Pediatrics Community Acquired Pneumonia case study.pptx

about pediatric community-acquired pneumonia

1. Pediatrics Community Acquired Pneumonia case study CPC CASE ENDORSEMENT By: MANDAL , AJAY KUMAR Clerkship Student Gullas college of Medicine  

2. GENERAL DATA C.Z.M.V. 2 years old MALE Filipino Catholic MARIBOJOC, Bohol DATE OF ADMISSION: 01/08/2022 Informant:Grandmother Reliability: 80%

3. CHIEF COMPLAINT Fever

4. HISTORY OF PRESENT ILLNESS 3 day prior to admission Patient had onset of fever (38.0°C) that started abruptly. The patient condition was relieved temporarily when he was given paracetamol (125 mg/5 ml), 5 ml every 4 hours(AD=10 mg/kg/dose) at primary health care. Fever was continuous with no associated symptoms (i.E. Cough, difficulty of breathing) no consult done. On day of admission Persistence of fever and this time associated with decrease in apatite and activity. No other symptoms noted, persistence of fever prompted the patient to seek consult in GCGMH and got admitted.

5. General (+) fever (+) Decrease activity (+) Irritability (+) Loss of appetite Skin (-) jaundice (-) rash (-) pigmentation (-) pruritus HEENT (-) headache (-) epistaxis (-) Ear and Nasal discharges CVS (-) Palpitations (-) chest pain Gastrointestinal (-) Abdominal pain (-) vomiting (-) hematochezia /melena Genitourinary (-) hematuria (-) dysuria Endocrine (-) cold and heat intolerance Musculoskeletal (-) limitation of motion (-) stiffness (-) limping Hema (-) pallor (-) easy bruisability REVIEW OF SYSTEM Thorax and lungs (-) cold (-) cough (+)tachypnea   Nervous/ Behavioral (-) Tremors (-) sleep problems (-) convulsions (-) Seizures

6. BIRTH AND METERNAL HISTORY (NATAL, PRENATAL AND PERINATAL) NATAL HISTORY Delivered full term by Normal spontaneous delivery in Health center, MARIBOJOC, BOHOL Cephalic NO Complications during delivery Duration of labor 5 Hrs. PERINATAL HISTORY Born to a 28 year old G2P2 (2002) mother Non-smoker, non-alcoholic beverage drinker No history of bleeding, infections and radiation exposure NEONATAL HISTORY Good cry, good activity Birth rank: 2nd Birthweight: 2.5 kg Birth length: Unrecalled Pediatric Aging: 37 weeks No resuscitation No complications during birth

7. GROWTH AND DEVELOPMENTAL HISTORY 3 months – no head lag 7 months – crawling 1 yrs old – walking, saying mama papa 18 months - run APPROPRIATE FOR AGE

8. GROWTH AND DEVELOPMENTAL HISTORY DEVELOPMENTAL MILESTONES FOR 2 YEAR OLD CHILD Gross Motor : Walks up and down steps without help Fine/Visual Motor/Problem Solving: Imitates stroke with pencil, builds tower of 7 blocks , turns pages one at a time, removes shoes, pants, etc. Language: Uses pronouns (I, you, me) inappropriately, follows two-step commands, uses two-word sentences Social/Adative: Parallel play

9. NUTRITIONAL/ FEEDING HISTORY Purely breastfed up to 6 month of age At 6 th month of age, solid foods were introduced (i.e., Lugaw, cereals), which patient tolerated Mixed feeding (breast milk + solid foods) until present He eats 3 times a day and diet includes mostly rice, fish and vegetables

10. IMMUNIZATION HISTORY Fully vaccinated for the age, as reported by informant

11. PAST MEDICAL HISTORY No any surgeries or hospitalization done.

12. FAMILY HISTORY Mother - 29 yrs/ housewife/ college level/ well Father - 31 yrs/ construction worker/ college level/well Paternal side – no known diseases Maternal side – no known diseases Has older brother 4 yrs old suffer from unspecified allergies ( skin rashes )

13. PERSONAL AND SOCIAL HISTORY Patient likes to watch cartoons videos in day time. The patient plays with his brother and neighbor's child.

