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Lower respiratory Infection in Children Dave Rupar, MD 8 January 2013

Lower respiratory Infection in Children Dave Rupar, MD 8 January 2013. Gooallll!. Goals for today. Get everybody thinking about pediatric Lower Respiratory Infection through some illustrative cases Avoid perseverating on RSV Help you develop a basic approach to diagnosis and management

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Lower respiratory Infection in Children Dave Rupar, MD 8 January 2013

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  1. Lower respiratory Infection in Children Dave Rupar, MD 8 January 2013

  2. Gooallll!

  3. Goals for today • Get everybody thinking about pediatric Lower Respiratory Infection through some illustrative cases • Avoid perseverating on RSV • Help you develop a basic approach to diagnosis and management • Help you recognize and deal with “problem cases”

  4. Case 1 • 5 month-old boy to office in February • 3 days of fever, runny nose & cough • Previously well • RR 50, temp 101.5ºF • Mild retractions • Rales, rhonchi, wheezes both lung fields

  5. Does this child have LRI/pneumonia? • Sinusitis? Pharyngitis? • Common cold? • Epiglottitis? • Croup (LTB)? • Tracheitis? • Bronchitis? • Bronchiolitis? • Pneumonia?

  6. Does this child have LRI/pneumonia? • History of: • Cough • Fever • Difficulty breathing • Exposures • Season • Sensitive but not specific

  7. PE #1: look and count • Visual inspection • Count 30-60 seconds • RR may be single best indicator of LRI • Abnormal • <2 months: >60 • 2-12 months: >50 • >12 months: >40 • 10/min/ºC

  8. PE #2: Signs of respiratory distress Assess Work of Breathing • Retractions • Chest indrawing/ ”paradoxical” • Flaring • Grunting • Mental status Then you can listen

  9. CXR

  10. Etiology of LRI in children-Viruses • RSV** • Influenza • Adenovirus • Parainfluenza • hMPV • Rhinovirus • HCoV? (SARS and beyond) • HBoV?? RSV virions budding from infected respiratory epithelium

  11. Etiology of LRI in children-Bacteria • Streptococcus pneumoniae • Mycoplasma pneumoniae • Staphylococcus aureus • Streptococcus pyogenes • Chlamydia pneumoniae? • Chlamydia trachomatis • Mtb

  12. Relative Importance of Etiologies of Childhood Pneumonias Data adapted from my own imagination

  13. Respiratory distress with noisy chest (bronchiolitis!) Exposure and season Diffuse involvement of respiratory tract CXR: Hyperinflation Bilateral Peribronchial infiltrates Atalectasis Diffuse changes Viral? 6-week old boy, RSV+

  14. Respiratory distress with quiet chest Preceding illness, getting worse WBC > 15,000 CXR 85% unilateral “Round” pneumonia Alveolar infiltrate Effusion (20-30%) Viral or Bacterial? 3-year old boy with fever and cough

  15. Respiratory distress with quiet chest Preceding illness, getting worse WBC > 15,000 CXR 85% unilateral “Round” pneumonia Alveolar infiltrate Effusion (20-30%) Viral or Bacterial? Lookie here

  16. Viral or Bacterial? • An imperfect science • Some patients have dual etiologies (superinfection?) • Careful consideration of patient can allow you to limit antibiotic use • Most of the time you will never know • 2011 Guidelines recommend BC: • Toxic, hospitalized • Failure of treatment Clin Infect Dis 2011;53:617

  17. A quick look at RSV: Epidemiology • Wintertime epidemics • Wide spectrum of disease: upper to lower tract • Attack rates: • 20% community • 50% household • 40% HCWs, children’s ward • 20% infants hospitalized > 7 days

  18. RSV: Everybody does it!

  19. Risk factors for severe disease CHD (esp PHT) BPD CF Any chronic lung disease Immunodeficiency Prematurity Age < 6 weeks RSV Bronchiolitis

  20. Diagnosis of RSV • Usual diagnosis is clinical • PCR, EIA, DFA, viral culture are all reliable • EBM guidelines say “don’t test” • Lab DX for epidemiology, difficult cases • Chest radiographs may be misleading

  21. Case 2: KH • 3 year-old presents to ED • Cough, fever for 2 days. • Previously well, immunizations “UTD” • Rx azithromycin KH CXR on day 1

  22. KH- continued • Rx azithromycin • Worsens over next 2 days, returns to ED • T 101.4º, RR 36, P 123 • Mild retracting, flaring, grunting • Chest clear • Possible decreased breath sounds on right • WBC 18K with 53N, 32B

