Community acquired pneumonia in children (1)

what is community acquired pneumonia(CAP),what is the prevalence of (CAP) ,what are the risk factors and what are the causative agents ,what are the clinical presentations ,how to diagnose it,what are the needed investigations ,what is the management ,what are the procedures to decrease the incidence,

1. Community acquired pneumonia in children Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Departments Khorfakkan Hospital Sharjah ,UAE [email protected]

2. Community acquired pneumonia (CAP) : Definition A clinical diagnosis of pneumonia caused by a community acquired infection in a previously healthy child 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 2

3. Introduction Around 14.4 per 10 000 children aged over 5 years and 33.8 per 10 000 under 5 years are diagnosed with CAP annually in European hospitals (1.2). 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 3 Clark JE, Hammal D, Hampton F, Spencer D, Parker L. Epidemiology of community-acquired pneumonia in children seen in hospital. Epidemiol Infect 2007;356:262-9. Senstad AC, 2.Surén P, Brauteset L, Eriksson JR, Høiby EA, Wathne KO. Community-acquired pneumonia (CAP) in children in Oslo, Norway. Acta Paediatr 2009;356:332-6.

4. Introduction (Cont.) CAP is more common in the developing world , estimated at 0.28 episodes per child per year and accounting for 95% of all cases 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 4 Rudan I, Tomaskovic L, Boschi -Pinto C, Campbell H. WHO Child Health Epidemiology Reference Group. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ 2004;356:895-903

5. Risk factors < 5 years old are at greatest risk ( In otherwise healthy children ) Boys have a higher incidence across all ages . Other risk factors include: Prematurity , Immunodeficiency , Chronic respiratory disease , Neurodisability 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 5

6. Facts Clinical and radiological features do not reliably distinguish between viral and bacterial etiology Obtaining cultures from the lower respiratory tract of young children is tricky More specific but invasive investigations such as pleural aspiration are infrequently indicated and reserved for severe cases 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 6

7. Facts (Cont.) Blood cultures are rarely performed in patients managed in the community, and hospitalized patients demonstrate a poor yield Nasopharyngeal secretions are easily obtainable , and the application of more sensitive techniques such as polymerase chain reaction ( PCR ) has resulted in pathogen identification in 65-83% of reported cases 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 7 Thomson A, Harris M. Community-acquired pneumonia in children: what’s new? Thorax 2011;356:927-8.

8. Etiology: Respiratory viruses Respiratory viruses are common , particularly in infants , accounting for 30-67% of hospitalised cases . Respiratory syncytial virus accounts for 30% of viral etiology . Other viruses include parainfluenza , influenza , and human metapneumovirus . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 8 Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr 2009;356:1429-36.

9. Etiology: bacterial causes Streptococcus pneumoniae is the commonest bacterial cause across all ages, accounting for 30-40% of cases. Other bacterial causes include: group A streptococcus and, in infants , group B streptococcus 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 9 Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr 2009;356:1429-36.

10. Community acquired pneumonia (CAP) : Etiology by age group 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 10 1-3 months Common Streptococcus pneumoniae Chlamydia pneumoniae Respiratory viruses Enterovirus

11. Community acquired pneumonia (CAP) : Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 11 1-3 months Less common Group A streptococcus Group B streptococcus Haemophilus influenzae

12. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 12 1-3 months Rare Mycobacterium spp Varicella zoster virus

13. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 13 < 5 years Common Streptococcus pneumoniae Respiratory viruses

14. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 14 <5 years Less common Mycoplasma pneumoniae Group A streptococcus Haemophilus influenzae Staphylococcus aureus

15. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 15 <5 years Rare Moraxella Mycobacterium spp

16. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 16 ≥ 5 years Common Streptococcus pneumoniae Mycoplasma pneumoniae Respiratory viruses

17. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 17 ≥ 5 years Less common Staphylococcus aureus Chlamydia pneumoniae Mycobacterium spp

18. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 18 ≥ 5 years Rare Group A streptococcus

19. Community acquired pneumonia (CAP) Etiology by age group (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 19 Immunocompromised (all ages) Common As with age group plus Fungi ,Burkholderia , Pseudomonas, and mycobacterium spp

20. CAP assessment It is difficult to distinguish clinically between bacterial and viral aetiologies . Consider bacterial pneumonia in children presenting with persistent or recurrent fever ≥38.5°C over the preceding 24-48 hours with chest wall recession and tachypnea 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 20

21. CAP assessment (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 21 Assess the likelihood and severity of CAP by : Fever Breathlessness Tachypnea Chest wall recession Cough Chest pain Respiratory rate and dyspnea are useful measures of severity and predict oxygen requirement

22. Assessment in the community Focus the examination on defining severity and identify children with underlying conditions who are at increased risk . Hypoxemia increases mortality risk, and oxygen saturations <95% in room air are a key indicator for hospital assessment 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 22

