking at the
  film even after being pointed out by radiologist
  

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Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents
Bacteria Virus Mycoplasma
Historical clues - Age Any,esp.infant Any School age,adolescent
- Temp. Majority 39 C lt 39 C Majority lt 39 C
- Onset Abrupt Gradually worsening URI Gradually worsening cough
- Others in home ill Infrequent Frequent Frequent,wk.apart
- Ass. Signs, symptom Meningitis,otitis,arthritis Myalgia,rash,conjunctivitis Headache,sorethroat,myalgia
- Cough Productive Nonproductive Hacking
- Pleuritic chest pain Frequent Infrequent Infrequent
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Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (cont)
Bacteria Virus Mycoplasma
Physical Findings - Auscultatory Confined rales,no rales.Occasional dullness to percussion,diminished tubular sounds Diffuse,bilat. Rales.Wheezes in young infant Unilateral rales in most
-Toxicity Degree illness gt findings Degree illness findings Degree illness lt findings
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Epidemiology,Clinical,and Laboratory features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (cont)
Bacteria virus mycoplasma
Radiographic Findings - Initial examination Hyperaeration alveolar infiltrate Hyperaeration interstitial infiltrate Alveolar-interstitial patchy infiltration
- Progression Frequent,rapid Infrequent May be migratory
- Pleural fuild May be large,rapidly progressive Infrequent,small,not progressive Infrequent,small,not progressive
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Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (cont)
Bacteria Virus Mycoplasma
Laboratory Findings - Peripheral WBC/cu.mm Majoritygt 15,000.Granulocytes predominate Majoritylt15,000.Lymphocytes predominate Majority normal or less than 15,000
- C-reactive protein Majority Infrequent Infrequent
- Sed rate 30 mm/hr Majority Majority Majority
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Etiology of Pneumonia in infants and Children
Winter
S.Pneumonia
Viral Agents Para 1,2,3 Influenza A,B Etc.
Mycoplasma
Summer
RSV C.Trachomatis CMV
1 Staph.
Strep.Gr.B E.coli
2Staph.
C. pneumoniae
H.Inf.B.
3 yrs.
5 yrs.
10 yrs.
6 mo.
1 mo.
3 mo.
1 yr.
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Prospective Studies of Perinatal Chlamydia
Infection

• 
  Infants
• City Mother Conjunctivitis()
  Pneumonia ()
• San
• Francisco 5 18
  16
• Seattle 13 44
  --
• Denver 9 44
  22
• Boston 2 33
  17
• Seattle 12 33
  8
• Lund 9 22
  --
• Nairobi 22 37
  12

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Clinical Features of C. Trachomatis Pneumonia

• Onset at 3 to 11 wks of age
• Cough greater than one week in duration
• Prior conjunctivitis
• Afebrile tachypnea with diffuse rales
• Hyperinflation and interstitial infiltrates on
  chest film
• Eosinophilia
• Increased IgM
• Increased IgA and IgG

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Number of patients
Treatment day
Treatment day when improvement first noted
26

• Pleural effusion

Age distribution of 107 hospitalized children
with identified bacterial pneumonia
27
Annual Rate of Bacteremia by Organism
Pedriatic Infect Dis J.1994131143-44
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Pneumococcal pneumonia

• Most common in late winter or early spring during
  the peak of viral infection
• Abrupt onset of fever
• Restlessness
• Respiratory distress following URI

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Physical exam Labs

• Diminished B. S or fine, crackling rales
• Neck rigidity without meningitis may occur (RUL)
• WBC 15,000 - 40,000
• Blood C/S positive only 30
• Lobar consolidation (less common in infants)
• Para-pneumonic effusion is relatively common