  23. KH CXR 48 hours later BC : S. pneumoniae, resistant to penicillin & erythromycin Did well on ceftriaxone iv for 7 days

  24. =

  25. Tan, et al. Pediatrics 1998; 102:1369

  26. Data on 85 Finnish children with bacteremic pneumococcal pneumonia Toikka et al. Clin Infect Dis 1999; 29:568

  27. Pneumococcal Resistance to β-lactams • Increase in 1990s • Good News!: Vaccine strains tend to be most resistant • May not matter outside CNS* • Often accompanied by other resistance mutations (macrolides, chloro, t/s) • Revised standards *Kaplan et al. Pediatr Infect Dis J 2001;20:392: 99/100 children with resistant Sp bacteremia/pneumonia treated with parenteral cephalosporins did well

  28. CHS Data on Pneumococcal Susceptibility Number is % susceptible

  29. Down but not out LCH opens Pneumococcal isolate from sterile sites <13 years old, CMC/LCH/Children’s ED 2000-6/2012

  30. Case 3: SH • 2 year old girl • Presents to office with URI, fever for one week • Mild distress, decreased breath sounds • CXR: infiltrate (where?) • IM ceftriaxone SH, CXR day 1

  31. Case 3: SH • 2 year old girl • Presents to office with URI, fever for one week • Mild distress, decreased breath sounds • CXR: LLL infiltrate • IM ceftriaxone • Next day: worse SH, CXR day 1

  32. Why do children fail treatment? • Effusions/empyema • Wrong drug • Wrong bug (tb, atypicals, virus) • Wrong Dx (FB, asthma) • Underlying immunodeficiency • Anatomic problem (sequestered lobe, CCAM)

  33. SH, CXR 48 hours later

  34. SH, CT on 11/26

  35. Case 3:SH, continued • Admitted for IV treatment with ceftriaxone • Day 3 thoracentesis, chest tube • 12 days in PICU • BC grew S. pneumoniae, penicillin sensitive

  36. Complicated Pneumonias • Retrospective review of 254 children with Sp pneumonia • 189 inpatients: 72 (38%)with effusion • 65 outpatients: 1 with effusion • Overall 29% had effusion Tan et al. Pediatrics 1998; 102:1369

  37. 42 pneumonias with empyema Mean age 54 mo (2-163) 50%♂; 50% ♀ CMC 2001-2007 Thanks to Kathryn Eaker, MD

  38. 42 children with pneumonia and empyema Mean age 54 mo (2-163) 50%♂; 50% ♀ Etiology: 16 pneumococcal 4 Staphylococcus aureus 2 Mycoplasma 2 GAS 18 Unknown CMC 2001-2007 Thanks to Kathryn Eaker, MD

  39. Complicated Pneumonia-Management

  40. Complicated Pneumonia-Management Why do you keep robbing banks, Willie?

  41. Why drain the effusion? 1. 2.

  42. Why drain the effusion? 1. Diagnosis 2. Therapy

  43. Case 4: CB • 13 y.o. girl • Fever, cough; presumptive influenza • Rx oseltamivir, then CRO + cefprozil • No improvement • RR 36, T 101.3ºF, ill • Flaring, retractions • Crackles on left

  44. Case 4: CB, continued • WBC 12.5, 80% N • Vanco, ceftriaxone • Mycoplasma pneumoniae IgM + • Rx azithromycin • Did well.

  45. Mycoplasma - Epidemiology • 20-30% childhood pneumonias • Spread by cough • No seasonal pattern • Long incubation: 1-3 weeks • ~40% family contacts infected (may be asymptomatic) • Peak in school-aged, adolescents but may affect younger children

  46. Mycoplasma - Clinical • “Walking pneumonia” • Tracheobronchitis • WARI • 25% extra-pulmonary manifestations • May be severe Mycoplasma colonies on agar

  47. Mycoplasma - Dx • CXR • Bronchopneumonia • May be lobar • 20% bilateral • 10% effusion • “Looks worse than the patient” • Cold agglutinins • Serology- IgM, IgG (acute and convalescent)

  48. Mycoplasma - Rx • Macrolides • Ketolides • Tetracyclines • Fluoroquinolones- post pubertal patients

  49. Antibiotic choices for community-acquired pneumonia-Outpatient, not sick * deviation from Clin Infect Dis 2011;53:617

  50. Antibiotic choices for pneumonia-Inpatient, sick

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