14. ENVIROMENTAL HISTORY They have 3 rooms in the house, where 6 people of family live and have a good water supply and living conditions. They maintain cleanliness, coconut trees surround the family’s house. And no standing water present

15. PHYSICAL EXAMINATION VITAL SIGNS TEMP: 38.9 °C BP: 90/60 mmHg HR: 149 bpm RR: 48 breaths/m SpO2: 99% at room air ANTHROPOMETRIC MEASUREMENT : Weight:11.7 kg Height: 90 cm Head Circumference: 49cm

16. PHYSICAL EXAMINATION ANTHROPOMETRIC MEASUREMENT : Weight for Age:11.7 kg (Z score of weight for age fall between 0 to below -1) Normal for age

17. PHYSICAL EXAMINATION ANTHROPOMETRIC MEASUREMENT : B. Length(height) for age : 90 cm (Z score of height for age fall between 0 to 2 ) Height is normal for age

18. PHYSICAL EXAMINATION ANTHROPOMETRIC MEASUREMENT : C. Weight-for-length/height (Z score of weight for length fall between 0 to below -1) Its normal for age.

19. PHYSICAL EXAMINATION ANTHROPOMETRIC MEASUREMENT : D. Head Circumference for age: 49 cm (Z score for head circumference fall between ≥ -2 to ≤ +2) Normal for age.

20. PHYSICAL EXAMINATION General survey: Patient is awake, (+) irritability , not in respiratory distress Skin Warm to touch, moist. No rash, petechiae, cyanosis or clubbing. HEENT Normocephalic/atraumatic head, hair with normal texture Pinkish palpebral conjunctivae, anicteric sclerae Mobile pinna without masses or tenderness, no discharge (-) Lymphadenopathy, (-) thyroid mass

21. PHYSICAL EXAMINATION Chest/lungs Inspection: thorax is symmetrical with equal chest expansion, no scar, no mass, intercostals and subcostal retractions, tachypneic Palpation: no tenderness, masses or lesions Percussion: resonant both lung fields Auscultation: (+) rales, both lungs Cardiovascular Inspection: AP, no lesions Palpation: apex beat at the 4 th ICS LMCL; (-) thrills/heaves Auscultation: tachycardic , DHS, no murmurs, no bruits on carotid arteries

22. PHYSICAL EXAMINATION Abdomen Inspection: flat, no scars or lesions Auscultation: normoactive bowel sounds Percussion: tympanitic all over Palpation: soft, non-tender, no scar and mass, no organomegaly, liver edge not palpable Extremities No deformities, no clubbing, no cyanosis or edema, strong pulses CRT <2 sec Genitourinary : Grossly male, no skin lesions

23. PHYSICAL EXAMINATION Neurological Mental status: conscious and well oriented to person and place able to recall father’s name. Cranial nerves CN I: smell intact CN II: PERRLA CN III, IV, VI: intact extraocular movements CN V: intact corneal reflexes, intact facial sensation of both side, normal jaw movements CN VII: symmetrical facial expression, closes eyes voluntarily CN VIII: startles to clap and loud noises

24. PHYSICAL EXAMINATION CN IX, X: positive gag reflex, able to swallow milk with good suck, soft palate movement is noticeable. Cn xi: not done CN XII; tongue midline Motor system (-) Asymmetry, weakness, clumsiness. Normal muscle bulk and tone throughout. Reflexes Meningeal signs (negative brudzinki’s and kernig’s sign) noted.  REFLEXES Biceps Triceps knee Ankle R +2 +2 +2 +2 L +2 +2 +2 +2

25. SALIENT FEATURES 2 yrs. old, male (+) Irritability Loss of appetite (+) Fever for 3 days On PE (+) rales , tachycardic Intercostals and subcostal retractions Tachypneic

26. DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS RULE IN RULE OUT A. Covid-19 History of fever Tachypnea Rapid progression of symptoms (-) Cough (-) Sore throat No known close contact Cannot be completely rule out B. Bronchiolitis (+) Fever (+) Loss of appetite (+) Rales (+) Tachycardia (+)Retraction (+)tachypneic (-) Vomiting (-) Nasal flaring and congestion (-) Wheezing Common in younger than 2 years of age C. Pneumonia, viral (+) 2yrs old patient (+) Irritability (+) Rales (+) most common in pCAP (4month- 4 yrs) (+)Retraction (+)Tachypneic (-) Cough (-) Rhinorrhea (-)Fever >38.5°C Cannot totally rule out D. Pneumonia, bacterial (+) Irritability (+) Rales (+) Fever>38.5°C (+)Retraction (-) Vomiting (-) Diarrhea (-) wheezing Most common in 3weeks to 3months of age Cannot totally rule out

