Pneumonia (peds): Difference between revisions

Revision as of 12:39, 14 October 2014

Background

Most common site of infection in neonates
Fever and tachypnea are sensitive but not specific

Bugs by Age Group

Newborn
1mo-3mo
3mo-5yr
- S. pneumoniae
- S. aureus
- H. influenzae type b
- Nontypeable H. influenzae
- C. trachomatis
- Mycoplasma pneumoniae
5–18 y
- M. pneumoniae
- S. pneumoniae
- C. pneumoniae
- H. influenzae type b
- S. aureus

Diagnosis

Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
- Productive cough is rarely seen before late childhood
Imaging
- CXR is not the gold standard!
- Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
- Consider for:
  - Age 0-3mo (part of w/u for sepsis)
  - <5yr w/ temp >102.2, WBC >20K and no clear source of infection
  - Ambiguous clinical findings
  - PNA that is prolonged or not responsive to abx
Consider rapid assays for RSV, influenza
Blood/nasal culture are low yield

Treatment^[1]

Newborn

Hospitalized
- Ampicillin (80-90mg/kg/day) + (gentamicin OR cefotaxime)
Outpatient
- Initial outpatient management not recommended

1-3 Month

Hospitalized
- Afebrile pneumonitis
  - Erythromycin or clarithromycin
- Febrile pneumonia
  - Cefuroxime ± (erythromycin IV or clarithromycin PO)
- Severe: choose one of
  - Cefuroxime + (erythromycin or clarithromycin)
  - Cefotaxime + erythromycin
  - Cloxacillin + clarithromycin
Outpatient
- Initial outpatient management not recommended

3mo - 5 year

Hospitalized
- Mild
  - PO: Amoxicillin or Amoxicillin-clavulanate
  - IV: Ampicillin or cefuroxime
- Moderate or severe
  - (Ampicillin or cefuroxime) + (erythromycin or clarithromycin) IV
Outpatient
- Amoxicillin or amoxicillin-clavulanate or cefuroxime axetil

5yr - 18yr

Hospitalized
- Ampicillin IV + (erythromycin OR clarithromycin)
- Alternative
  - Cefuroxime or amoxicillin-clavulanate or erythromycin or clarithromycin
- Moderate to severe
  - Cefuroxime + (erythromycin or clarithromycin)
Outpatient
- Erythromycin or clarithromycin or amoxicillin or amoxicillin-clavulanate or cefuroxime axetil

Disposition

All Children less than 2 months should be hospitalized^[1]
Consider admission for:
- Age of birth to 3mo
- History of severe or relevant congenital disorders
- Immune suppression (HIV, SCD, malignancy)
- Toxic appearance/resp distress
- SpO2 <90-93%

Source

↑ ^1.0 ^1.1 AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.

Authors:

[AAP-1] 1.0 ^1.1 AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.

[1]

@@ Line 1: / Line 1: @@
 == Background ==
 *Most common site of infection in neonates
-*Fever and tachypnea are Sensitive but not Specific
+*Fever and tachypnea are sensitive but not specific
-=== Causes ===
-==== Neonatal ====
-{| class="wikitable"
-|-
-! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Etiology
-! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Clinical Presentation
-! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Management Approach
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
-Bacterial
-[[Group B Streptococcus]] (most common), [[Escherichia coli]], [[Listeria monocytogenes]], [[Haemophilus influenzae]], [[S. pneumoniae]] [[Klebsiella]] species, [[Enterobacter]] aerogenes
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Full evaluation for sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative. Two culture samples may increase diagnostic yield fourfold.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | A lumbar puncture should be done if there are no contraindications.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Hospitalization, supportive care (<small>O</small><sub>2</sub>), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available).<br/>&nbsp;
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nosocomial infections in premature infants (''Staphylococcus aureus'',''Pseudomonas aeruginosa'')&nbsp;
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Same as for common bacterial etiology.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Same as for common bacterial etiology.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ''Chlamydia''&nbsp;
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Develops in 3%–16% of exposed neonates (in colonized mothers).
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR may show hyperinflation with interstitial infiltrates.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Definitive diagnosis by nasopharyngeal swab PCR or cultures.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Eosinophilia may be seen on peripheral blood count.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Treatment: macrolide (erythromycin, clarithromycin, or azithromycin).
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
-''Bordetella pertussis''
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | In addition to pneumonia, may causes paroxysms of cough, ± cyanosis and post-tussive emesis in otherwise well-looking infant. Characteristic whoop is not present in neonates. Apnea may be the only symptom. Suspect when adult caregiver also has persistent cough.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Diagnosis via nasopharyngeal swab for PCR and/or culture.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Macrolides are efficient against&nbsp;''B. pertussis''&nbsp;but is not approved by the U.S. Food and Drug Administration for infants <6 mo.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Neonates need to be admitted during treatment and monitored for severe adverse effects.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" |
-''Mycobacterium tuberculosis''
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Half of infants born to actively infected mothers develop TB if not immunized or treated.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as for bacterial pneumonia.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR, culture of urine, gastric and tracheal aspirates.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Skin testing not sensitive in neonates.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Routine anti-TB treatment.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Supportive treatment as needed.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly).
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="6" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza)
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Initial upper respiratory illness progressing to respiratory distress and feeding difficulty.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sepsis evaluation as indicated.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab).
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Hypoxia and apnea may be present.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Often indistinguishable from bronchiolitis.
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Rate of concurrent bacterial infections in confirmed viral infection is low.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | CXR for significant respiratory distress.
-|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;"
-| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Supportive therapy; monitoring for apnea in young and premature infants.
-|}
-==== Infants and Children ====
-*More likely to have viral cause
-**Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
-***Pneumococus, H. flu, staph, pertussis
-**If age >5 consider mycoplasma (treat w/ macrolide)
 ===Bugs by Age Group===
@@ Line 124: / Line 29: @@
 == Diagnosis ==
 *Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
 **Productive cough is rarely seen before late childhood

Pneumonia (peds): Difference between revisions

Revision as of 12:39, 14 October 2014

Background

Bugs by Age Group

Diagnosis

Treatment[1]

Newborn

1-3 Month

3mo - 5 year

5yr - 18yr

Disposition

Source

Treatment^[1]