Elaf AlShammari 2019-2020

Community Acquired Pneumonia (CAP) & Complicated Pneumonia

❖ Introduction:
▪ Definition of Pneumonia: Acute inflammation of the parenchyma of the lower respiratory tract caused by Microbial Pathogen.
▪ Definition of CAP: pneumonia in a previously healthy child caused by an infection acquired outside hospital.
▪ Definition of Empyema: Intrapleural pus or a moderate to large exudative parapneumonic effusion (stage1), which can progress to being loculated
(stage2), with further development of a fibrinous peel (stage3).
▪ Leading cause of death in children aged <5years.

❖ Etiology:

▪ Bacterial:
• Rapid onset of fever, ill appearance, Elevated WBC, lobar infiltration, rapid respond to Abx.
• Bacterial causes increase in incidence with age.

• Bacterial Etiologies:
o Streptococcus Pneumoniae:
- MCC in all age groups.
- Cases Declined after PCV7 & PCV13 vaccins.
o Staphylococcus aureus & streptococcus pyogenes (GAS).
- Increases rates of severe Pneumonia due to MRSA.
< (Influenza + S aureus): cause severe Pneumonia & high Mortality rate>
- GAS is less common but severe.
o Mycoplasma Pneumoniae.
- Epidemics occur every 3-7 years, 20% asymptomatic with only 3% resulting in pneumonia.
- PCR is a preferred test.
o Less common Bacterial Causes.
- Clamydophila pneumoniae, Non typeable Heamophilus Influenzae, Moraxella catarrhalis.

▪ Viral:
• Gradual onset of symptoms, respiratory distress, wheezing, rhinitis, interstitial infiltrate bilaterally, no response to Abx.
• Viral etiologies predominant in < 5years.
• MCC: RSV, Human Metapneumovirus (HMPV), Influenzas, Rhinovirus, Adenovirus, Parainfluenza, Coronavirus.
• Influenza can cause life threatening illness especially with co-infection or superinfection with Bacteria.

▪ Immunodeficient patients:
• In addition to typical etiologies of CAP, rare or opportunistic pathogens such as: Legionella pneumophila, Pneumocystis jiroveci, Gram negative &
fungal organisms.

❖ Evaluation:
History, physical Examination, & laboratory findings help differentiate Viral from Bacterial causes.

▪ History.
• Symptoms of pneumonia nonspecific, Acute onset of fever, cough, respiratory symptoms, difficulty breathing, poor feeding, vomiting, decrease in
activity, <Chest or Abdominal pain may be prominent features>.
• PMHx: Asthma, atopy & night symptoms.
• Immunization Hx.:
Signs of pneumonic Consolidation:
- 2,4,6 months vaccines for Pneumococcal conjugate & H influenza type B.
- Current Influenza Vaccine. ▪ Dullness on percussion.
• Family Hx.: Parents or siblings with Asthma, Atopic dermatitis or Allergic rhinitis. ▪ Increased tactile fremitus.
▪ Reduced normal vesicular
breath sounds.
▪ Vital signs. ▪ Increased bronchial breathing.

• Temperature: REMMBER, All of whitch may be

- High fever < may be the ONLY clinical sign>. difficult to detect in children ☺
- Occult Pneumonia. <acute onset of abdominal pain & High fever>
• RR:
Signs of an effusion:
- May be elevated due to Fever or pain.
- Serial assessment of RR over the course of the visit > provide more accurate of respiratory status. ▪ Dullness on percussion.
▪ Decreased tactile fremitus.
• Pulse Oximetry: ▪ Decreased or absent breath
- Hypoxemia “but not severe”. sounds.

▪ Physical examination.
No Single sign or symptom is pathognomonic for diagnosis of Pneumonia.
• Appearance: Ill appearing, Respiratory distress, retraction, Increase work of breathing, WITHOUT wheezing.
• Auscultation: No single findings on Auscultation increases or decrease the likelihood of pneumonia.
Elaf AlShammari 2019-2020

❖ Diagnostic studies:
▪ Differentiating viral from bacterial pneumonia on the basis of radiological or laboratory fining is difficult.
▪ Laboratory & Radiographic evaluation depends on the age, clinical scenario, severity of diseases, & wether a child requires hospitalization.
▪ Pneumonia should be considered in febrile children with elevated WBC even in the absence of respiratory symptoms.

▪ Laboratory studies:
• CBC:
- WBC >15000 Bacterial Vs <15000 Viral, However Adenovirus can cause leukocytosis >15000 ☺
• Inflammatory Markers.
- Should not be used routinely, only in sever cases.
- ESR, CRP, Procalcitonin (>7 bacterial etiology, 0.1 indicate nonbacterial).
• Chemistries.
- Useful only in critically ill or clinically dehydrated children.
- Hyponatremia (SIDAH).
• Blood Culture.
- Confirmation of Bacterial etiology is difficult because Most pts with CAP have negative blood cultures & sampling of pleural fluid or lung
tissue is performed only in complicated cases.
- Obtain blood culture ONLY in high risk patients:
(Immunocompromised, < 6months, central line, requiring hospitalization, critically ill, evidence of empyema).
- Higher likelihood of bacteremia occurs in patents with Empyema, MCC is pneumococcal.
- Blood culture should be at least 1-2ml in infants, 4-5ml in <10 years, 10-20ml >10 years.
• Sputum Culture.
- ONLY at the time of intubation of patients with Respiratory Failure. <to provide optimal Abx for specific pathogen>.
- >10 years.
• PCR.
- PCR is a preferred test for a viral etiology; However +ve result may be due to Asymptomatic infection or Viral shedding.
• Urinary S pneumoniae antigen testing.
- Not recommended due to false-positive rates.