27. PRIMARY IMPRESSION Pediatric Community Acquired Pneumonia, Category C BASIS: (+) Irritability Loss of appetite (+) fever for 3 days On PE (+) rales , Tachycardic Intercostals And subcostal retractions Tachypneic

28. COURSE IN THE WARDS

29. AT THE ER (January 8, 2022) Subjective Objective Assessment Plan (+) Fever (+) Coryza (-) vomiting (-) abdominal pain (-) cough (+) decreased appetite General survey: Awake, irritable , not in respiratory distress Vital Signs: T: 38.5 o C HR: 120 bpm RR: 48 cpm O2 Sat: 99% RA Weight: 11.7 kg SKIN: warm, dry, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, pink moist lips C/L: equal chest expansion, (+) subcostal & intercostal retractions , resonant, (+) rales on bilateral lung fields , no wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, normoactive bowel sounds, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C T/C Dengue fever without warning signs Admit patient to ISO 5 Secure consent to care Diet for age Start IVF: D5LR 1L at 45 cc/hr Diagnostics: CBC Dengue Duo Chest X-ray Procalcitonin CRP Blood C/S RAT, NPS/OPS Therapeutics: Penicillin G 600,000 units every 6 hours (AD: 205,000 mkD) Paracetamol 140 mg IVTT now, then every 4 hours for temp >38 C (AD: 12 mkD) Monitoring: Vital signs every 4 hours I & O every shift Refer accordingly COURSE IN THE WARDS

30. Serum Chemistry & Serology January 8, 2022 Procalcitonin 5.11 ng/ml (0-0.50) CRP 92.90 mg/L SARS-CoV-2 antigen test (immunochromatography) Negative Dengue NS1 Antigen Positive Dengue IgM Negative Dengue IgG Negative

31. Complete Blood Count LABORATORY RESULTS January 8, 2022 WBC 38.5 x10^9/L RBC 4.32 x10^12/L Hgb 10.60 g/dL Hct 33.1 % Plt Count 304 x10^9/L Neutrophils 87 % Lymphocytes 7% Monocytes 6% Eosinophils 0% Basophils 0%

32. Trachea in midline No bony deformities Distinct cardiac borders Sharp costophrenic angles Well-defined hemidiaphragms No effusion Densities on both inner lung zones Gastric bubble not well defined Impression: pneumonia both lungs January 8, 2022: Chest X-ray PA view

33. Subjective Objective Assessment Plan (+) cough (+) fever Poor appetite (-) vomiting General survey: awake, not in respiratory distress Vital Signs: T: 40.3 o C HR: 120 bpm RR: 30 cpm O2 Sat: 96% RA SKIN: warm, fair, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, pink moist lips C/L: equal chest expansion, no retractions, resonant, (+) rales bilateral lung fields, (+) wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C Trans out to Pedia Ward under Pulmo Service IVF shift to heplock Therapeutics: Continue Penicillin G Zinc Sulfate syrup 55 mg/5 ml OD PO Give Paracetamol 140 mg IVTT PRN every 6 hours for temp >/= 38 C (AD: 12 mkD) Salbutamol nebulizer now x 3 doses every 15 minutes Hook to O2 via nasal cannula at 2 LPM Monitoring: Vital signs every 4 hours I & O every shift Refer accordingly Hospital Day 1 (January 9, 2022) COURSE IN THE WARDS

34. Subjective Objective Assessment Plan (+) febrile episodes (-) vomiting (-) cough (-) coryza General survey: Awake, irritable , not in respiratory distress Vital Signs: T: 36.5 C HR: 109 bpm RR: 28 cpm O2 Sat: 99% on 2 LPM NC SKIN: warm, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctiva, (-) alar flaring, pink moist lips C/L: equal chest expansion, no retractions, resonant, (-) rales, (-) wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C Diet as tolerated Trial room air and note if tolerated Diagnostic: Repeat CBC Therapeutics: Continue Penicillin G D2 Continue Zinc Sulfate syrup Monitoring: Vital signs every 4 hours I & O every shift Refer accordingly Hospital Day 2 (January 10, 2022) COURSE IN THE WARDS

