UpdateonPediatricCommunity-AcquiredPneumonia

K.JaneMcClureLeslieHerrmannCindiMondesir

Introduc>on

MainResource

IDSAGuidelines

•  2011•  Childrenolderthan3monthsofage•  Issuesaddressed:– Whotohospitalize– Whatteststoorder– Drugsofchoice– Treatmentfailures

YKGuidelines

•  UpdatedMay2015•  BasedonIDSAGuidelines•  InputfromIDexperts,PICU,ANMC,andYOU!!•  Coverschildren>3monthsold

What’schanged?

•  Inpa>entIVtherapy:–  First-line:ampicillin–  Second-line:Unasyn–  Third-line:ce\riaxone

•  Newemphasisonsuppor>vemeasures.•  Evalua>ngandtrea>ngbasedonseverityofrespiratorydistressAFTERsuppor>vemeasures.

•  Forma`ngmirrorsotherpediatricrespiratoryguidelines.

Background

Epidemiology•  Pneumoniaistheleadingcauseofdeathinchildrenworldwide.

•  Inthedevelopedworld,theannualincidenceofpneumoniais3-4casesper100children<5yearsold.

•  WehaveveryhighratesofpediatricpneumoniaintheYKDelta.–  Recurrentpneumonialeadstochroniclungdiseaseandbronchiectasis.

–  Bronchiectasishasahighmortalityrate,withpa>entsdyingintheir30’sinlocalstudycohorts.

E>ology

•  Difficulttodeterminetruepathogeninmostcases.

•  Virusesmorecommonininfantsandtoddlers.– RSVdetectedin40%ofchildren<2years.

•  Bacteriamorecommoninolderchildren.

E>ology-CommonTrends

•  S.pneumoniaeisthemostcommonbacterialcauseofpneumoniainchildren.

•  Virusesaccountfor14-35%ofpneumoniacases,andashighas50%ofcasesinyoungchildren.

•  Virusesaremorecommonlyiden>fiedinchildren<5years.

•  Inchildren>5years,MycoplasmapneumoniaeandChlamydiapneumoniaearemorecommon.

Source:UpToDate

BacterialCausesinChildren<5Years

•  S.pneumoniaeisthesinglemostcommonbacterialpathogencausingpneumoniainallpa>entsbeyondthefirstfewweeksoflife.

•  H.influenzaetypebisararecauseofpneumoniaincountrieswithuniversalchildhoodimmuniza>on.

•  S.aureus(par>cularlyCA-MRSA)andS.pyogenesarebecomingincreasinglyfrequentcausesofCAP,par>cularlythosecomplicatedbynecrosisandempyema.

•  TheprevalenceofM.pneumoniaeandC.pneumoniaemaybeincreasinginpreschoolchildrenwithCAP.

Source:UpToDate

BacterialCausesinChildren>5Years

•  S.pneumoniaeisthemostcommontypicalbacterialcauseofpneumoniainchildrenolderthanfiveyears.

•  M.pneumoniaeismorecommonamongchildren≥5yearsthanamongyoungerchildren.

•  C.pneumoniaealsoisemergingasafrequentcauseofpneumoniainolderchildrenandyoungadults.

Source:UpToDate

So…

•  Streppneumo

•  Streppneumo

•  Streppneumo!!

Diagnosis

Pneumoniaisaclinicaldiagnosis.•  CXRfindingsarenotrequiredtomakethediagnosisofpneumonia.Consistenthistoryandfocalcracklesonexamaresufficient.

•  However,giventhehighincidenceofchroniclungdiseaseinourpopula>on,physicalexamfindingsarenotalwaysreliable.– Achildcanhaveclearlungswithaninfiltrate.– AchildcanhavefrankcrackleswithaclearCXR.

•  Thus,wehavealowthresholdtoorderCXRsinourpa>entsandinterprettheresultsinlightoftheen>reclinicalpicture.

Treatmentdecisionshouldbebasedonseverityofrespiratorydistress.

Toadmitornottoadmit?

•  Childrenwithmoderatetosevererespiratorydistressa\ersuppor>vemeasuresshouldbeadmiledtoYKorsenttoAnchoragebymedevac.

•  Whostays?Whogoes?– Staytunedforexci>ngdevelopmentsinthisarea!– Amul>disciplinaryteamisworkingonthis!

Labwork

•  Moderatetosevererespiratorydistress(admissionan>cipated):– CBC– CRP– Bloodculture– RSVandflu(if<3years)– Sputumandculture(if>5years)

•  Mildornorespiratorydistress(outpa>entmanagement):Nolabworkrequired

ManagementNowwhat?

Management/Treatment?

Somebackground…

LookwhatLesliefoundintheKasiglukclinic!(That’swheresheisrightnow.)

2003An>biogram

Streppneumo

•  Historically,theYKDeltahashadhighresistanceratesofSpneumoforpenicillins.

•  Asaresult,weusedce\riaxoneasthefirst-linetreatmentforpneumonia.

•  However,resistanceratesaredecreasing.