▪ Imaging:
• Chest X-ray.
- Order it in:
highly febrile >39 & aged < 3years with ill appearing or concerning signs, Children with Leukocytosis >20000, fever with Abdominal pain,
prolonged fever without a clear source of infection, asses the extent of pneumonia & presence of pleural effusion or complication.
- Bacterial: Lobar infiltration, pleural effusions, cavitation, & Pneumatoceles.
- Viral: Interstitial infiltrates
- S pneumonia: Posteriorly located consolidation Round, <3cm.
- Radiographic resolution may take up to 4-6 weeks, repeated CXR is not recommended.

• Ultrasound.
- Operator dependent & may lead to overdiagnosis & unnecessary treatment of CAP in patients with asthma.
- Use ONLY as initial modality for Empyema demonstrated in CXR.

• Computed Tomography (CT).

- High risk of ionizing radiation, No need ☺

❖ Treatment:
• Oxygen.
- For any patient with saturation <90% or in respiratory distress with saturation <95%.
• Antipyretics.
- Acetaminophen & Ibuprofen. <will improve general appearance, decreasing HR & RR>.
- More serious causes of fever should be considered in patients without significant improvement after antipyretics administration.
• IVF.
- Assess Hydration status in all patients.
- NGT hydration not recommended for infants > impair respiratory status.

• Albuterol & Corticosteroids.

- Trial of Bronchodilators should be based on PMHx & FHx, and if there is no improvement discontinue it.
- Steroids should be considered in children with Wheezing that is responsive to Bronchodilators therapy even in patients with CAP.
• Viral Causes:
- If Influenza is detected > Neuraminidase inhibitors (Oseltamivir, Zanamivir).
- Other Viruses > supportive (Oxygen & Hydration).

Criteria for Hospitalization:

▪ Inadequate oral intake.

▪ Intolerance of oral therapy.
▪ Severe illness or respiratory compromise.
▪ Complicated Pneumonia.
▪ Younger than 6 months.
Elaf AlShammari 2019-2020

• Antibiotics.
- If no improvement with Abx, search for complication.

▪ Outpatients.

Empiric therapy for atypical Pneumonia

Empiric therapy for Bacterial Pneumonia
In inpatients & out patients
Amoxicillin PO 90mg/Kg/day divided BID or TID Azithromycin PO10mg/kg on Day1 followed by 5mg/Kg/day
1st line
For 7-10 days. once daily on days 2-5.
Amoxicillin/ Clavulanate PO 90mg/Kg/day divided BID or Clarithromycin or Erythromycin
Alternative
TID Children > 7years: doxycycline.
3rd Generation: Cefpodoxime, Cefdinir, Cefuroxime.
Penicillin Allergy:
Or Use Azithromycin , Clarithromycin.

▪ Inpatients.

Empiric therapy for Bacterial Pneumonia

1st line Alternative
▪ Fully Immunized with Conjugate vaccines for H
Ceftriaxone
influenzae & S pneumoniae
Ampicillin for 7-10days. For suspected Co-MRSA: add Vancomycin or
▪ Minimal penicillin resistance <25%
Clindamycin.
▪ Not Fully Immunized with Conjugate vaccines
Levofloxacin
for H influenzae & S pneumoniae.
Ceftriaxone For suspected Co-MRSA: add Vancomycin or
▪ Significant penicillin resistance >25%.
Clindamycin.
▪ Life threatening infection, including Empyema.

❖ Complication:
▪ Bacteremia, septic shock, or respiratory failure > 3ed generation cephalosporin.
▪ Empyema, Lung abscess, Pleural effusion. or necrotizing lung.

❖ Pneumonic effusion & Empyema:

▪ Initial empiric therapy: 3rd generation Cephalosporin for 2-4weeks (Ceftriaxone or Cefotaxime).
< If you considered for S aureus Add vancomycin or Clindamycin>
▪ Transition to oral Abx when drainage is completed & patient improved clinically & off O2: Amoxicillin.

▪ Size & degree of respiratory compromise are important factors in management:

- Small effusion (10mm or ¼ thorax opacified): Respond well to ABx therapy ALONE.
- Moderate effusion ( >1/4 but <1/2 thorax opacified): Drainage.
- Large effusion ( >1/2 thorax opacified): Drainage.

▪ Option for Drainage: <any pleural fluids should be sent for stain, cultures, & other labs studies>
• Chest Tube (with or w/out Fibrinolytic Therapy " tissue plasminogen activator") < CTWF is best >
• Video assisted Thoracoscopic surgery (VATS).

▪ Prognosis/ Outcome:
• Small number of patients will have minor abnormalities of both mild restrictive & mild obstructive, should follow after discharge until they have clinically
recovered & CXR returned to normal (2-3months).

❖ Patients with Neuromuscular diseases

▪ Cerebral Palsy or Muscular dystrophy often have multiple risk factors for Pneumonia.
▪ Swallowing dysfunction, GERD, muscle weakness lead to inadequate cough & clearance of oral secretion
- Consider initial Positive-Pressure ventilation prior to administering O2 .
- Empiric Abx <Ampicillin/Sulbactam, Amoxicillin/ Clavulanate> is first line or Clindamycin if allergic to Penicillin.

❖ References.
▪ Pediatric Emergency Medicine Practice April 2019.
▪ Canadian Pediatric Society Oct 2018.