Severe pneumonia in childhood.

Robert GieDepartment Paediatrics and Child

HealthStellenbosch University.

3 month old infant

Doing well after birth

Onset of cough and fast breathing

Severely hypoxic with rapid progression of disease

Started on PJP treatment

HIV infected

Proven PJ pneumonia

Initially improves then deteriorates

Proven CMV co-infection

2 month old ex-premature

Presented with cough and progessive respiratory distress

Required ventilatory support Due to hypercarbia

Culture proven PTB.

Source case CXR:

10 year old child

Previous well

Develops the symptoms of an influenza like disease

Rapid progression of respiratory failure

H1N1 proven

Predominant cause of pneumonia by age and HIV status

HIV-uninfected children Additional organisms HIV-infected children

For children 2-12 months: S. pneumoniae H. influenzae S. aureusGram-negative bacteria Viruses

For children 12 – 59 months: S. pneumoniae H. influenzae S. aureusViruses.

For children 2-12 monthsPneumocystis jiroveciCytomegalovirusM TuberculosisCo-infections

For children 12-59 monthsM TuberculosisGram-negative bacteria Co-infections

P Enarson 2010

Table 3 WHO standard antibiotic regimens for low and high HIV prevalent settings

Child 2-59 months

Low HIV prevalence setting

High HIV prevalence settingHIV infected or HIV suspected

Very severe pneumonia

Ampicillin 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily ORif ampicillin unavailable replace with benzylpenicillin 50 000units/kg The total course of treatment is 10 days

Ampicillin (OR PENICILLIN) 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily (10 days) ANDHigh-dose cotrimoxazole (8 mg/kg trimethoprine/40 mg/kg sulfamethoxazole IV 8 hourly or orally 3 times a day for 3 weeks

Severe pneumonia

Benzylpenicillin 50 000 units/kg 6 hourly for at least 3 days when improved switch to oral amoxicillin 25mg/kg twice daily The total course of treatment is 5 days

Ampicillin 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily (10 days) ANDHigh-dose cotrimoxazole (8 mg/kg trimethoprine/40 mg/kg sulfamethoxazole) IV 8 hourly or orally 3 times a day for 3 weeks

[1] World Health Organisation. Management of Children with Pneumonia and HIV in low-resource settings. Report of a consultative meeting. Harare, Zimbabwe,Jan 30–31, 2003. Geneva: World Health Organisation/Boston University, 2004.)

Further adaptation:

Consider PJP CMV co-infection in infantsLess than 6 months

Add Gancyclovir for 21 days

Surgical enucleation of obstructing glands.

Indication: hypercapnea and not able to wean

Zinc supplementation10mg/day

Micronutrients

Predicting for failure

Child lung Health Project:Malawi

• In 5 years 48702 in hospital children treated for pneumonia

• Age– 52% 2-11 months– 37% 12-59 months

• Severity of disease– 62.8% severe pneumonia– 25.2% very severe pneumonia

• Mortality – Decreased from 18.6% to 8.4%

P Enarson