Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age

1. Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD Department of Pediatrics, Boonshoft School of Medicine, Wright State University, The Children’s Medical Center of Dayton

2. Clin Infect Dis 2011; 53 (7): 617-630

3. Objectives List common pathogens causing community-acquired pneumonia (CAP) in infants and children. Discuss appropriate use of diagnostic laboratory and imaging tests in a child with CAP in an outpatient or inpatient setting. Review choice of anti-infective therapy and duration of treatment provided to a child with suspected CAP in the outpatient or inpatient setting.

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5. A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient? • Complete blood count • Chest radiograph • Pulse oximetry • Blood culture • All of the above

6. A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria? • Able to tolerate outpatient meds, greater level of activity, improving appetite. • Afebrile for over 24 hours • Pulse oximetry measurements >90% in room air at least 12 hours • A and C • A, B, and C

7. Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient? • A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days. • Amoxicillin 90mg/kg/day divided 2 times a day for 10 days • Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5 • Combined treatment with both amoxicilln and azithromycin as noted above • No anti-infective therapy indicated

8. A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended? • A third-generation parenteral cephalosporin (e.g., cefotaxime or ceftriaxone) • Intravenous clindamycin • A third-generation parenteral cephalosporin plusazithromycin • Intravenous ampicillin • Intravenous vancomycin

9. A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of: • Ceftriaxone intravenously at 100mg/kg/day • Levofloxacin intravenously at 20 mg/kg/day • Ampicillin intravenously at 400 mg/kg/day • A or C • A, B, or C

10. Introduction • The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple subspecialists and expert consultants to create and review guidelines • Guidelines endorsed by AAP, American College of Emergency Physicians, Society of Critical Care Medicine…. • The guidelines grade method of recommendation, low or very low evidence situations require clinical judgment

11. Strength of Recommendations

12. Strength of Recommendations

13. Inpatient Criteria • Age 3-6 months with a suspicion of bacterial pneumonia • Suspicion or documentation of methicillin-resistant Staphylococcus aureus(MRSA) pneumonia • Concern for follow up or administration of home therapy

14. Patients Requiring Hospitalization

15. Diagnostic approach to the child with pneumonia

16. Outpatient Diagnostics • Chest radiography, blood culture, CBC, ESR/CRP not necessary • Pulse oximetry should be obtained in all patients • If available a rapid test for influenza and for other viral pathogens should be obtained • Testing for Mycoplasmapneumoniaeshould be obtained if suspicious • If no improvement on antibiotics for 48-72 hrs, a CXR and blood culture should be obtained

17. Inpatient Workup • All pt’s should have CXR • Blood culture • CBC • ESR/CRP • Urinary antigen for Pneumococcal infection is not recommended • Sputum samples if able (weak; low evidence) • Rapid tests for Influenza and viruses should be used • Mycoplasmapneumoniaeshould be tested for if suspicious • No reliable test for Chlamydophilapneumoniae

18. Inpatient Diagnostics • A routine repeat CXR is not necessary • Repeat CXR should be obtained if no clinical improvement is demonstrated by 48-72 hrs • If blood culture yields MRSA, a repeat culture is mandatory todocument sterility of the blood. • If blood culture is positive for another organism, repeat culture of blood is not mandatory • Tracheal aspirate should be obtained in patient with endotracheal intubation

19. Criteria for admission to an ICU

20. Criteria for admission to an ICU

21. Criteria for admission to an ICU • Intubation, continuous CPAP or BIPAP • Sustained tachycardia or hypotension • <92% SpO2 on >50% FiO2 • Altered mental status • Clinical judgment should be used regardless of scores

22. Discharge Criteria • Improved Clinical Status >12 hrs • RA with Sp02 >90% >12 hrs • No increased work of breathing , tachypnea or tachycardia • Able to tolerate outpatient therapy • Chest tube out for >12 hrs

23. Outpatient Treatment of Pneumonia • Antibiotics not routinely required for preschool-aged children • High-dose amoxicillin should be considered first line for presumed bacterial pneumonia in all ages • 90 mg/kg/day divided bid • TID dosing is required for Pen-resistant pneumococcus (MIC > 2 µg/mL) • Macrolides (azithromycin) should be considered in school-aged and adolescents with illness consistent with atypical pneumonia

24. Gradual onset Malaise, headache, sore throat, ear infections Lower fevers (101-102) Usually nonproductive, persistent cough May or may not have rales Gradual or acute onset Fatigue, dyspnea, chest pain Fevers often higher (>103) Cough more often productive Decreased or bronchial breath sounds, rales, dullness to percussion, egophony Atypical vs. Bacterial

25. Manifestations of Mycoplasma pneumonia

26. Outpatient Treatment of Pneumonia • For presumed atypical pneumonia, azithromycin is first-line • 10 mg/kg on day 1; 5 mg/kg on days 2-5 • In season, treat influenza presumptively until a sensitive test is negative • 10-day course of antibiotics is usually adequate • Azithromycin: 5 day course • MRSA will require a longer course (and hospitalization!)