23. Assessment in hospital All children require pulse oximetry . Level of C reactive protein is not useful to differentiate viral and bacterial causes, but it can guide investigation and management of CAP complicated by effusions, empyema, or necrosis . Urinary pneumococcal antigen detection has a high sensitivity but very low specificity . If it is available, consider using it as a negative predictor . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 23 Charkaluk M-L, Kalach N, Mvogo H, et al. Assessment of a rapid urinary antigen detection by an immunochromatographic test for diagnosis of pneumococcal infection in children. Diagn Microbiol Infect Dis 2006;356:89-94

24. Assessment in hospital (cont.) Avoid routine chest radiography in children requiring hospital admission Radiographic appearance correlates poorly with clinical signs and outcome Consider radiography: In severe cases Where complications such as effusion or empyema are suspected 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 24

25. British Thoracic Society recommended investigations for complicated or severe community acquired pneumonia ( CAP) Bloods (full blood count, urea and electrolytes, C reactive protein, blood culture, anti-streptolysin O titre, serology for viruses, Mycoplasma pneumoniae and Chlamydia pneumoniae, atypical CAP screen) Nasopharyngeal secretions and swabs for viral PCR or immunofluorescence detection 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 25

26. British Thoracic Society recommended investigations for complicated or severe community acquired pneumonia ( CAP) (Cont.) Chest x ray to assess for effusion or empyema Consider pleural fluid for : Microscopy , culture (including tuberculosis ) Pneumococcal antigen for PCR Biochemistry Cytology (if aspiration required) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 26

27. CAP assessment (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 27

28. CAP assessment (Cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 28

29. Chest X-rays of a CAP patient before ( left ) and after treatment 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 29 https:// en.wikipedia.org/wiki/Community-acquired_pneumonia

30. Gram stain showing Streptococcus pneumoniae 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 30 https:// emedicine.medscape.com/article/234240-overview

31. British Thoracic Society criteria for referral to paediatric intensive care Indications for referral : Development of respiratory failure requiring assisted ventilation Pneumonia complicated by septicaemia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 31

32. British Thoracic Society criteria for referral to paediatric intensive care (cont.) Clinical features: Failure to maintain oxygen saturations >92% with FiO2 60% Clinical features of shock Increasing respiratory and heart rates with severe respiratory distress and exhaustion, with or without raised pCO2 Recurrent apnoea or slow irregular breathing 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 32

33. Red flag features for community acquired pneumonia (CAP) History of underlying comorbidities, including: Bronchopulmonary dysplasia Disorders of mucus clearance (such as cystic fibrosis) Congenital heart disease Immunodeficiency Severe cerebral palsy 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 33

34. Red flag features for community acquired pneumonia (CAP ) (cont.) Relevant medical history : History of severe pneumonia (inpatient stay requiring oxygen, paediatric intensive care admission, complications of CAP (such as lung abscess, effusion, empyema) Recurrent pneumonia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 34

35. CAP management Children with clinical features consistent with CAP require antibiotics . CAP in a fully vaccinated child less than 2 years old (who has received the pneumococcal vaccine) with mild symptoms is unlikely to be bacterial , and antibiotics are not required unless symptoms become more severe . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 35

36. British Thoracic Society recommendations for antibiotic selection in community acquired pneumonia (CAP) Preferred route of administration Oral antibiotics are safe and effective for children even with severe CAP Use intravenous antibiotics in children who: – Are unable to tolerate oral fluids (such as because of vomiting ) or – Have signs of septicaemia or complicated pneumonia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 36

37. British Thoracic Society recommendations for antibiotic selection in community acquired pneumonia (CAP ) (cont.) Which antibiotic? Amoxicillin is first line therapy (use macrolides as first line in penicillin allergy) Macrolides can be added at any age if : There is no response to first line therapy Mycoplasma or Chlamydia pneumoniae are suspected Disease is severe 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 37

38. British Thoracic Society recommendations for antibiotic selection in community acquired pneumonia (CAP ) (cont.) Which antibiotic? (Cont.) Co- amoxiclav is recommended for pneumonia associated with influenza Intravenous antibiotic treatment with amoxicillin, co-amoxiclav , cefuroxime, cefotaxime, or ceftriaxone is recommended for severe pneumonia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 38

39. Supportive therapies and advice for care givers Advice on signs of deterioration, dehydration, and complications Ask the parents or carers to seek further advice if fever persists or symptoms deteriorate despite 48 hours of antibiotic treatment In secondary care , children with oxygen saturations <92% in room air require supplemental oxygen to maintain >95% saturation 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 39

40. Supportive therapies and advice for care givers Oxygen can be administered via face mask, nasal cannulae, or head box . Nasogastric feeds can maintain hydration, but if they are not tolerated because of vomiting or severe illness, intravenous fluid replacement may be required, with daily electrolyte monitoring for sodium depletion or syndrome of inappropriate antidiuretic hormone secretion. There is no any benefit from physiotherapy on radiological resolution, length of hospital stay, or symptom improvement 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 40

