Pediatric Community Acquired Pneumonia and CAP

Pcap cap

1. PEDIATRIC COMMUNITYPEDIATRIC COMMUNITY
ACQUIRED PMEUMONIAACQUIRED PMEUMONIA
By: Nelly M. Wata
Clinical Clerk

2. EtiologyEtiology

3. EpidemiologyEpidemiology
According to WHO, pneumonia is the single
most common cause of death in children,
estimated at 1.2 million every year.
This represents 18% of all deaths below 5
years of age worldwide.5 The large majority
of deaths occur in low to middle income
countries
In the Philippines, pneumonia is the third
leading cause of death across all ages and is
the most common cause of death among
children <5 years of age
Philippines has a relatively high age-
standardized death rate of 126.05 per
100,000 population as of 2017

4. PATHOGENESISPATHOGENESIS
Resipratory tract organisms colonize the trachea
and subsequently gain access to the lungs
S. pneumoniae Group B Streptococcus Staphylococcus aureus
local edema --> focal
l lobar involvement.
necrosis of tracheobronchial mucosa;
formation of large amounts of exudate,
edema, and local hemorrhage, with
extension into the interalveolar septa;
involvement of lymphatic vessels
unilateral and characterized
by the presence of extensive
areas of hemorrhagic necrosis
and irregular areas of
cavitation of the lung
parenchyma
sloughed cellular debris, inflammatory cells,
and mucus cause airway obstruction

5. PARAMETERS: FOR ADMISSIONPARAMETERS: FOR ADMISSION

6. PARAMETERS: FOR ADMISSIONPARAMETERS: FOR ADMISSION

7. PARAMETERS: ANTIBIOTIC THERAPYPARAMETERS: ANTIBIOTIC THERAPY
Empiric antibiotic therapy is considered in patients with clinical signs
and symptoms of PCAP with any of the following:
High WBC
High CRP
High PCT
Imaging
Alveolar infiltrates in chest x-ray
Unilateral, solitary lung consolidation and/or air bronchograms
and/or pleural effusion in lung ultrasound

8. PARAMETERS: ANTIBIOTIC THERAPYPARAMETERS: ANTIBIOTIC THERAPY
For severe PCAP:
Start Penicillin G at 200,000 units/kg.day q6 (complete Hib
vaccinations) or Ampicillin at 200mg/kg/day q6 (no
vaccination)
Cefuroxime at 100-150mg/kg/day q8 or Ceftriaxone at 75-
100mg/kg/day q12-24 or Ampicillin-sulbactam at
200mg/kg.dat q6 (high penicillin resistant pneumococci)
Clindamycin at 20-40mg/kg/day q6-8 (Staphylococcal origin)
Vancomycin at 40-60mg/kg/day q6-8 for severe cases

9. PARAMETERS: ANTIVIRAL THERAPYPARAMETERS: ANTIVIRAL THERAPY
OSELTAMIVIR must be started immediately within 36 hours
in laboratory-confirmed influenza infection

10. PARAMETERS: GOOD RESPONSEPARAMETERS: GOOD RESPONSE
FOR SEVERE PCAP, a GOOD response is considered when ANY of the
following is observed within 24-72 hours after initiation of treatment:
Absence or Resolution of hypoxia
Absence or Resolution of danger signs
Absence or Resolution of tachypnea
Absence or Resolution of fever
Absence or Resolution of tachycardia
Resolving or Improving radiologic pneumonia
Resolving or Absent chest ultrasound findings
Normal CRP and/or PCT

11. PARAMETERS: POOR RESPONSEPARAMETERS: POOR RESPONSE
FOR SEVERE PCAP and not improving or clinically worsening within 24-72
hours after initiation of treatment, futher diagnostic evalutation to determine if
any of the following is present:
Coexisting or other etiologic agents
Etiologic agent resistant to current antibiotic, if being given
Other diagnosis
Pneumonia-related complication
Pleural effusion
Necrotizing pneumonia
Lung abscess
Asthma
Pulmonary tuberculosis

12. PARAMETERS: POOR RESPONSEPARAMETERS: POOR RESPONSE
Diagnostic evaluations in the treatment failure in severe PCAP:
Culture
PCR
Serology
Imaging: Chest X-ray, UTZ, CT Scan
Biomarkers: CBC, CRP, PCT
*referral to a specialist is considered.