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Characteristics of 65 Patients with Pneumonia due
to Haemophilus influenzae Type b
Characteristic No.()
Physical Examination Temp. gt 39C Decreased breath sounds over af- fected area cough Ass. Conditions Otitis media Meningitis Pericarditis Bacterial Cultures Bl. Pleural fluid CSF 58( 89 ) 53 ( 82) 49 (75) 28 (43) 10 (15) 3 (5) 49/65(75) 36/46(78) 10/40(25)
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Characteristics of 65 Patients with Pneumonia due
to Haemophilus influenzae Type b (cont)
Characteristic No. ()
Bacterial Cultures(cont) Middle ear fluid Lung aspirate Roentgenographic Examination 49 Patients with consolidation Unilateral disease Bilateral disease Pleural fluid 16 Patients with bronchopneumonia Unilateral disease Bilateral disease Pleural fluid 8/9 (89) ½ (50) 28 (57) 11 (22) 37 (76) 11 (69) 5 (31) 12 (75)
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Months of age
Ages of 65 patients with H.influenzae b pneumonia
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WBC x 10³
The peripheral leukocyte count at the time of
hospital admission in 65 patients with
H.influenzae b pneumonia
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Factors Influencing the Case Fatality Rates in 79
Infants and Children with staphylococcal pneumonia
Factor No. died/total P
1.Primary pneumonia Secondary pneumonia 2.1965-1971 1972-1978 3. 12 mos. Of age gt 12 mos. Of age 4.Unilateral pneumonia Bilateral and/or multilobe pneumonia 5.Initial WBC 10,000/cu mm Initial WBC gt10,000/cu mm 6.Appropiate ATB Inappropiate 7.Empyemadrainage No drainage 14/61 (23) 6/18 (33) 15/40 (37.5) 5/39 (12.5) 14/45 (31) 6/34 (18) 5/42 (11.9) 14/20 (70) 6/59 (11.8) 4/54 (7) 12/21 (57) 8/50 (16) 3/10 (300) 0.35 lt0.05 lt0.5 lt0.001 lt0.001 0.19
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Age 6 yrs and older

• Febrile pneumonia
• Mycoplasma pneumoniae
• C. pneumoniae
• S. pneumoniae
• - Treatment
• ?Erythromycin
• ?Clarithromycin
• ?Azithromycin

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Mycoplasma pneumoniae in the United
States

• Syndrome Incidence/year Total cases
• Pneumonia 2/1.000
  500,000
• Tracheobronchitis 46/1,000
  11,500,000
• Asymptomatic 12/1,000
  3,000,000
• Infections
• All infections
  15,000,000

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Incubation Clinical
illness Convalescence
0
3
4
5
6
Wks.-2
-1
1
2
Symptoms
Headache,malaise Fever Sore throat Cough
Signs Sputum Dullness Rales
Laboratory Positive culture x-ray
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M.pneumoniae Infections

• Asymptomatic
• Respiratory diseases with or without pneumonia
• Responsible for 35 of out patient pneumonias
• 3-18(median 7) of community acquired pneumonias
  necessitating hospitalization

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Diagnostic of Mycoplasma Pneumonia Diseases

• Consider in all cases of pneumonia.
• Flu-like Febrile illness of gradual onset.
• Symptom of acute tracheobronchitis.
• Paucity of physical findings.
• CXR.
• Exclude bacterial disease.
• Cold hemagglutinin test.
• Mycoplasma culture.
• Mycoplasma serology.

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BEDSIDE COLD HEMAGGLUTININ

• 0.2 ml. patient blood is mixed with and equal
  volume of sodium citrate solution in a small tube
  which is iced for 15 sec.The tube is then tipped
  and rotated for inspection of the blood film.A
  positive is indicated by agglutination which
  disappears when the tube is warmed to 37C.A
  positive test indicates a standard method titer
  1 64

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Diagnostic Tests for Mycoplasma pneumoniae
Test Specimen Sensitivity() Specificity() Comments
Culture Throat or NP swab, gt 90 50-90 Not routinely available sputum, bronchial slow-growing organism washing tissue PCR Throat or NP swab, 95 95-99 Not commercially available sputum, potencially useful for rapid broncial washings, diagnosis test tissue Serology cold agglutinins 50 lt 50 Nonspecifictakes several wks to develop Serum 75-80 80-90 Paired acute-convalescent Complement sera preferredtakes 4-9wks fixation for seroconversion Elisa Diagnostic criteria Definite 4-fold increase in titer
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Respiratory and Nonrespiratory Complications of
Mycoplasma Pneumoniae Infections

• General
  Hematologic
• Skin rashes
  Anemia (including
  hemolytic)
• Erythema multiforme
  DIC
• Maculopapular eruptions
  Throboembolism
• Vesicular eruption
  Cardiac
• Toxic epidermolysis
  Pericarditis
• Erythema nodosum
  Myocarditis
• Arthritis
  Neurologic
• Glomerulitis
  Encephalitis
• Pulmonary
  Meningitis
• ARDS
  Poliomyelitis-like
  syndrome
• Broncial asthma exacerbation
  GB syndrome
• Bronchiectasis
  Brain-stem syndrome
• 
  celabellar ataxia
• Bronchiolitis obliterans
  Psychosis
• Hyperlucent lung syndrome
• Interstitial fibrosis
• Lung abscess
• Pleuritis,pulmonary embolism

