Pediatric Pneumonia
Serious human illness since history ever recorded Egyptian mummies( 1250 to 1000 BC ) also had lungs
compatible with Pneumococcal pneumonia.
Important Landmarks:Approval of a heptavalent conjugate polysaccharide vaccine ( Prevnar, Wyeth-Lederle vaccines) by FDA in
Feb,2000 in USA.
[ A 14 valent Pneumococcal polysaccharides vaccine in 1977 and a 23- valent vaccine in 1983 ]
Approval of a conjugate polysaccharide vaccine for H.influenzae Type B in October 1990.
Microbiology
Dr.Robert Austrian estimates that bacteria are response for 1/10 to 1/3 of acute pneumonia
Finish study using antigen detection and antibody assays found bacteria in 45%
Lung punctures in developing countries found S.pneumonia, H.influnenzae and S.aureus as the leading
pathogens.
Attack Rates
Overall annual rate of pneumonia 12/1000 pop per yr.
Highest at 0-4 yr age group 12-15/1000 pop per yr.
Leading Etiologic Agents of Pneumonia Infants and Children
Clues to The Etiology of Pneumonia Obtained Through History - Taking
Clues to The Etiology of Pneumonia Obtained Through History – Taking
Clues to The Etiology of Pneumonia Obtained Through History – Taking ( con’t)
Clues to The Etiology of Pneumonia Obtained Through History – Taking ( con’t)
Respiratory Rates (Breaths/minute) of Normal children
Diagnostic Tools for pneumonia
CXR
Sputum culture
Blood culture
Urine antigen test – CIE or latex agglutination
Lung tap
Pleural fluid culture
Three Types of Pediatric Pneumonia
The pediatrician can see when looking at the film.
The pediatrician can not see when looking at the film until pointed out by radiologist.
The pediatrician can not see when looking at the film even after being pointed out by radiologist
Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents
Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Epidemiology,Clinical,and Laboratory features of Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children
According to Etiologic Agents (con’t)
Etiology of Pneumonia in infants and Children
Prospective Studies of Perinatal Chlamydia Infection
Infants
City
Mother
Conjunctivitis(%)
Pneumonia (%)
San
Francisco
5
18
16
Seattle
13
44
-Denver
9
44
22
Boston
2
33
17
Seattle
12
33
8
Lund
9
22
-Nairobi
22
37
12
Clinical Features of C. Trachomatis Pneumonia
Onset at 3 to 11 wks of age
Cough greater than one week in duration
Prior conjunctivitis
Afebrile tachypnea with diffuse rales
Hyperinflation and interstitial infiltrates on chest film
Eosinophilia
Increased IgM
Increased IgA and IgG
Annual Rate of Bacteremia by Organism
Pneumococcal pneumonia
Most common in late winter or early spring during the peak of viral infection
Abrupt onset of fever
Restlessness
Respiratory distress following URI
Physical exam & Labs
Diminished B. S or fine, crackling rales
Neck rigidity without meningitis may occur (RUL)
WBC 15,000 - 40,000
Blood C/S positive only 30%
Lobar consolidation (less common in infants)
Para-pneumonic effusion is relatively common
Characteristics of 65 Patients with Pneumonia due to Haemophilus influenzae Type b
Characteristics of 65 Patients with Pneumonia due to Haemophilus influenzae Type b (con’t)
Factors Influencing the Case Fatality Rates in 79 Infants and Children with staphylococcal pneumonia
Age 6 yrs and older
Febrile pneumonia
■ Mycoplasma pneumoniae
■ C. pneumoniae
■ S. pneumoniae
- Treatment:
▲Erythromycin
▲Clarithromycin
▲Azithromycin
Mycoplasma pneumoniae in the United States
Syndrome
Incidence/year Total cases
Pneumonia
2/1.000
500,000
Tracheobronchitis
46/1,000
11,500,000
Asymptomatic
Infections
12/1,000
All infections
3,000,000
15,000,000
M.pneumoniae Infections
Asymptomatic
Respiratory diseases with or without pneumonia
Responsible for 35% of out patient pneumonias
3-18%(median 7%) of community acquired pneumonias necessitating hospitalization
Diagnostic of Mycoplasma Pneumonia Diseases
Consider in all cases of pneumonia.
“Flu-like” Febrile illness of gradual onset.
Symptom of acute tracheobronchitis.
Paucity of physical findings.
CXR.
Exclude bacterial disease.
Cold hemagglutinin test.
Mycoplasma culture.