13. PARAMETERS: SWITCH THERAPYPARAMETERS: SWITCH THERAPY
Switch therapy when ALL of the clinical parameters are
present:
Parenteral antibiotic is given for at least 24 hours
Able to feed and without vomiting or diarrhea
Absence of hypoxia, danger signs, tachypnea, fever,
tachycardia

14. ADJUNCTIVEADJUNCTIVE
THERAPYTHERAPY
Vitamins A is strongly recommended for measles
pneumonia
Zinc: not considered
it does not have any effect in shortening recovery
time.
Vitamin D: not considered
as it does not reduce the length of hospital stay
Bronchodilators are considered in the presence of
wheezing
Mucokinetic, secretolytic, and mucolytic agents are not
considered

15. EFFECTIVE INTERVENTIONSEFFECTIVE INTERVENTIONS
Vaccination against S. pneumoniae, H. influenzae, B. pertussis,
Rubeola virus, Influenza virus
Breastfeeding
Avoidance of environmental tobacco smoke or indoor biomass
fuel exposure
Zinc supplmentation
Vitamin A, C, D supplmentation

16. Typically, 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.
A repeat chest radiograph is the first step in determining
the reason for delay in response to treatment.
PROGNOSISPROGNOSIS

17. pleural effusion
empyema
pericarditis
bacteremia and hematologic spread
RARE: Meningitis, suppurative arthritis, and osteomyelitis
(pneumococcal or H. influenzae type b infection)
MOST COMMON: S. aureus, S. pneumoniae, and S.
pyogenes parapneumonic effusions and empyema
COMPLICATIONSCOMPLICATIONS

18. Vaccination has reduced the incidence of pneumonia
hospitalizations
Seven-valent pneumococcal conjugate vaccine (PCV7) was
licensed and recommended.
Studies suggest that vaccination has resulted in preventing
hospitalization for young children with pneumonia.
In 2010, the 13-valent pneumococcal conjugate vaccine
(PCV13) was licensed and may prevent more cases of
pneumococcal disease not covered by the PCV7
PREVENTIONPREVENTION

19. Community Acquired
Pneumonia
by: Nelly M. Wata

20. RISK
STRATIFICATION
for CAP

21. ETIOLOGY

22. Pathophysiology
It results when the
pathogen reaches the
alveolar level → host
defenses are
overwhelmed →
inflammatory event →
damage of the lung
parenchyma →
pneumonia

23. Clinical Manifestation
Cough
Fever
Chills and or sweats
Tachycardia
Tachypnea
Percussion note: dull
(consolidated lung) or
flat (pleural fluid)
Auscultation:
crackles, pleural
friction rub

24. Diagnostics
Chest Radiography
Microbiologic studies (sputum and
blood culture)
Complete blood count
COVID-19 RTPCR test: to rule out
COVID

25. Treatment (Pharmacologic)
Amoxicillin 1g TID
Clarithromycin 500mg BID
Azithromycin 500 mg OD
LOW RISK

26. Treatment (Pharmacologic)
Ampicillin-sulbactam 1.5-3 g IV every 6hrs or
Cefotaxime 1-2g IV every 8 hrs or
Ceftriaxone 1-2 g IV daily
PLUS
Azithromycin 500 mg daily or
Clarithromycin 500 mg twice daily
MODERATE RISK

27. Treatment (Pharmacologic)
(HIGH RISK ADULT CAP)
Ampicillin-sulbactam 1.5-3 g IV every 6hrs or
Cefotaxime 1-2g IV every 8 hrs or
Ceftriaxone 1-2 g IV daily
PLUS
Azithromycin 500 mg PO/IV daily or
Erythromycin 500 mg PO every 6 hrs or
Clarithromycin 500 mg PO twice daily
HIGH RISK

28. Prevention
Pneumococcal vaccination

29. Thank
you

30. REFERENCESREFERENCES
Nelson's Textbook of
Pediatrics 21st Edition
Philippine Academy of
Pediatric Pulmonologists
Philippine Foundation
for Vaccination, Inc.
Philippine Pediatric
Society
Pediatric Infectious
Disease Society of the
Philippines
Department of Health
(Philippines)

31. References