Case presentation #4

Christoph Berger

Luca 4 4/12 years of age

Actual presentation (March 23) • Fever for 24h, sore throat, abdominal pain without vomiting or diarrhoea

Presentation in the pediatric office • Good general condition, axillary temp 38.2°C, pharyngitis, soft abdomen, stool roll in the left hemi abdomen.

Luca 4 4/12 Jahre Symptoms (March 24) • Fever for 2 days referral with severe abdominal pain, 1x defecation, prone to constipation.

• Dry cough, sore throat, has vomited 3 times.

Findings: • Fairly well condition, afebrile with diclofenac, coughing, rhinitis, pharyngitis, moist mucous membranes, normal abdomen.

• Nach Einlauf Atmung

Luca 4 4/12 Jahre Symptoms (March 24) • Fever for 2 days referral with severe abdomial pain, 1x defecation, prone to constipation.

• Dry cough, sore throat, has vomited 3 times.

Findings: • Fairly well condition, afebrile with diclofenac, coughing, rhinitis, pharyngitis, moist mucous membranes, normal abdomen.

• After enema: difficult (increased) breathing • Nach Einlauf Atmung

Luca 4 4/12 Jahre Do you initiate additional investigations ?

A no

B yes, blood cell count and CRP

C yes, B plus chest x ray + abdominal sonography

D yes, chest x ray

E yes, B plus chest x ray

Luca 4 4/12 Jahre

Luca 4 4/12 Jahre Pneumonia of the lower lobe: Do you prescribe laboratory tests ?

A no

B yes, blood cell count and CRP

C yes, blood cell count, CRP and hemocultures

D yes, blood cell count, CRP, procalcitonin and hemocultures

E other

Luca 4 4/12 Jahre Laboratory results: • leukocytes 23000 G/l • CRP > 160 mg/l • Blood drawn for hemoculture

Luca 4 4/12 Jahre Empiric treatment of community­ acquired pneumonia ?

A amoxicillin

B amoxicillin + clavulanic acid

C azithromycin

D cefuroxim

E clarithromycin

Luca 4 4/12 Jahre Laboratory results: • leukocytes 23000 G/l • CRP > 160 mg/l • blood drawn for hemoculture

Treatment: amoxicillin+clavulanic acid (Augmentin Duo) 75 mg/kg/d for 10 days

Luca 4 4/12 Jahre Pneumonia of the right lower lobe Treatment: amoxicillin + clavulanic acid

after 5 days consultation (05 h) for • chest/abdominal pain • much less coughing, no vomiting • in the day mobile, in the night right­sided abdominal pain

Luca 4 4/12 Jahre Differential diagnosis: What are your next steps ?

A probiotics

B change treatment to a macrolide

C abdomen: ultrasound and/or x­ray

D another chest x ray

E blood cell count, CRP and parenteral rehydration

Case presentation #5 or: to be continued…

Christoph Berger

Luca 4 4/12 Jahre

CA­pneumonia in the right lower lobe Treatment: amoxicillin + clavulanic acid

after 5 days consultation (05 h) for • chest/abdominal pain • much less coughing, no vomiting • in the day mobile, in the night right­sided abdominal pain

Luca 4 4/12 Jahre Pneumonia with effusion (sekundondary): What are your next steps ?

A parenteral antibiotic treatment (without B­E)

B A + pleural tap

C A + chest tube drain (continuous drainage)

D A + intrapleural streptokinase

E A + thoracoscopic drainage

Luca 4 4/12 Jahre

Pneumonia with effusuion secondary under amoxiclav

• chest CT • puncture

Luca 4 4/12 Jahre Pneumonia with effusion secondary under treatment with amoxiclav: Antibiotic treatment ?

A parenteral amoxicav

B ceftriaxon or cefotaxim

C A + aminoglycoside

D A + vancomycin

E amoxicillin

Luca 4 4/12 Jahre

Pneumonia with effusion secondary under amoxiclav

• chest CT • tap

• pneumococcal antigen in pleural fluid (tap) and urine detected

• Treatment: amoxicillin 75 mg/kg/d (iv) 2 weeks from tap

Luca 4 4/12 Jahre Pneumonia with effusion secondary under treatment with amoxiclav: Duration of antimicrobial treatment ?

A 10 days

B 14 days from tap

C 21­28 days

D 4­6 weeks

E depending on the chest x ray

Luca 4 4/12 Jahre Pneumococcal pneumonia with effusion • secondary under amoxiclav • pneumococcal antigen for pleural fluid positive • amoxicillin 75 mg/kg/d, 2 weeks from tap

after 1 month: ­ clinical recovery, ­ chest x ray: residua

CT after 3 months: ­ normal (full recovery)

Pneumonie: bakteriell oder viral?

254 Kinder hospitalisiert mit CAP (Rx Infiltrat + Fieber +/oder resp. Symptome)

Bakteriell Viral • Thorax­Röntgenbild lobäres/alveoläres Infiltrat 97(72%) 40(50%)* interstitielles Infiltrat 37(28%) 40(50%)*

• Leukozytose (>15x10 9 /l) 48% 47% • BSR (>30mm/h) 66% 60% • CRP (>80mg/l) 52% 28%* • alveol. Infiltrat + CRP >80mg/l 46% 22%*

Alveoläres Infiltrat + CRP↑: eher bakteriell, aber: Interstitielles Infiltrat: zur Hälfte bakteriell !