File TimetalID clinic NA vol.12,No.3,Sept 1998
45
Chlamydia pneumoniae ( TWAR )

• This organism cause pneumonia,
• bronchitis,sinusitis and pharyngitis
• and is a common cause of infection
• in children from the age 5 15 years.
• Of the three Chlamydia species,
• Chlamydia pneumonia is by far the
• most common cause of human infection

46
Clinical Finding in Pneumonia Associated with
M.Pneumoniae,TWAR and Viral Respiratory Agents
///////////////// TWAR ( N26 ) M.pneumoniae ( N35 ) Viruses ( N86 )
Cough 100 97 89
Sore throat 50 48 50
Horesness 48 32 37
WBCgt10,000 25 21 37
Fevergt106F 67 94 93
Hospitalized 4 3 5
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Diagnostic Tests For Chlamydia Pneumoniae
Test Specimen Sentivity () Specificity() Comments
Culture NP swab,sputum.broncial 50-90 ? Requires tiss. Culture washings,pleural fluid requires several days incubation PCR Sputum,broncial washings 80-90 gt85 potential for rapid pleural fluid,tiss.,throat or diagnosis NP swab Serology Serum microimmunofluo- 50-90 ? Paired IgG and IgM Acute and convalescent Diagnostic criteria Definite 4 fold rise microimmunofluorescence Ab Possible IgG1512 IgM 132
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Minimal Inhibitory Concentration(MIC) of Selected
Antibiotics Against C.pneumoniae
Drug MIC Utility Activity
Rifampin 0.005 - 0.25 not used very high Tetracyclines tetracycline 0.05 - 0.1 drug of high doxycycline 0.03 - 0.05 choice high Erythomycin 0.1 - 1.0 alternative high Sulfamethoxazole 0.5 4.0 alternative moderate Fluoroquinolones ofloxacin 0.5 - 1.0 may prove moderate ciprofloxacin 1.0 - 4.0 useful moderate enoxacin 2.0 8.0 low norfloxacin 4.0 - 16.0 not reliable Penicillins ampicillin 0.5 10.0 low penicillin 1.0 10.0 Cephalosporins ceftriazone 10-100 none none moxalactam 100 none none Gentamicin 500 none none Vancomicin 1000 none none
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SARS Outbreak in Humans
Dates and Location Total Cases Deaths
Comments November 16, 2002-June 15, 2003
8,096 774 (9.6) Global spread
began February 21, 2003 Guangdong Province,
China, then WHO declares epidemic
contained on July 5, worldwide
2003 August 26, 2003-October 1, 2004
1 0(0.0) 27-year-old
postgraduate medical student Singapore,
Malaysia working in a virology
laboratory December 5-30, 2004 1
0(0.0) 44-year-old military
research scientist working Taipei, Taiwan
in a virology laboratory December 16,
2003-January 17, 2004 1 0(0.0)
32-year-old television producer, source
of Guangzho, Guangdong Province, China
infection unknown December 25, 2003-January
17, 2004 1 0(0.0)
20-year-old waitress who worked in a Guangzho,
Guangdong Province, China
restaurant serving wild game and civet
cats source of infection
unknown
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SARS Outbreaks (continued)
Dates and Location Total Cases Deaths
Comments December 31, 2003-January 21,2004
1 0(0.0)
35-year-old businessman, source of Shenzen,
Guangdong Province, China
infection unknow January 7-30, 2004
1 0(0.0) 40-year-old
hospital director and physician Guangzho,
Guangdong Province, China source
of infection unknown March, 2004-April 19,
2004 9
1(11.1) First reported April 22, 2004.
Declared Beijing, and Anhui Province, China
contained by WHO on May 18, 2004.
Index case worked at the
National Institute of Beijing
and infected her mother in Anhui Province.
The mother died. The index case
traveled by train from Beijing
to Anhui twice, but no other
infected contacts were found. A nurse who
treated the index case in Beijing
spread it to her family and to
another patient and the patients
daughter. Another ill researcher at the
National Institute of Virology
also was confirmed to have
SARS-CoV. TOTAL 8,111 775
(9.6)
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Severe Acute Respiratory Syndrome (SARS)

