Management of Pneumonia

The main treatment for pneumonia is antibiotics, along with rest and drinking plenty of water. If you have chest pain, you can take pain killers such as paracetamol. Treatment depends on how severe your pneumonia is. Treatment with antibiotics should be started as soon as possible after diagnosis.

1. Management of Pneumonia Sumi Singh Nepal Medical College and Teaching Hospital

2. Investigation Complete Blood Count : Leukocytocis C-Reactive Protein Arterial Blood Gas Analysis Renal function test (Urea >7 mmol /L and Hyponatremia indicates severity) Liver Function Test

3. Blood Culture & Sensitivity Sputum Examination : Gram Staining and Culture Pleural fluid : Gram staining and culture ELISA during the acute stage : IgM antibody (in atypical pneumonia) Complement fixation test after one week of illness : IgG antibodies Polymerase Chain Reaction (PCR)

4. Chest X – ray : Hyperinflation & Interstitial infiltrates (Viral Pneumonia) Consolidation Pneumatoceles (Staphylococcal & Klebsiella ) Blunt Costo -Phrenic angles (Pleural Effusion,Empyema , pyopneumothorax (Staphylococcus))

5. Definitive diagnosis of a viral infection Isolation of a virus in respiratory tract secretions by culture Growth of respiratory viruses in conventional viral culture usually requires 5-10 days, although shell vial cultures can reduce this “ turnaround time ” to 2-3 days. Detection of the viral genome or antigen in respiratory tract secretions by PCR

6. Other investigation for Viral Pneumonia Reliable DNA or RNA tests for the rapid detection of RSV, parainfluenza, influenza, and adenoviruses are available and accurate. Serologic testing may be valuable as an epidemiologic tool

7. Definitive diagnosis of a bacterial infection Isolation of an organism from the blood, pleural fluid, or sputum. Blood culture results are positive in only 10% of children with pneumococcal pneumonia.

8. Diagnosis of Mycoplasma pneumonia infection Acute infection caused by M. pneumoniae can be diagnosed on the basis of a positive polymerase chain reaction (PCR) test result. Seroconversion in an IgG assay

9. Cold agglutinins at titers > 1 : 64 are found in the blood in ≈ 50% of patients with M. pneumoniae infections

10. Treatment

11. Treatment of suspected bacterial pneumonia is based on the presumptive cause and the age and clinical appearance of the child. For mildly ill children who do not require hospitalization, amoxicillin is recommended (25 – 50 mg/kg/day) In communities with a high percentage of penicillin-resistant pneumococci, high doses of amoxicillin (80-90 mg/kg/24 hr ) should be prescribed. Therapeutic alternatives include cefuroxime (75 – 150 mg/kg/day)and amoxicillin/ clavulanate (40 – 60 mg/kg/day)

12. Suspected M.pneumoniae or C. pneumoniae School going children : A macrolide antibiotic such as azithromycin is an appropriate choice In adolescents, a respiratory fluoroquinolone (levofloxacin, moxifloxacin , gemifloxacin ) may be considered as an alternative

13. If viral pneumonia is suspected Withhold antibiotic therapy, especially for those patients who are mildly ill, clinical evidence suggesting viral infection, and are in no respiratory distress. Deterioration in clinical status should signal the possibility of superimposed bacterial infection, and antibiotic therapy should be initiated

14. In – Hospital Management Nil Per Oral O 2 supplementation Nebulization Antipyretics for fever Intravenous fluids Anti – microbial therapy

15. Parenteral cefotaxime or ceftriaxone is the mainstay of therapy when bacterial pneumonia is suggested. If clinical features suggest staphylococcal pneumonia (pneumatoceles, empyema), initial antimicrobial therapy should also include vancomycin or clindamycin.

16. Duration of therapy Antibiotics should probably be continued until the patient has been afebrile for 72 hours, and the total duration should not be less than 10 to 14 days (or 5 days if azithromycin is used). oral zinc (20 mg/day) helps accelerate recovery from severe pneumonia.

17. MANAGING COMPLICATIONS

18. Complications of pneumonia are usually the result of direct spread of bacterial infection within the thoracic cavity (pleural effusion, empyema, pericarditis) or bacteremia and hematologic spread Meningitis, suppurative arthritis, and osteomyelitis are rare complications of hematologic spread of pneumococcal or H. influenzae type b infection.

19. S. aureus, S. pneumoniae , and S. pyogenes are the most common causes of parapneumonic effusions and of empyema The treatment of empyema is based on the stage (exudative, fibrinopurulent , organizing). Imaging studies including ultrasonography and CT are helpful in determining the stage of empyema. The mainstays of therapy include antibiotic therapy and drainage with tube thoracostomy .

20. Additional approaches include the use of intrapleural fibrinolytic therapy ( urokinase,streptokinase , tissue plasminogen activator) and selected videoassisted thoracoscopy (VATS) to debride or lyse adhesions, and drain loculated areas of pus. Late Stage requires thoracotomy and open debridement.

21. Intercostal Chest tube drainage under water seal for large effusions causing respiratory distress Mechanical Ventilation for Impending Respiratory Failure

22. PROGNOSIS

23. Patients with uncomplicated community-acquired bacterial pneumonia show response to therapy, with improvement in clinical symptoms (fever, cough, tachypnea, chest pain), within 48-96 hr of initiation of antibiotics

24. A number of factors must be considered when a patient does not improve with appropriate antibiotic therapy: (1) complications, such as empyema; (2) bacterial resistance; (3) nonbacterial etiologies such as viruses and aspiration of foreign bodies or food; (4) bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs;

25. (5) pre-existing diseases such as immunodeficiencies , ciliary dyskinesia, cystic fibrosis, pulmonary sequestration, or cystic adenomatoid malformation; and (6) other noninfectious causes (including bronchiolitis obliterans, hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, and Wegener’s granulomatosis).

26. A repeat chest radiograph is the 1st step in determining the reason for delay in response to treatment

27. Mortality Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.4 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide

28. Protecting children from pneumonia include promoting exclusive breastfeeding and hand washing, and reducing indoor air pollution; prevent pneumonia with vaccinations; treat pneumonia are focused on making sure that every sick child has access to the right kind of care - either from a community-based health worker, or in a health facility if the disease is severe - and can get the antibiotics and oxygen they need to get well.

29. PREVENTION Universal childhood vaccination with conjugate vaccines for H. influenzae type b and S. pneumonia Annual influenza vaccine is recommended for all children over 6 months of age Trivalent, inactivated influenza vaccine is licensed for use beginning at 6 months of age; live, attenuated vaccine can be used for persons 2 to 49 years of age

30. Prevention of Hospital Acquired Pneumonia Reducing the duration of mechanical ventilation and administering antibiotics judiciously reduces the incidence of ventilator-associated pneumonias The head of the bed should be raised to 30 to 45 degrees for intubated patients to minimize risk of aspiration, and all suctioning equipment and saline should be sterile. Hand washing before and afterevery patient contact and use of gloves for invasive procedures are important measures to prevent nosocomial transmission of infections.

31. References Nelson Textbook of Pediatrics – 19 th Edition Nelson Essential Pediatrics – 7 th Edition Ghai Essential Pediatrics – 8 th Edition Management of Pediatric Community-acquired Bacterial Pneumonia-AAP Publications