2014An>biogram

Zoomedin…

LowpenicillinresistanceforSpneumo

•  Ampicillinandamoxicillinarenowthefirst-linedrugsofchoiceforCAP.

•  DosingonguidelineisbasedonlocalMIC:– Ampicillin50mg/kg/doseIVQ6h– Amoxicillin45mg/kg/dosePOQ12h

Thisisinlinewithna>onalguidelines.

Caveats

Excep>ons

•  RULinfiltrateàconsideran>bio>cwithoralanaerobecoverage– Augmen>n/Unasyn– Clindamycin

•  Childreceivedamoxicillin/ampicillininlast30daysàgotosecond-line:Augmen>n/Unasyn.

•  Childisincompletelyimmunized:considerbroader-spectrumcoverage.

•  Effusioninpa>entwithpossiblesepsis,considerVanco

Whenisce\riaxoneindicatedasfirst-linetherapy?

•  Hospitalizedpa>entswhoarenotappropriatelyimmunized.

•  Inregionswherepneumococcushashigh-levelpenicillinresistance.

•  Pa>entswithlife-threateninginfec>on,includingempyema.(alsoconsideraddingVanco)

Transla>on:“Areyourshotsup-to-date?”

HideousTableofAn>microbialTherapyChoices

HideousTableofAn>microbialTherapyChoices

HideousTableofEmpiricAn>bio>cChoices

Changeisscary.Whatifitdoesn’twork?

Follow-upStudies•  Dinur-Scheiteretal(2013):319childrenaged3monthsto2yearsadmiledwithnon-complicatedpneumoniabetween2003-2008treatedwitheitherpenicillin/ampicillinorcefuroxime.– NodifferenceinnumberofdaysofIVtreatment,daysofsupplementaloxygenrequirement,orlengthofhospitaliza>on.

– Nosignificantdifferenceintreatmentfailures.– Oneweeka\eradmission,nodifferencebetweenthegroups.

Follow-upStudies

•  Amarilvoetal(2014):prospec>ve,randomizedstudywith58childrenaged3monthsto15yearswithcommunity-acquiredpneumonia.Childrenwererandomlyassignedtoreceivelow-dosepenicillinG,high-dosepenicillinG,orcefuroximeIVfor4-7days.– Nosignificantdifferencein>metodefervescenceordura>onofhospitaliza>on.

–  ThereweredifferencesinleukocytecountsandC-reac>veproteinatdischarge,butthese“wereofques>onableclinicalsignificance.”

CaseScenarios

TreatmentforCAP

•  Outpa1ent– Amoxicillin45mg/kgPOBIDX10d– Augmen>n45mg/kgPOBIDX10d– Cefdinir14mg/kg/ddivBID

•  Inpa1ent/Transfer– Ampicillin50mg/kg/doseIVq6h– Unasyn50mg/kg/doseIVq6– Ce\riaxone75mg/kgdoseIVq12

CaseScenario•  14montholdfemalewithh/opreviousRULPNA1/2015presentstoEDwith1wkcoughandrunnynose,fever

•  v/s:T102.8HR185RR52SpO298%RA

•  PE:lungsclear•  TX:Amoxicillin45mg/kgPObidX10d

FollowUpExam•  14montholdpresentsforf/

uevalua>onwithincreasedlethargy,decreasedoralintake,decreasednumberofwetdiapers,moaningat>mes

•  v/sT98.9HR154RR34SpO298%onRA

•  PE:pale,childlayingonmother,coursebreathsounds,drymucousmembranes,caprefill<4sec

•  Whatdowedonow?

CaseScenario2•  12montholdfemale

presentstohealthaideat3PMwithcoughX4days,feverX2daysTm101andpullingatears.Diffusewheezingcoursecrackles.

•  V/S:T101.4HR170RR64sats95%RA

•  Albuterolnebsgiveninvillageclinic

•  V/S:100.7HR174RR72sats95%RA

•  ArrivesinEDcommercialflight6PM

TheGoldenHour

References•  Bradleyetal.“Themanagementofcommunity-acquiredpneumoniaininfantsand

childrenolderthan3monthsofage:clinicalprac>ceguidelinesbythePediatricInfec>ousDiseasesSocietyandtheInfec>ousDiseasesSocietyofAmerica.”ClinicalInfec<ousDiseases2011;53(7):e25-76.

•  UpToDate•  SealleChildren’sHospitalCommunity-AcquiredPneumoniaclinicalpathway.•  Dinur-Scheiteretal.“An>bio>ctreatmentofchildrenwithcommunity-acquired

pneumonia:comparisonofpenicillinorampicillinversuscefuroxime.”PediatricPulmonology2013Jan;48(1):52-8.

•  Amarilyoetal.“IVpenicillinGisaseffec>veasIVcefuroximeintrea>ngcommunity-acquiredpneumoniainchildren.”AmericanJournalofTherapeu<cs2014Mar-Apr;21(2):81-4.

•  LodhaR,KabraSK,PandeyRM.“An>bio>csforcommunity-acquiredpneumoniainchildren.”CochraneDatabaseofSystema<cReviews2013Jun4;6:CD004874.