• CDC continues to recommend consideration of
  testing for SARS-CoV in patients who require
  hospitalization for radiographically confirmed
  pneumonia or ARDS without identifiable etiology
  AND who have one of the following risk factors in
  the 10 days before the onset of illness
• Travel to mainland China, Hong Kong, or Taiwan,
  or close contact with an ill person with a
  history of recent travel to one of these areas,
  OR
• Employment in an occupation associated with a
  risk for SARS-CoV exposure (e.g., health care
  worker with direct patient contact worker in a
  laboratory that contains live SARS-CoV), OR
• Part of a cluster of cases of atypical pneumonia
  without an alternative diagnosis.

52
Avian Influenza Outbreaks in Humans (through
November 2004)
Dates and Location Subtype Total Cases
Deaths Comments May-December 1997
H5N1 18
6(33.3) First confirmed avian influenza
outbreak Hong Kong in humans March 1999
H9N2 2
0(0.0) Two children with mild influenza-like Hong
Kong symptoms April 2002 H7N2
1 0(0.0) First
probable case in US had mild Virginia,
USA influenza-like symptoms diagnosis
made by serology only February 2003
H5N1 2-3 1-2
(50.0-66.7) Family had visited China, one
childs cause Hong Kong of death is
unknown February 2003 H7N7
84 1(1.2) Most presented with
conjunctivitis one Netherlands veterinarian
died
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Avian Outbreaks (continued)

Dates and Location Subtype Total Cases
Deaths Comments November 2003
H7N2 1
0(0.0) No known avian contacts source New York,
USA remains unknown December 2003
H9N2 1
0(0.0) 5-year-old hospitalized with Hong
Kong influenza-like symptoms December
2003-present H5N1 44 to date 32
to date (72.7) No cases from April-June
2004 Thailand and Vietnam epidemic is
ongoing, with possible 17 in Thailand 12
in Thailand human-human transmission 27 in
Vietnam 20 in Vietnam February-April 2004
H7N3 2
0(0.0) Both had conjunctivitis and mild British
Columbia, Canada influenza-like
symptoms Bold indicates highly pathogenic
avian influenza. Overall mortality in human
beings from all avian influenza or all HPAI
strains combined is about 19, whereas it is gt60
of H5N1 is the infecting subtype.
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Cambodia Aug 2005 4 cases 4 deaths
Indonesia Aug 2005 1 cases 1 deaths
Thailand Aug 2005 17 cases 12 deaths
Vietnam Aug 2005 90 cases 40 deaths
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Clinical manifestation of Avian Flu

• Respiratory symptoms - Flu like illness
• - ARDS
• GI symptoms Acute diarrhea, vomiting,
  abdominal pain
• CNS Encephalitis
• Multiple organ dysfunction
• Sepsis / septic shock

Not all cases have respiratory symptoms
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Influenza A(H5N1) Virus Infections (Avian Flu)
I. Testing for influenza A(H5N1) is indicated
for hospitalized patients with a.
Radiographically confirmed pneumonia, acute
respiratory distress syndrome (ARDS), or
other severe respiratory illness for which
an alternate diagnosis has not been established,
AND b. History of travel within 10 days of
symptom onset to a country with documented
H5N1 avian influenza in poultry and/or humans
(for a listing of H5N1-affected countries, see
the OIE Web site at www.oie.int/eng/en_index.
htm and the WHO Web site at www.who.int/en).
59
II. Testing for influenza A(H5N1) should be
considered on a case- by-case basis in
consultation with state and local health depart-
ments for hospitalized or ambulatory patients
with a. documented temperature of gt38ºC
(gt100.4ºF), AND b. one or more of the
following cough, sore throat, shortness of
breath, AND c. history of contact with
domestic poultry (e.g., visited a poultry
farm, household raising poultry, or bird market)
or a known or suspected human case of
influenza A(H5N1) in an H5N1- affected
country within 10 days of symptom onset.
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Interim Recommendations Infection Control
Precautions for Influenza A(H5N1)

• Standard Precautions
• Pay careful attention to hand hygiene before
  and after all patient contact
• Contact Precautions
• Use gloves and gown for all patient contact
• Eye protection
• Wear when within 3 feet of the patient
• Airborne Precautions
• Place the patient in an airborne isolation room
  (i.e.,monitored negative air pressure in
  relation to the surrounding areas with 6 to 12
  air changes per hour).
• Use a fit-tested respirator, at least as
  protective as a NIOSH- approved N-95 filtering
  facepiece respirator, when entering the room.

