An infant seen in the ER, presents with a fever and persistent cough.

Physical examination and a chest x-ray suggest pneumonia. What are the probable microorganisms causing this infection?

The probable microorganisms that may cause pneumonia include :

-

Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Respiratory syncytial virus (RSV) Parainfluenza viruses Chlamydia trachomatis

Streptococcus pneumoniae - most common bacterial pathogen causing pneumonia in infant - an encapsulated gram positive coccus - diameter : 0.5 1.2m - shape : oval - arrangement : pairs or short chains - normal inhabitant of upper respiratory tract - can multiply in the tissues

largest cause of death in children worldwide an acute lower respiratory infection that specifically affects the lungs bacterial pathogens that are present in a child s nose or throat are inhaled into the lungs infants with weakened natural defenses cannot protect their lungs from invading pathogens alveoli are filled with pus and fluid in one or both lungs, and thus results in breathing difficulty and decreased oxygen intake risk factors are malnutrition, AIDS and environmental factors symptoms include tachypnea, shortness of breath, cough, fever, chills, headache, loss of appetite, and wheezing

Chest X-ray

-Indicated when symptoms suggest pneumonia. -X-ray results may:

Suggest the type of organism (bacterial, viral, or fungal) causing pneumonia.

Show complications of pneumonia. Show conditions that may occur with pneumonia, such as fluid in the chest cavity or a collapsed lung.

Normal

Pneumonia

Complete WBC & Differential count -Helpful as an increased white blood count with predominance of polymorphonuclear cells may suggest bacterial cause. - However, leucopoenia can either suggest a viral cause or severe overwhelming infection.

Blood Culture precise aetiology of pneumonia.

- The gold standard for determining the

Blood samples are drawn into vials that contain nutrients which support the growth of microorganisms.

Sensitivity is very low. (10-30% pneumonia patient will have positive results.)

Performed in severe pneumonia or poor response to 1st line antibiotics.

Sputum Culture & Gram Stain -Primary tests ordered to detect and identify the cause of bacterial pneumonia  Susceptibility Testing -Performed on pathogenic bacteria grown in culture and identified by testing. -Determines which antibiotic is to be used.


Culture from Respiratory Secretions - Bacteria from throat swabs and upper respiratory tract secretions are not representative of pathogens in the lower respiratory tract. - Samples from the nasopharynx and throat have no predictive values.
 

Other tests - Bronchoalveolar lavage (BAL) is usually necessary for the diagnosis of Pneumocystis carini infections in immunosuppressed children. - Done only when facilities and expertise are available.

Mild Pneumonia Severe pneumonia Very severe pneumonia

Fast breathing Chest indrawing Not able to drink Convulsions Drowsiness Malnutrition

Desired outcome in treating pneumonia

Eradication of the offending organism

through selection of appropriate antibiotic and complete clinical cure Minimize associated morbidity Focus on designing the most cost-effective approach therapy Oral route is preferable over parenteral for drug administration, encouraging outpatient management than that of hospitalization.

humidified oxygen for hypoxemia bronchodilators (albuterol) when bronchospasm is present rehydration fluids control of fever chest physiotherapy for masked accumulation of retained respiratory secretion postural drainage. Antibiotics regimens should be selected based on causative pathogens.

Antibiotic concentration in respiratory secretions in excess of the pathogen MIC (minimum inhibitory concentration) are necessary for successful treatment of pulmonary infection Antimicrobial therapy should be initiated in hospitalized patients with acute pneumonia within 8 hours of admission because an increase in mortality has been demonstrated when therapy was delayed beyond 8 hours of admission Pneumococcal vaccination is recommended for patients at high risk for severe pneumococcal infections.

Empirical antimicrobial therapy for pneumonia in pediatric patients

1 month: Group B streptococcus

(Streptococcus agalactiae)or Staphylococcus aureus with presumptive therapy of ampicillin-sulbactam, cephalosporin carbapenem 1-3 months: Pneumococcus, S. aureus with semisynthetic penicillin or cephalosporin > 3months: pneumococcus with amoxicillin or cephalosporin

Community-acquired pneumonias, for example, are usually caused by the typical bacteria Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, which were previously treated with related antibiotics. Mild CAP in otherwise healthy patients be treated with oral macrolide antibiotics (azithromycin, clarithromycin, or erythromycin).