35. Complete Blood Count LABORATORY RESULTS January 10, 2022 1/8/22 1/10/22 WBC 38.5 x10^9/L 22.6 x10^9/L RBC 4.32 x10^12/L 4.63 x10^12/L Hgb 10.60 g/dL 11.10 g/dL Hct 33.1 % 34.3% 1/8/22 1/10/22 Plt Count 304 x10^9/L 315 x10^9/L Neutrophils 87 % 74% Lymphocytes 7% 18% Monocytes 6% 7% Eosinophils 0% 1% Basophils 0% 0%

36. Subjective Objective Assessment Plan (+) febrile episodes Decreased appetite (-) cough (-) vomiting (-) abdominal pain General survey: irritable , NIRD Vital Signs: T: 36.4 C HR: 92 bpm RR: 24 cpm O2 Sat: 97% room air SKIN: warm, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctiva, (-) alar flaring, pink moist lips C/L: equal chest expansion, no retractions, resonant, (-) rales, (-) wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C Diet as tolerated On room air Diagnostics: Repeat Chest X-ray Repeat CBC, procalcitonin, CRP Urinalysis Blood C/S Serum Na, K, iCa, i Mg, Cl Therapeutics: Continue Penicillin G D3 Continue Zinc Sulfate syrup Monitoring: Vital signs every 4 hours I & O every shift Refer accordingly Hospital Day 3 (January 11, 2022) COURSE IN THE WARDS

37. Complete Blood Count LABORATORY RESULTS January 11, 2022 1/8/22 1/10/22 1/11/10 WBC 38.5 x10^9/L 22.6 x10^9/L 12.6 x10^9/L RBC 4.32 x10^12/L 4.63 x10^12/L 4.83 x10^12/L Hgb 10.60 g/dL 11.10 g/dL 11.60 g/dL Hct 33.1 % 34.3% 35.8% 1/8/22 1/10/22 1/11/22 Plt Count 304 x10^9/L 315 x10^9/L 320 x10^9/L Neutrophils 87 % 74% 53% Lymphocytes 7% 18% 32% Monocytes 6% 7% 10% Eosinophils 0% 1% 5% Basophils 0% 0% 0%

38. Serum Chemistry January 11, 2022 Chloride 107 mmol/L Ionized Magnesium 0.45 mg/L Sodium 137.4 mmol/L Potassium 4.10 mmol/L Ionized Calcium 1.16 mmol/L Ionized Magnesium 0.45 mmol/L

39. Findings are similar from previous image taken on January 8, 2022 except for resolution of inner lung zone densities. Impression: resolution of pneumonia January 11, 2022: Chest X-ray Comparative

40. Subjective Objective Assessment Plan (-) febrile episodes (-) vomiting (-) dyspnea (-) abdominal pain General survey: Awake, comfortable, not in respiratory distress Vital Signs: T: 37.2 C HR: 120 bpm RR: 24 cpm O2 sat: 98% SKIN: warm, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctiva, (-) alar flaring, pink moist lips C/L: equal chest expansion, no retractions, resonant, (-) rales, (-) wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C resolving Diet as tolerated Remove heplock On room air Increase fluid intake Diagnostics: Urinalysis Therapeutics: Shift Penicillin G to Amoxicillin suspension 250 mg/5ml, 4 ml TID (AD: 50 mg/kg/day) Monitoring: CBS monitoring every 24 hours Vital signs every 4 hours I & O every shift Watch out for hypoglycemia, decreased sensorium, dyspnea Refer accordingly Hospital Day 4 (January 12, 2022) COURSE IN THE WARDS

41. January 12, 2022 Urinalysis Red cell 1 /uL Pus cell 1 /uL Epithelial cell 0 /uL Bacteria 25 /uL Color Yellow Transparency Clear pH 6.5 Specific Gravity 1.030 Blood Negative Leukocyte Negative Glucose Negative Nitrite Negative Protein Negative Urobilinogen Normal Ketones ++ Bilirubin Negative

42. Subjective Objective Assessment Plan (-) febrile episodes (-) vomiting (-) dyspnea (-) abdominal pain (-) decreased sensorium General survey: Awake, comfortable, not in respiratory distress Vital Signs: T: 36.8 C HR: 104 bpm RR: 20 cpm O2 Sat: 99% room air CBS: 91 mg/dl SKIN: warm, fair, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctiva, no alar flaring, moist oral mucosa C/L: equal chest expansion, no retractions, resonant, no rales, no wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs PCAP-C resolving Diet As tolerated On room air Increase fluid intake Diagnostics: HbA1c Therapeutics: Continue amoxicillin suspension Monitoring: Vital signs every 4 hours I & O every shift Continue CBS monitoring every 24 hours Watch out for hypoglycemia, decreased sensorium, dyspnea Refer accordingly Hospital Day 5 (January 13, 2022) COURSE IN THE WARDS