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Laboratory Testing Procedures

• Highly pathogenic avian influenza A(H5N1) is
  classified as a select agent and must be worked
  with under Biosafety Level (BSL) 3 laboratory
  conditions. Therefore, respiratory virus
  cultures should not be performed in most clinical
  laboratories and such cultures should not be
  ordered for patients suspected of having H5N1
  infection.
• Clinical specimens from suspect A(H5N1) cases and
  SARS-CoV cases may be tested by PCR assays using
  standard BSL 2 work practices in a Class II
  biological safety cabinet. In addition,
  commercial antigen detection testing can be
  conducted under BSL 2 levels to test for
  influenza.

62
Considerations for Inpatient Management of
Children with Pneumonia
Toxic appearance Respiratory distress Pleural
effusion Age considerations lt3 months lt3 years,
with lobar pneumonia lt5 years, with lobar
pneumonia (more than 1 lobe)
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Considerations for Inpatient (continued)
Existing chronic disease Pulmonary (including
asthma) Cardiac Renal Diabetes
mellitus Metabolic disorders Anemia (including
sickle cell disease) Malignancies Immunocompromis
ed host Progression of pneumonia during
outpatient therapy
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Initial Therapy of Pneumonia
Age Treatment Treatment Principal pathogens
Age Outpatient Hospitalized Principal pathogens
0-4 wks. - Ampicillin and Gentamicin (/-cefotaxime) Group B Streptococcus() Enteric gram negative bacilli()
1-5 mo. Amoxicillin ( or amoxicillin-clavulanate) Cefotaxime Pneumococcus()virus()S.aureus()
6 mo.-6 yr. Amoxicillin ( or amoxicillin-clavulanate) Cefotaxime /- macrolide Pneumococcus()virus()S.aureus()Group A Streptococcus()Mycoplasma()
6 yr. Macrolide (/-amoxicillin) Cefotaxime and macrolide Mycoplasma( )pneumococcus()S.aureus()Group A Streptococcus()Chlamydia()
Immunocompromised - Cefazidime and Vancomycin /-macrolide Many
Occasional cause common cause or ceftriazone
or cefuroxime ,Erythromycin azithromycin or
clarithromycin ,cefepime
65

• Outpatient
• 0-20 days
• Admit pt.
• 3wks-3mos
• Afebrile give PO erythromycin. Admit for fever
  or hypoxia
• 4mos-4yrs
• PO amox or azithro. If gt8 yrs, PO doxycycline
  (4mg/kg/day, 2 divided doses)

• Inpatient
• (septic, alveolar infiltrate, large pleural
  effusion or all)
• 0-20 days
• IV amp/gent with or w/o IV cefotaxime
• 3wks-3mos
• Give IV cefotaxime or ceftriaxone
• 4mos-4yrs
• IV cefotaxime, ceftriaxone, if pt not well
  consider IV azithromycin

66

• The end!

67
Pleural Empyema In Children

• Stages of infection
• Exudative (allows needle aspiration)
• Fibrinopurulent (may be loculated)
• Organizing
• Treatment options
• Exudative Repeated needle aspiration (1-5 days)
• Exudative or Chest tube drainage
• fibrinopurulent
• Organizing Decortication
• If gt50 limitation of lung shown by CT scan
• After 2-4 weeks of medical management
• tachypnea, asymmetry of chest wall
• expansion, fever,or leukocytosis remain