Mycoplasma serology.
BEDSIDE COLD HEMAGGLUTININ
0.2 ml. patient blood is mixed with and equal volume of sodium citrate solution in a small tube which is
iced for 15 sec.The tube is then tipped and rotated for inspection of the blood film.A positive is indicated
by agglutination which disappears when the tube is warmed to 37°C.A positive test indicates a standard
method titer ≥ 1: 64
Diagnostic Tests for Mycoplasma pneumoniae
Respiratory and Nonrespiratory Complications of Mycoplasma Pneumoniae Infections
General
Hematologic
Skin rashes
Anemia (including hemolytic)
Erythema multiforme
DIC
Maculopapular eruptions
Throboembolism
Vesicular eruption
Cardiac
Toxic epidermolysis
Pericarditis
Erythema nodosum
Myocarditis
Arthritis
Neurologic
Glomerulitis
Encephalitis
Pulmonary
Meningitis
ARDS
Poliomyelitis-like syndrome
Broncial asthma exacerbation
GB syndrome
Bronchiectasis
Brain-stem syndrome
celabellar ataxia
Bronchiolitis obliterans
Psychosis
Hyperlucent lung syndrome
Interstitial fibrosis
Lung abscess
Pleuritis,pulmonary embolism
Pneumatocele,pneumothorax
Chlamydia pneumoniae ( TWAR )
This organism cause pneumonia,
bronchitis,sinusitis and pharyngitis
and is a common cause of infection
in children from the age 5 – 15 years.
Of the three Chlamydia species,
Chlamydia pneumonia is by far the
most common cause of human infection
Clinical Finding in Pneumonia Associated with M.Pneumoniae,TWAR and Viral Respiratory Agents
Diagnostic Tests For Chlamydia Pneumoniae
Minimal Inhibitory Concentration(MIC) of Selected Antibiotics Against C.pneumoniae
SARS Outbreak in Humans
SARS Outbreaks (continued)
Severe Acute Respiratory Syndrome (SARS)
CDC continues to recommend consideration of testing for SARS-CoV in patients who require
hospitalization for radiographically confirmed pneumonia or ARDS without identifiable etiology AND who
have one of the following risk factors in the 10 days before the onset of illness:
Travel to mainland China, Hong Kong, or Taiwan, or close contact with an ill person with a history of
recent travel to one of these areas, OR
Employment in an occupation associated with a risk for SARS-CoV exposure (e.g., health care worker with
direct patient contact; worker in a laboratory that contains live SARS-CoV), OR
Part of a cluster of cases of atypical pneumonia without an alternative diagnosis.
Avian Influenza Outbreaks in Humans
(through November 2004)
Avian Outbreaks (continued)
Clinical manifestation of Avian Flu
Respiratory symptoms
- Flu like illness
- ARDS
GI symptoms : Acute diarrhea, vomiting, abdominal pain
CNS : Encephalitis
Multiple organ dysfunction
Sepsis / septic shock
Influenza A(H5N1) Virus Infections (Avian Flu)
Interim Recommendations: Infection Control Precautions for Influenza A(H5N1)
Standard Precautions
Pay careful attention to hand hygiene before and after all
patient contact
Contact Precautions
Use gloves and gown for all patient contact
Eye protection
Wear when within 3 feet of the patient
Airborne Precautions
Place the patient in an airborne isolation room (i.e.,monitored negative air pressure in
relation to the surrounding areas with 6
to 12 air changes per hour).
Use a fit-tested respirator, at least as protective as a NIOSHfacepiece respirator, when entering the
room.
approved N-95 filtering
Laboratory Testing Procedures
Highly pathogenic avian influenza A(H5N1) is classified as a select agent and must be worked with under
Biosafety Level (BSL) 3+ laboratory conditions. Therefore, respiratory virus cultures should not be
performed in most clinical laboratories and such cultures should not be ordered for patients suspected of
having H5N1 infection.
Clinical specimens from suspect A(H5N1) cases and SARS-CoV cases may be tested by PCR assays using
standard BSL 2 work practices in a Class II biological safety cabinet. In addition, commercial antigen
detection testing can be conducted under BSL 2 levels to test for influenza.
Considerations for Inpatient Management of Children with Pneumonia
Considerations for Inpatient (continued)
Initial Therapy of Pneumonia
Outpatient
0-20 days
Admit pt.