43. Subjective Objective Assessment Plan (-) febrile episodes (-) vomiting (-) dyspnea (-) abdominal pain (-) decreased sensorium General survey: Awake, comfortable, not in respiratory distress Vital Signs: T: 36.7 C HR: 110 bpm RR: 30 cpm O2 Sat: 99% room air CBS: 91 mg/dl SKIN: warm, fair, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctiva, no alar flaring, moist oral mucosa C/L: equal chest expansion, no retractions, resonant, no rales, no wheeze CVS: adynamic precordium, distinct heart sounds, no murmur ABDOMEN: Flat, NABS, tympanitic, soft, non-tender EXTREMITIES: strong peripheral pulses, CRT <2 secs HbA1c: 5.3% PCAP-C resolved May go home Take home medications: Amoxicillin 250 mg/5 ml, give 4 ml 3x a day for 5 more days Zinc Sulfate 55 mg/5 ml, give 5 ml once a day for 3 months Increase fluid intake Observe good physical and oral hygiene Keep away from crowded places Follow-up immunization at LHC Follow-up check-up on January 21, 2022 at LHC Advised Hospital Day 5 (January 14, 2022) COURSE IN THE WARDS

44. CASE DISCUSSION PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

45. EPIDEMIOLOGY PNEUMONIA Inflammation of the lung parenchyma Leading infectious cause of death globally among children <5 years old Closely linked to poverty, with more than 99% of pneumonia deaths in low-middle income countries 45

46. EPIDEMIOLOGY In Philippines Setting: Age standard death rate of 126.05/100,000 population (2017) 3rd leading cause of death across all ages. In Filipino children below 5 years old , it is the most common cause of death - 14% of all causes of mortality 46

47. ETIOLOGY Most cases are caused by microorganisms, but there are also non-infectious causes – Aspiration of food and gastric acid, hypersensitivity reaction, drug-induced Streptococcus pneumoniae -Most common bacterial pathogen in children 3 weeks- 4 years of age Mycoplasma pneumoniae, Chlamydophila pneumoniae - most frequent bacterial pathogen in children 5 years and older Viral pathogens- Most common cause of lower respiratory tract infection in children >1 month-<5 years old Respiratory Syncitial Virus and Rhinoviruses - most common pathogen in less than 2 year old 47

48. ETIOLOGY 48

49. ETIOLOGY In Philippine setting: In a study on viral etiology among pediatric pneumonia patients in CAR, respiratory syncytial virus (RSV) was the most prevalent (93 out of 106 positive swab results) Other important etiologies: Measles Covid-19 49

50. ETIOLOGY RISK FACTORS: Not exclusively breastfed - mixed feeding at 1 month old Undernutrition Zinc deficiency Exposure to indoor air pollution - father who is a smoker Low birthweight-2100 grams Socioeconomic factors Comorbidities 50

51. PATHOGENESIS Lower respiratory tract defense mechanisms Mucociliary clearance Macrophages Secretory IgA Coughing reflex Pneumonia results from disruption of a complex lower respiratory ecosystem that is the site of dynamic interactions between potential pneumonia pathogens, resident microbial communities, host immune defenses. Viral pneumonia -Results from spread of infection in airways accompanied by direct injury of respiratory epithelium resulting in airway obstruction, Which further predisposes to secondary bacterial infection. 51

52. Viral pneumonia results from spread of infection in airways accompanied by direct injury of respiratory epithelium, which lead to airway obstruction from swelling, abnormal secretions and cellular debris. Furthermore-atelectasis, interstitial edema, hypoxemia from ventilation perfusion mismatch often lead to airway obstruction , which predisposes secondary bacterial infection by disturbing normal host defense mechanisms, altering secretions and through disruptions in the respiratory microbiota.   Bacterial pneumonia occurs when respiratory tract organisms colonize the trachea and subsequently gain access to the lungs and may also result from direct seeding of lung tissue after bacteremia. When bacterial infection is established in the lung parenchyma, the pathologic process Varies according to the invading organism PATHOGENESIS