28. Inpatient Treatment of Pneumonia • For the fully immunized child in regions that do not demonstrate high-level pneumococcal penicillin resistance: • Ampicillin or Penicillin G are first-line • Azithromycin for suspected atypical pneumonia (with a beta-lactam if diagnosis is in question) • Vancomycin or clindamycin should be added when S. aureusis suspected by labs, clinical findings or imaging • Ceftriaxone or cefotaxime are alternatives

29. Inpatient Treatment of Pneumonia • For a not fully immunized child or in regions that demonstrate high-level pneumococcal penicillin resistance: • Ceftriaxone or cefotaxime is preferred • Add azithromycin if considering atypical pneumonia • Add vancomycin or clindamycin for S. aureus • Ceftriaxone or cefotaxime also preferred for life-threatening infections and empyema

30. Empiric Inpatient Treatment of CAP

31. Pneumococcal Penicillin Resistance • MIC < 0.06 µg/mL: very susceptible • Standard-dose oral amoxicillin effective • MIC 0.12-1 µg/mL: susceptible • High-dose oral amoxicillin effective • MIC 1-2: somewhat resistant • High-dose oral amoxicillin >90% effective • MIC 2-4: resistant • Oral therapy likely to fail; IV ampicillin or penicillin • MIC >4: very resistant • Standard-dose ampicillin likely to fail; ceftriaxone effective

33. Specific Treatment for CAP

34. Specific Treatment of CAP

35. Specific Treatment of CAP

36. Specific Treatment of CAP

37. Specific Treatment of CAP

38. Viral Pneumonia in Children • Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia (except influenza) • Hamano-Hasegawa, J Infect Chemother (2008) • Younger children more likely to have viral pneumonia • Evidence of bacterial co-infection in 33% • Michelow, Pediatrics (2004) • Bacterial co-infections seen in 54% of viral pneumonias • 67% of influenza pneumonia • 55% of RSV pneumonia

39. Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.

40. Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.

41. Viral Pneumonia in Children Dagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized With Laboratory-Confirmed Influenza, 2003-2008.” Pediatr Infect Dis J. 2010 Jul;29(7):585-90. • A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pneumonia • 27% developed influenza-associated pneumonia • Of these, 2% had a bacterial co-infection • 18 identified by blood cultures; 3 by pleural fluid • The actual incidence of secondary bacterial pneumonia with influenza is likely much higher

42. Adjunctive Therapy • CXR should be obtained if suspicious for effusion • US or CT if CXR is inconclusive • Size of effusion and respiratory compromise will determine treatment

44. Pleural Fluid Tests • Gram stain (+25-50%) • Antigen or PCR if available (S. pneumoniae, S.aureus) • Pleural fluid analysis rarely changes management and is not recommended • WBC count with differntial helps differentiate source • Majority of cultures will be negative

45. Effusion/Empyema • Total antibiotic therapy 2-4 weeks or 10 days after resolution of fever • If abscess or necrosis is identified tx should begin with IV antibiotics • If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV antibiotics • Abscess secondary to congenital malformation requires surgery consultation • Necrosis should not routinely be managed surgically given high rates of broncho-pleural fistulas

46. A 3yr old female presents to your office in November with cough and tachypnea. You hear crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good fluid intake. Previously healthy and immunizations up to date. You believe patient may be well enough to manage as an outpatient. Which diagnostic tests should be performed on this patient? • Complete blood count • Chest radiograph • Pulse oximetry • Blood culture • All of the above

47. A school aged child hospitalized with community-acquired pneumonia can be safely discharged if he meets which of the following criteria? • Able to tolerate outpatient meds, greater level of activity, improving appetite. • Afebrile for over 24 hours • Pulse oximetry measurements >90% in room air at least 12 hours • A and C • A, B, and C

48. Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided to this child managed as an outpatient? • A second-or third-generation cephalosporin (e.g., cefdinir, cefixime) for 10 days. • Amoxicillin 90mg/kg/day divided 2 times a day for 10 days • Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5 • Combined treatment with both amoxicilln and azithromycin as noted above • No anti-infective therapy indicated

49. A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended? • A third-generation parenteral cephalosporin (e.g., cefotaxime or ceftriaxone) • Intravenous clindamycin • A third-generation parenteral cephalosporin plusazithromycin • Intravenous ampicillin • Intravenous vancomycin

50. A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this pathogen consists of: • Ceftriaxone intravenously at 100mg/kg/day • Levofloxacin intravenously at 20 mg/kg/day • Ampicillin intravenously at 400 mg/kg/day • A or C • A, B, or C