3wks-3mos
Afebrile; give PO erythromycin. Admit for fever or hypoxia
4mos-4yrs
PO amox or azithro. If >8 yrs, PO doxycycline (4mg/kg/day, 2 divided doses)
Inpatient
(septic, alveolar infiltrate, large pleural effusion or all)
0-20 days
IV amp/gent with or w/o IV cefotaxime
3wks-3mos
Give IV cefotaxime or ceftriaxone
4mos-4yrs
IV cefotaxime, ceftriaxone, if pt not well consider IV azithromycin*
The end!
Pleural Empyema In Children
Stages of infection
Exudative (allows needle aspiration)
Fibrinopurulent (may be loculated)
Organizing
Treatment options
Exudative
Repeated needle aspiration (1-5 days)
Exudative or
Chest tube drainage
fibrinopurulent
Organizing
Decortication
If >50% limitation of lung shown by CT scan
After 2-4 weeks of medical management
tachypnea, asymmetry of chest wall
expansion, fever,or leukocytosis remain
Characteristics of Different Types of Pleural Effusions
Reported frequency of pleral effusion in pneumonia
Bacterial Isolates from Pleural Effusions and Empyema in Children and Adolescents
Bacterial Isolates from Pleural Effusions and Empyema in Children and Adolescents(con’t)
Duration of Antimicrobial Therapy and Hospitalization in Empyema Survivors
Guidline for Chest Tube Insertion in Patients With Nonpurulent,Gram-Negative Parapneumonic Effusions
Guidline for Chest Tube Inserttion in Patients With Nonpurulent,Gram-Negative Parapneumonic Effusions
(con’t)
Algorithm for Empyema
Pleural effusion
Common Causes of Community-Acquired Pneumonia in Otherwise Healthy Children
Uncommon Causes of Community-Acquired Pneumonia in Otherwise Healthy Children
Uncommon Causes (continued)
Uncommon Causes (continued)
Which of the following statements regarding pneumonia in children is true?
A .Specific microbial pathogen usually can be identified
B. All children who have pneumonia should be hospitalized for observation and treatment
C. Pneumonia is a rare cause of child mortality worldwide
D. Radiographs of the chest always should be obtained to determine the cause
E. Viral agents are the most common causes of pneumonia in older infants and children
You are evaluating an 8 year old boy who has 7 day history of malaise and worsening cough. His mother
reports that he has had low grade fever. PE reveals a well appearing boy with normal RR and pulse ox.
Lung exam reveals bilateral crackles without wheezing . Chest x-ray show bilateral interstitial infiltrates
without effusion.
Most likely pathogen is:
A. Haemophilus influenzae
B. Mycobacterium tuberculosis
C. Mycoplasma pneumoniae
D. Respiratory syncytial virus
E. Streptococcus pneumonia
An 8 week old girl presents to ER with increased work of breathing x 1 day. Temp of 101.1 F, difficulty
breastfeeding due to nasal congestion. RR 70, pulse ox 90% on RA. Lung exam reveals bilateral wheezes
and crackles. CXR shows increased perihilar markings bilaterally and right middle lobe opacity.
Most likely cause of her symptoms is;
A. Adenovirus
B. Bordetella pertussis
C. Chlamydia trachomatis
D. Group B Streptococcus
E. Respiratory syncytial virus
#4
Main Cause of Necrotizing Pneumonia is:
Streptococcal hyaluronidase
Teichoic acid
Pneumolysin
Fibrinolysin
Ponton-valentine leukocidine
#5
The following microorganisms are frequent causes of pleural effusion EXCEPT:
S. aureus
Strep pneumoniae
Group A streptococcus
Haemophilis influenzae type B
Mycoplasma pneumoniae
#6
Characteristics chlamydial pneumonia include the following EXCEPT:
Afebrile
History of conjunctivitis
Staccato cough
Eosinophilia
Present at 4-6 months of age
#7
Distinguish features of exudate from transudate are as follows EXCEPT:
Pleural fluid: serum protein ratio > 0.5
Pleural fluid LDH > 200 IU/ml
Pleural fluid: serum LDH > 0.6
Pleural fluid protein > 3 gm/ml
Leukocyte count > 1,000/CU/mm
Features Differentiating Exudative & Transudative Pleural Effusion
Transudate
Exudate
WBC
pH
Protein
Protein ratio
LDH
LDH ratio
Glucose
<10,000/mm³
>7.2
<3.0 g/dL
<0.5
<200 IU/L
<0.6
≥60 mg/dL
>50,000/ mm³
<7.2
>3.0 g/dL
>0.5
>200 IU/L
>0.6
<60 mg/dL