53. PATHOGENESIS Bacterial pneumonia -Occurs when respiratory tract organisms colonize the trachea and gain access to the lungs. M.Pneumoniae : attaches to respiratory epithelium, inhibits ciliary action leading to cellular destruction and inflammatory response to submucosa. S. pneumoniae: Produces local edema that aids in the proliferation of organisms and their spread to adjacent portion of lung resulting in focal lobar involvement 53

54. PATHOGENESIS Group A streptococcus: R esults in more diffuse lung involvement with interstitial pneumonia causing necrosis of tracheobronchial mucosa, formation of large amount of exudate, edema, and local hemorrhage. S.Aureus: M anifest as confluent bronchopneumonia, often unilateral with extensive areas of hemorrhagic necrosis and irregular areas of cavitation of lung parenchyma resulting in pneumatoceles, bronchopulmonary fistula. Recurrent pneumonia: 2 or more episodes in single year or 3 or more episodes ever with radiographic clearing between occurrences . 54

55. Pneumonia is frequently preceded by several days of symptoms of an URTI ( Rhinitis and cough). Tachypnea (most consistent manifestation) Other common: retractions, nasal flaring, use of accessory muscles,  In infants, it may be accompanied by: poor feeding, abrupt onset of fever, restlessness, apprehension and respiratory distress(Grunting, nasal flaring, Retractions, Tachypnea, tachycardia and Cyanosis) PE findings Diminished breath sounds Scattered crackles Ronchi over the affected areas Dullness on percussion 55 Clinical Manifestations

56. 56 VIRAL PNEUMONIA BACTERIAL PNEUMONIA CLINICAL MANIFESTATION Low grade fever of >37.5c-<38c High grade fever >38c CHEST RADIOGRAPH Hyperinflation with bilateral interstitial infiltrates peribronchial cuffing Confluent lobar consolidation CBC WBC increased but not higher than 20,000/mm3, lymphocyte predominance WBC in the range of 15,000-40,000/mm3, Neutrophil predominance Clinical Manifestations

57. DIAGNOSIS Recommendations for PCAP C AND D: Routine exams- X-RAYS( PA or Lateral) WBC Count Culture and Sensitivity of: Blood, Pleural fluid and Tracheal aspirate for PCAP D Sputum for older children The following should not be Requested: ESR C-Reactive Protein

58. DIAGNOSIS VIRAL PNEUMONIA Hyperinflation with Bilateral interstitial infiltrates Peribronchial cuffing BACTERIAL PNEUMONIA Confluent lobar consolidation is typically seen with pneumococcal pneumonia POSSIBLE RADIOGRAPHY FINDING

59. treatment

60. CLASSIFICATION BASED ON PAPP

61. WHO WILL REQUIRE ADMISSION? A patient initially classified as PCAP A or B but is not responding to current treatment after 48 hours may be admitted A patient classified as PCAP C may be Admitted to the regular ward. Managed initially on an outpatient basis if all of the following are not present at initial site-of-care Age less than 2 years old. Convulsion. Chest x-ray with effusion, lung abscess, air leak or multilobar consolidation. Oxygen saturation < 95% at room air. A patient classified as pcap d may be admitted to a critical care unit.

62. WHEN IS ANTIBIOTIC RECOMMENDED? For PCAP A or PCAP B, an antibiotic may be administered if a patient is Beyond 2 years of age or With high grade fever without wheeze For PCAP D, a specialist may be consulted For PCAP C, empiric antibiotic may be started if any of the following is present. Elevated Serum c-reactive protein [CRP] S erum procalcitonin level [PCT] white blood cell [WBC] count greater than 15,000 lipocalin 2 [lpc-2] Alveolar consolidation on chest x-ray Persistent high-grade fever without wheeze

63. Empiric Antibiotic if Bacterial Etiology Considered PCAP A or PCAP B without previous antibiotic, regardless of immunization status against hib and S.Pneumoniae: Amoxicillin 40-50 mg/kg/day in 3 DD minimum 3 days May be given in 2 DD for min 5 days Azithromycin or clarithromycin 10 mg/kg/day OD for 3 days Hypersensitive to amoxicillin Suspicion of atypical organisms (M.Pneumoniae) 63