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Percent Incorrectly Classified
Annals of Internal Medicine 77507-513,1972
69
Characteristics of Different Types of Pleural
Effusions
Clinical Condition Type of effusion Predominate Cells in Effusion Glucose Level(mg/dL) pH
Empyema Exudate PMN cellsgt50,000/mm3 lt30 lt7.00
Parapneumonic effusion Exudate PMN cellslt50,000/mm3 gt30 lt7.20
Tuberculosis Exudate Lymphocytes 30-60 7.00-7.30
Congestive heart failure Transudate Lymphocytes gt60 gt7.40
Hypoalbuminemia Transudate Lymphocytes(few) lt60 gt7.40
Malignancy,SLE Exudate Lymphocytes,malignant cells Variable Variable
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Reported frequency of pleral effusion in pneumonia
Etiology Frequency() Etiology Frequency()
S.aureus Strep.pneumoniae H.Influenzae Group A Streptococcus Mycoplasma pneumoniae Adenovirus 72-76 57 49-75 86-91 21 11-33
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Bacterial Isolates from Pleural Effusions and
Empyema in Children and Adolescents
Bacterial Species Percentage of Isolates Percentage of Isolates
Bacterial Species Brook,1990(72 cases) Freij et al,1984(227 cases)
-Strep.pneumoniae -Group A Streptococcus(Streptococcus pyogenes) -Viridans streptococci -Nonhemolytic streptococci -Enterococcus faecalis -Other streptococcus -S. aureus -H.influenzae 18 4 7 6 3 - 14 21 22 1 lt1 - - 1 29 18
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Bacterial Isolates from Pleural Effusions and
Empyema in Children and Adolescents(cont)
Bacterial Species Percentage of Isolates Percentage of Isolates
Bacterial Species Brook,1990(72 cases) Freij et al,1984(227 cases)
-E.coli -Klebsiella pneumoniae -Pseudomonas aeruginosa -Proteus mirabilis -Gram-positive anaerobic isolates -Gram-negative rod anaerobic isolates -Mixed infections -sterile 3 4 3 1 17 29 - - - 1 1 - - - 4 24
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Duration of Antimicrobial Therapy and
Hospitalization in Empyema Survivors
Duration of Antimicrobial therapy(Days) Duration of Antimicrobial therapy(Days) Duration of Hospitalization(Days) Duration of Hospitalization(Days)
No. of cases Mean SD No. of cases Mean SD
S.aureus 40 24.2 10.6 50 26.8 9.5
Strep.pneumoniae 41 12.3 6.3 48 12.9 7.9
Haemophilus 34 13.0 4.8 37 16.7 10.4
Sterile 37 11.8 5.9 51 11.7 7
Mixed bacteria 7 21.9 13.6 8 31.4 21.6
74
Guidline for Chest Tube Insertion in Patients
With Nonpurulent,Gram-Negative Parapneumonic
Effusions
Pleural Fluid Result Management
Light Recommendations -pHlt 7.00 or glucoselt40 mg/dL -pH 7.00-7.20 or LDH gt1000 IU/L -pHgt7.20 and glucosegt40 mg/dL and LDHlt1000 IU/L Placemant of chest tube for drainage in most patients Consider chest tube for drainage ( loculate or large ) Chest tube not indicated,even for loculationreevaluate with repeat thoracentesis( patient not response or effusion increases)
Light RWManagement of parapneumonic
effusions.Chest 100892-893,1991 LDH,lactate
dehydrogenase
75
Guidline for Chest Tube Inserttion in Patients
With Nonpurulent,Gram-Negative Parapneumonic
Effusions (cont)
Pleural Fluid Result Management
Sahn Recommendations -pH lt7.10,usually with glucoelt40 mg/dL, LDHgt1000 IU/L -pH 7.10-7.29 glucose 40-60 mg/dL, LDH 500-1000 IU/L -pH 7.30,pleural fluid to serum glucose ratio gt0.5. LDHlt1000 IU/L Placement of chest tube for drainage Repeat thoracentesis in 6-8 hrif pH decreases and clinical status worsens,placement of chest tube indicated No indication for chest tube drainagecontinue close observation
Strange C.Sahn S. Management of parapneumonic
pleural effusions and empyema.Infect Dis Clin
North Am 5539-559,1991
76
Algorithm for Empyema