→ alle Antibiotika !?! Virkki et al, Thorax 2002; 57:438

Pneumonie: Pneumokokken vs. viral

Likelihood ratio der Kombinationen: 1.5­1.9

i.e. pretest probability 50%

→ posttest probability 65­70%

(Likelihood ratio eines guten Tests: >3 bzw. 5­10!)

Likelihood ratio bleibt <2: d.h. auch Testkombination ist ungenügend für die klinische Praxis

Korppi et al, Pediatr International 2004; 46: 545

132 Kinder hospitalisiert mit CAP 1.Suche Best mögliche Cut­off (P75 bzw. P90) 2. alle Kombinationen CRP, BSR, WBC, PCT

CRP: >80mg/l WBC: >17x10 9 /l PCT: >0.84µg/l ESR:> 63mm/h

Community acquired Pneumonia Aetiologie bzw. Therapie ?

Aetiologie der Pneumonie Rolle des Alters

Pathogen Alter 0­3 Mt. 4 Mt

­ 5 Jahre 6 ­16 Jahre

Viren ++ ++ + Streptococcus pneumoniae ++ ++ ++ Staphylococcus aureus + + (+) Haemophilus influenzae + ++ (+)

Gramnegative Stäbchen + ­ ­ Chlamydia trachomatis + ­ ­ Mycoplasma pneumoniae ­ + ++ Chlamydia pneumoniae ­ + ++

BAG Bulletin 2007;12:228 (19.3.07)

Galetto­Lacour, A. et al. Pediatrics 2003;112:1054

Okkulte Bakterielle Infektionen: BB, CRP, PCT? 110 Kinder: 29% schwere bakterielle infektionen Bakterämie (4) Lobärpneumonie (2) Pyelonephritis (21) Mastoiditis (1) Retropharyngealabszess (1)

PCT LH ratio <0.5 ng/mL 0.5–2 >2 CRP <40 mg/L 40–100 >100 Leukocytes <15 G/L 15–20 >20

0.09 .8 5.2

0.26 2.0 14.5

0.65 1.6 2.4

3 54 68

10 45 86

21 40 49

Posttest Probability

CRP 100

CRP 40

Prävalenz bakt. Infekte 5% →Posttest Probability

Pneumonie beim Kind: BTS guidelines Diagnostik und Management

Mikrobiologische Diagnostik Blutkulturen bei ­ V.a bakt. Pneumonie ­ Hospitalisation • Serumasservat NPS ­Viren: Kinder < 18 Mt ­ V.a. Pertussis Rachenabstrich ­ V.a. Mykoplasmen ? Pleurapunktat ­ signifikanter Erguss Urin Antigen ?

Management

Kontrolle nach 48h Ansprechen ? Komplikation ? Antipyrese, Hydratation Hypoxie (Agitation!) O2 Sättigung

Antibiotika: Impfstatus erheben ! Primär Amoxicillin oral (oder iv) ­Staphylococcus aureus (<1J) Amoxiclav ­ Mykoplasmen (>5J ) evtl. Makrolide

Komplikation Fieber oder AZ >48­72h Therapie: Reevaluation

Thorax 2002; 57;1­24

Pleuropneumonie 1990­2000 in Utah 1 , Memphis 2 , USA 3

Kinder mit Pleuropneumonie bezogen auf alle Pneumonien – Alter ↑ (> 3 ­ 5 Jahre) – häufiger Thoraxschmerzen – Fieber Dauer ↑ vor Hospitalisation (mean 5.7 vs. 3.1 Tage)

bis Entfieberung (mean 8.3 vs 2.5 Tage)

Pleuropneumonie 47% Erguss sekundär 56% erhielten Antibiotika vor Diagnose der Pleuropneumonie

Erreger: S.pneumoniae >> S.aureus > S.pyogenes Pneumokokken > 2/3 Penicillin sensibel

(wie Pneumonien total)

(1)Byington, CID 2002:34:434; (2)Buckingham PIDJ 2003;22:499; (3)Tan, Pediatrics 2002; 110:1

Reapraisal of lung tap in childhood pneumonia: Review of 59 studies

Microbiologic yield

without pretreatment: 56% (651/1159 pneumonias) ­ S.pneumoniae 38%, ­ S.aureus 22%, ­ H.influenzae 17%

after pretreatment: 40%

Microbiologic yield in lung tap versus blood culture

only blood culture positive 6% 25% pos blood cultures

tap + culture positive 19% 52% pos taps

only tap positive 33%

Vuori­Holopainen CID 2001;32:715

Maskell N A et al. The New Engl J of Medicine 2005;352;9:865­875

UK Trial: Intrapleural streptokinase for pleural infection ?

Intrapleurale Streptokinase hat keine Wirkung auf

­ Reduktion der Letalität ­ Notwendigkeit chirurgischer Drainage ­ Hospitalisations­Dauer ­ Langzeit Outcome

und soll deshalb generell vermieden werden

N 454, doppelblind Streptokinase (250000 IU 2x/d über 3 Tage) bzw. Placebo

Pediatric Pleural Empyema • Decortication is not necessary to prevent long term problems with pleural thickening (Satish, Arch Dis Child 2003)

• Primare operative versus nonoperative therapy may reduce inhospital mortality rate, reintervention rate, hospital stay, time of antibiotic therapy, relative risk of failure (Metaanalysis; Avansino, Pediatrics 2005)

• Medical management (antibiotic, chest drain insertion and intrapleural urokinase) is effective and associated with good long­term outcome (Barnes Ped Pulmonol 2005)