41. CAP complications Empyema Is the most common complication 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 41 Risk factors Age >3 years Recent varicella infection

42. Empyema (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 42 Signs and symptoms Fever >7 days Evidence of effusion: - Decreased chest expansion - Dull percussion - Reduced or absent breath sounds ± Cyanosis Pleuritic chest pain Severe CAP symptoms No response to 48 hours antibiotics

43. Empyema (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 43 Investigations Chest x ray Ultrasound scan Blood tests Microbiology

44. Empyema (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 44 Treatment Referral to tertiary centre • High dose IV antibiotics ± Thoracentesis or decortication ± Fibrinolytic therapy Oral antibiotics for further 1-4 weeks

45. CAP complications (Cont.) Necrotising pneumonia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 45 Risk factors Congenital lung abnormalities Bronchiectasis Immunodeficiency Neurological disorders Staphylococcal aureus with PVL toxin • • • PVL = Panton-Valentin leucocidin

46. Necrotising pneumonia (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 46 Signs and symptoms Insidious onset Productive foul smelling sputum Persistent fever Weight loss Night sweats Pleuritic chest pain

47. Necrotising pneumonia (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 47 Investigations Chest x ray CT scan Blood tests Microbiology

48. Necrotising pneumonia (cont.) 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 48 Treatment Referral to tertiary centre • High dose IV antibiotics (2-3 week course) Prolonged oral antibiotic course ± Surgical intervention

49. CAP complications (Cont.) Other complications include: Systemic sepsis Haemolytic uremic syndrome Bronchiectasis following severe or complicated CAP 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 49

50. Measurements to reduce CAP incidence The schedule of giving the following vaccines is hoping to reduce CAP incidence: P neumococcal conjugate vaccine (PCV) at 2, 4, and 12 months old . Haemophilus influenzae type B (Hib) vaccination is given at 2, 3, and 4 months with a booster at 1 year . An annual influenza vaccine is given to children between 2 and 8 years old every September, including children in school years 1, 2, and 3 . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 50

51. Measurements to reduce CAP incidence (cont.) Additional pneumococcal, and in some cases influenza, vaccination is provided for high risk children with: asplenia or splenic dysfunction cochlear implants (due to the meningitis risk ) chronic disease complement disorders immunosuppression. 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 51

52. Conclusion Pneumonia can be diagnosed clinically when there are signs of a lower respiratory tract infection and wheezing syndromes have been ruled out . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 52

53. Conclusion Blood tests and microbiological investigations are NOT recommended for routine use in the diagnosis and management of CAP . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 53

54. Conclusion CXR does not need to be performed in those with mild disease who will be managed as an outpatient . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 54

55. Conclusion Respiratory viruses are common , particularly in infants , accounting for 30-67% of hospitalised cases 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 55

56. Conclusion Streptococcus pneumoniae is the commonest bacterial cause across all ages, accounting for 30-40% of cases. 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 56

57. Conclusion < 5 years old are at greatest risk (In otherwise healthy children) Boys have a higher incidence across all ages . 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 57

58. Conclusion For non-severe pneumonia , high dose oral amoxicillin is recommended even for inpatient use.  IV benzylpenicillin can be considered if patient is not tolerating oral intake and not vomiting. 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 58

59. Conclusion Empyema and necrotizing pneumonia are the most serious complications of Community acquired pneumonia 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 59

60. Conclusion To reduce the CAP incidence ,the following vaccines have been given : Pneumococcal conjugate vaccine (PCV) Haemophilus influenzae type B (Hib) vaccination An annual influenza vaccine 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 60

61. References Thomson A, Harris M. Community-acquired pneumonia in children: what’s new ? Thorax 2011;356:927-8 Clark JE. Determining the microbiological cause of a chest infection. Arch Dis Child 2015;356:193-7. Clark JE, Hammal D, Hampton F, Spencer D, Parker L. Epidemiology of community-acquired pneumonia in children seen in hospital. Epidemiol Infect 2007;356:262-9. Senstad AC, 2.Surén P, Brauteset L, Eriksson JR, Høiby EA, Wathne KO. Community-acquired pneumonia (CAP) in children in Oslo, Norway. Acta Paediatr 2009;356:332-6 . Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr 2009;356:1429-36 Charkaluk M-L, Kalach N, Mvogo H, et al. Assessment of a rapid urinary antigen detection by an immunochromatographic test for diagnosis of pneumococcal infection in children. Diagn Microbiol Infect Dis 2006;356:89-94 https:// www.scribd.com/document/358621252/Basic-Concepts-on-Communityacquired-Bacterial-Pneumonia-in-Pediatrics https:// en.wikipedia.org/wiki/Community-acquired_pneumonia https://www.rch.org.au/clinicalguide / 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 61

62. 2/5/2019 Commuinity acquired pneumonia in children Prof.Dr.Saad S Al Ani 62