• Pleural effusion

Thoracentesis
Gram stain-neg
Gram stain-pos
Observe
Chest tube
Resolution
Increasing fluid
Resolution
Non-resolution
Open drainage
Decortication
77
Common Causes of Community-Acquired Pneumonia in
Otherwise Healthy Children
Viruses Respiratory syncytial
virus Influenza A or B Parainfluenza
viruses 1, 2, and 3 Adenovirus Measles
virus Mycoplasma Mycoplasma pneumoniae Chlamydia
Chlamydia trachomatis Chlamydia
pneumoniae Bacteria Streptococcus
pneumoniae Mycobacterium tuberculosis Stap
hylococcus aureus Haemophilus influenzae type
b II Nontypeable H. influenzae
78
Uncommon Causes of Community-Acquired Pneumonia
in Otherwise Healthy Children
Virus Varicella zoster virus Coronaviruses
Enteroviruses (coxackievirus and
echovirus) Epstein-Barra virus Mumps
virus Herpes simplex virus (in
newborns) Hantavirus Chlamydia C.
psittaci Coxiella C. burnettii
79
Uncommon Causes (continued)
Bacteria S. pyogenes Anaerobic mouth flora
(S. milleri, Peptostreptococcus) Non-type b
(but typeable) Haemophilus influenzae B.
pertussis K. pneumoniae E. coli L.
monocytogenes N. menigitidis (often group
Y) Legionella Pseudomonas
pseudomallei F. tularensis B.
abortus Leptospira
80
Uncommon Causes (continued)
Fungi C. immitis H. capsulatum B.
dermatitidis
81
(No Transcript)
82
Which of the following statements regarding
pneumonia in children is true?

• A .Specific microbial pathogen usually can be
  identified
• B. All children who have pneumonia should be
  hospitalized for observation and treatment
• C. Pneumonia is a rare cause of child mortality
  worldwide
• D. Radiographs of the chest always should be
  obtained to determine the cause
• E. Viral agents are the most common causes of
  pneumonia in older infants and children

83
You are evaluating an 8 year old boy who has 7
day history of malaise and worsening cough. His
mother reports that he has had low grade fever.
PE reveals a well appearing boy with normal RR
and pulse ox. Lung exam reveals bilateral
crackles without wheezing . Chest x-ray show
bilateral interstitial infiltrates without
effusion.

• Most likely pathogen is
• A. Haemophilus influenzae
• B. Mycobacterium tuberculosis
• C. Mycoplasma pneumoniae
• D. Respiratory syncytial virus
• E. Streptococcus pneumonia

84
An 8 week old girl presents to ER with increased
work of breathing x 1 day. Temp of 101.1 F,
difficulty breastfeeding due to nasal congestion.
RR 70, pulse ox 90 on RA. Lung exam reveals
bilateral wheezes and crackles. CXR shows
increased perihilar markings bilaterally and
right middle lobe opacity.

• Most likely cause of her symptoms is
• A. Adenovirus
• B. Bordetella pertussis
• C. Chlamydia trachomatis
• D. Group B Streptococcus
• E. Respiratory syncytial virus

85
4

• Main Cause of Necrotizing Pneumonia is
• Streptococcal hyaluronidase
• Teichoic acid
• Pneumolysin
• Fibrinolysin
• Ponton-valentine leukocidine

86
5

• The following microorganisms are frequent causes
  of pleural effusion EXCEPT
• S. aureus
• Strep pneumoniae
• Group A streptococcus
• Haemophilis influenzae type B
• Mycoplasma pneumoniae

87
6

• Characteristics chlamydial pneumonia include the
  following EXCEPT
• Afebrile
• History of conjunctivitis
• Staccato cough
• Eosinophilia
• Present at 4-6 months of age

88
7

• Distinguish features of exudate from transudate
  are as follows EXCEPT
• Pleural fluid serum protein ratio gt 0.5
• Pleural fluid LDH gt 200 IU/ml
• Pleural fluid serum LDH gt 0.6
• Pleural fluid protein gt 3 gm/ml
• Leukocyte count gt 1,000/CU/mm

89
Features Differentiating Exudative Transudative
Pleural Effusion

• Transudate Exudate
• WBC lt10,000/mm³ gt50,000/ mm³
• pH gt7.2 lt7.2
• Protein lt3.0 g/dL gt3.0 g/dL
• Protein ratio lt0.5 gt0.5
• LDH lt200 IU/L gt200 IU/L
• LDH ratio lt0.6 gt0.6
• Glucose 60 mg/dL lt60 mg/dL

90
TIME TO WAKE UP!!!
91
Atypical Pneumonia Clues to Traditional
Causes(cont)
Pathogens Clinical Clues
Legionella pneumophila Geographic fungi (e.g.,Histoplasma) a. Acute onset,multiple shaking chills,high fever,pleurisy b.Associated CNS,GI,GU abnormalities c. Underlying smoking history or lung disease d. Sporadic or epidemic cases a. Regional diseases importance of travel history b. Outdoor exposures c. Mimics tuberculosis d. Skin,bone,lymph node extrapulmonary manifestations e. May occur in epidermics