64. Empiric Antibiotic if Bacterial Etiology Considered PCAP C without previous antibiotic and requires hospitalization Penicillin G Completed primary immunization against hib 100,000 units/kg/day in 4DD Ampicillin Not completed primary immunization against hib or immunization status unknown. 100 mg/kg/day in 4 DD Amoxicillin Oral feeding tolerated No O2 support required 40-50 mg/kg/day in 3 divided doses for 7 days

65. Empiric Antibiotic if Bacterial Etiology Considered PCAP D: A Specialist may be consulted For a patient suspected to have community-acquired methicillin-resistant Staphylococcus aureus Vancomycin may be started A specialist may be consulted Ancillary treatment 65

66. PCAP A, B, C, D In which non-influenza virus is the suspected, antiviral therapy may not be beneficial For PCAP C, D Antiviral drug therapy for clinically suspected or laboratory-confirmed influenza virus to reduce Risk of pneumonia may not be beneficial Time to symptom resolution may be beneficial Oseltamivir 3-8 months old: 3mg/kg/dose BID x 5 days 9-11 months old: 3.5 mg/kg/dose BID x 5 days 12 months old: 30mg-75 mg BID x 5 days Zanamavir >7 years old: 10 mg BID x 5 days What treatment should be initially given if a viral etiology is strongly considered?

67. Patient responding to treatment? PCAP A or B: Assess within 24 to 48 hours Cough improved Body temperature returns to normal PCAP C: Assess within 24 to 48 hours if any of the following improves or returns to normal: Respiratory rate O2sat at room air Body temperature Cardiac rate Work of breathing For PCAP D: Assess within 48-72 hrs if all parameters have significantly improved: Respiratory rate Tachypnea O2sat Body temperature Cardiac rate

68. Patient not responding to treatment PCAP A or B Treatment failure: Not improving or clinically worsening within 72 hrs. after initiating treatment Diagnostic evaluation to determine: Coexisting or other etiologic agents Etiologic agent resistant to current antibiotic Other diagnosis Necrotizing pneumonia Pleural effusion Asthma Pulmonary tuberculosis 68

69. Treatment failure: not improving or clinically worsening within 48 hrs. after initiating treatment Diagnostic evaluation to determine: Coexisting or other etiologic agents Etiologic agent resistant to current antibiotic Other diagnosis Acute respiratory failure Pleural effusion Pneumothorax, Necrotizing pneumonia Lung abscess, Asthma Pulmonary tuberculosis and Sepsis Patient not responding to treatment PCAP C 69

70. Switch therapy For PCAP C, switch from IV to oral may be beneficial to reduce length of hospital stay provided all the following should be present: Current parenteral antibiotic has been given at least 24 hrs Afebrile within the last 8 hrs without antipyretic Responsive to current antibiotic Able to feed; without vomiting or diarrhea Without pulmonary complications O2sat > or = to 95% at room air 70

71. Ancillary treatment PCAP A & B: Oral steroid with coexisting asthma Bronchodilator if with wheezing PCAP C: Nasal prong or catheter for oxygen Zinc supplement Bubble CPAP Steroid or spirulina Oxygen (if < 95% at room air) 71

72. Conjugated vaccine (PCV 10 or 13) against streptococcus pneumoniae Vaccine against haemophilus influenzae type b , influenzae sp, and diphtheria, pertussis, rubeola, and varicella. Breastfeeding Avoidance of cigarette smoke 72 prevention

73. Usually the result of direct spread of bacterial infection within the thoracic cavity or bacteremia and hematologic spread Parapneumonic effusions and empyema Meningitis, endocarditis, suppurative arthritis, and osteomyelitis 73 complications

74. Patients with uncomplicated community-acquired bacterial pneumonia show response to therapy, with improvement in clinical symptoms within 48-72 hrs. of initiation of antibiotics Radiographic evidence of improvement lags substantially behind clinical improvement. Mortality from community-acquired pneumonia in developed countries is rare, and most children with pneumonia do not experience long-term pulmonary sequelae Some data suggest that up to 45% of children have symptoms of asthma 5 yrs after hospitalization for pneumonia 74 prognosis

75. Possibilities considered when a patient does not improve with appropriate antibiotic therapy Complications, such as pleural effusion or empyema Bacterial resistance Nonbacterial etiologies such as viruses or fungi and aspiration of foreign bodies or food Bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs Pre-existing diseases Other noninfectious causes 75 prognosis