HPISetting: EDPatient: 7mo maleHPI:
Rhinorrhea, cough x 3 daysIncreased cough with post-tussive emesis
this AMOne episode of perioral cyanosis with
retractionsNo improvement noted with 2.5mg albuterol
at homeNo fevers at home
PMHRight congenital diaphragmatic hernia
V-V ECMO DOL 0-4Repaired DOL 5Revised at 3mo age
History of adrenal insufficiencyHistory of pulmonary hemorrhageChronic lung diseaseFeeding problems, NG dependent with
thickened PO feedsRecent hospitalization 1wk ago for RSV with
reactive component
PMHMeds: MVI, Albuterol PRN (finished
prednisolone 6 days ago)Allergies: NKDAImms: UTDFHx: No chronic or childhood illnessesSHx: Lives with parents and 6 older
siblings. One brother with cough x 4 days.
Physical examVS: T 39.9, P 209, R 54, BP 105/63, SpO2 78% RAGEN: awake, alert, cryingHEENT: NG in place, TM’s clear, no oropharyngeal
lesionsRESP: Increased work of breathing, subcostal and
intercostal retractions, coarse breath sounds throughout, scattered end-expiratory wheeze
CV: Tachycardic, perioral cyanosis, no murmurs or gallops appreciated, heart sounds more prominent on right.
GI: soft, nontender, nondistended, no HSMEXT: warm, well-perfused, CRT 2 secSKIN: No rashes or lesions
DDxRESPIRATORY
AsthmaAspiration pneumonitisForeign body aspirationCDHLung hypoplasiaCCAM/CPAMPneumothoraxHemidiaphragm paralysis
CARDIOVASCULARVSDASDTOFTAPVR/PAPVRHLHSSVTVascular ringPulmHTN
INFECTIOUSbronchiolitisCAPHAPInfluenzapertussis
ENTTEFLaryngeal clefttracheomalacia
HEME/ONCAnemiaLeukemic lung infiltrate
NEUROstrokeSeizure
OTHERPregnancyLupus
StudiesPertinent labs:
WBC 46 (33% bands, 56% PMNs)VRP: negativeBlood culture: negative
Pertinent imaging:CXR: New focal LLL opacity. Unchanged
hypoplastic right lung and mediastinal shift to the right.
Community-acquired pneumonia>150 million cases per year1.2 to 2 million deaths per year
18% of U5MLeading cause of childhood mortality
worldwide40% hospitalization rateStrep pneumo, H. flu, Mycoplasma most
commonMoraxella, Chlamydia, Staph less common
Diagnostic testingBlood culture
If inpatientIf not improving or deteriorating
VRPMycoplasma
Test if suspiciousCBC
If inpatientESR/CRP
Response to therapyCXR
If inpatientIf hypoxemic
TreatmentOral
Immunized -> Amoxicillin +/- AzithromycinAlternatives: clindamycin, cephalosporin,
levofloxacinUnimmunized -> Augmentin +/- Azithromycin
Alternatives: clindamycin, cephalosporin, levofloxacin
IVImmunized -> Ampicillin +/- Azithromcyin
Alternatives: clindamycin, cephalosporinUnimmunized -> Ceftriaxone +/-
AzithromycinAlternatives: clindamycin
DosingAmoxicillin 90 mg/kg/day divided TID x 10
days
Augmentin 90 mg/kg/day divided BID x 10 days
Ampicillin 200 mg/kg/day divided Q6hCeftriaxone 75 mg/kg Q24h
Clindamycin 40 mg/kg/day divided TID x 10 days
Azithromycin 10 mg/kg Q24h x 3 days
ResourcesIntermountain CAP guidelines
https://intermountainhealthcare.org/ext/Dcmnt?ncid=522578601
Intermountain CAP flashcardhttps://intermountainhealthcare.org/ext/Dcm
nt?ncid=522833243
Empyema1-2% of pneumonias (closer to 28% in
Utah)Treatment affected by size
< 25% of hemithoraxAntibiotics (Cefotax/Ceftriaxone/Ceftaroline +
Clindamycin)25-50% of hemithorax
CT + TPA or VATS> 50% of hemithorax
CT + TPA or VATSIf drainage >2 days, may need open debridement
Ibuprofen and empyema?OR 4 (2.5-6.5) if Ibuprofen used prior to
hospitalization (p <0.0001)Ibuprofen caused empyema?
Pro-inflammatory at low doses (3 mg/kg) Increased neutrophils and cytokines
Also associated wth increased necrotizing fasciitis with Strep pyogenes
Ibuprofen result of empyema?Increased pain with empyema -> more medsDelay in hospitalization if more comfortable
ReferencesGereige RS, Laufer PM. Pneumonia. Peds in Rev. 2013; 34(10):438-56.Bradley JS et al. The management of community-acquired pneumonia in
infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53(7):e25-76.
Byington CL et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: Risk factors and microbiological associations. Clin Infect Dis. 2002; 34:434-40.
Rinaldo JE, Pennock B. Effects of ibuprofen on endotoxin-induced alveolitis: biphasic dose response and dissociation between inflammation and hypoxemia. Am J Med Sci 1986; 291:29-38.
Konstan MW et al. Effect of ibuprofen on neutrophil migration in vivo in cystic fibrosis and healthy subjects. J Pharmacol Exp Ther 2003; 306(3):1086-91.
Peterson CL et al. Risk factors for invasive group A streptococcal infections in children with varicella: a case-control study. Pediatr Infect Dis J 1996; 15:151-6.
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