Many cases of CAP are caused by S. pneumoniae -- Gram-positive bacteria that usually respond to antibiotics known as beta-lactams and to macrolides.

However, resistant strains of S. pneumoniae are increasingly common. They responds to fluoroquinolines such as levofloxacin, gemifloxacin or moxifloxacin . Another common cause of communityacquired pneumonia is H. influenzae.

Current recommendations call for 7 - 10 days of treatment for S. pneumoniae. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to 6 weeks to resolve completely.

Penicillin (penicillin G/amoxicillin) remains the drug of choice for strains that are fully sensitive Cefotaxime and ceftriaxone are the first-line alternatives in cases with higher levels of resistance.

22

Treatment is usually with Beta-lactam antibiotics. In the 1960s, nearly all strains of S. pneumoniae were susceptible to penicillin, but since that time, there has been an increasing rate of resistance. They may also be resistant to erythromycin, macrolides, and clindamycin and the quinolones. Amoxicillin: first choice in < 5 years

23

Most resistant species remain susceptible to vancomycin, which is a less desirable antibiotic because of dosing and tissue penetration issues.

24

newer macrolide antibiotics (clarithromycinazithromycin) possess excellent activity against most S. pneumoniae and Mycoplasma organisms. Azithromycin offers the added advantage of once-daily dosing and short-course therapy because of the drugs extensive tissue distribution characteristics and prolonged elimination half-life.

Newer Fluoroquinolone may be effective alternative agents for treatment of CAP. However, fluoroquinolone use in pediatirc patients remains restricted and limited due to possibility of fluoroquinolone-induced destructive lesions of growing cartilage.

Hospitalization should be considered for infants who are younger than 2 months or premature because of the risk of apnea in this age group. Red blood cells should be administered to ensure a hemoglobin concentration of 13-16 g/dL in acutely ill infants to ensure optimal oxygen delivery to body tissues.

Increased respiratory support requirements such as increased inhaled oxygen concentration are usually required before recovery begins. Attempts at enteral feeding often are withheld. Parenteral nutritional support is preferred until respiratory and hemodynamic status is sufficiently stable. Delivery of adequate amounts of glucose, maintenance of thermoregulation and electrolyte balance are also essential.

If the patient has pleural effusion, chest tube placement for drainage of the effusion or empyema may be performed. Intrapleural instillation of a fibrinolytic agent (eg. tissue plasminogen activator) has been used as an adjunctive agent when drainage and medical management fail. These agents may help to dissolve loculations and increase chest tube drainage by breaking down fibrin in the pleural collection.

The time to resolution of initial presenting symptoms, and the lack of appearance of new associated symptoms should be determined. For community-acquired pneumonia, the time to resolution of cough, decreasing sputum production, fever and other symptoms should be noted. If supplemental oxygen therapy is required, the amount and need should also be assessed regularly.

A gradual and persistent improvement in the resolution of symptoms should be observed. Initial resolution should be observed within the first 2 days after treatment, and should progress to complete resolution within 5 to 7 days, but usually no more than 10 days.

Research has shown that prevention and proper treatment of pneumonia could avert one million deaths in children every year. The cost of treating all children with pneumonia in 42 of the world's poorest countries is estimated at around US$ 600 million per year. Treating pneumonia in South Asia and subSaharan Africa which account for 85% of deaths would cost a third of this total, at around US$ 200 million. The price includes the antibiotics themselves, as well as the cost of training health workers, which strengthens the health systems as a whole.

vaccination vaccines stimulate antibody formation 7-valent conjugated pneumococcal vaccine (PCV7) ------> discontinued 13-valent conjugated pneumococcal vaccine (PCV13) influenza virus vaccine - children aged 6 months and older - inactivated vaccine ------> IM injection - cold-adapted attenuated vaccine ------> nasal spray adequate nutrition good environmental factors

http://www.who.int/mediacentre/factsheets/fs331/en/index.html http://emedicine.medscape.com/article/967822-treatment#aw2aab6b6b9aa http://emedicine.medscape.com/article/967822-medication#9 http://www.unicef.org/publications/files/Pneumonia_The_Forgotten_Killer_of_Children.p df Wald E. Recurrent pneumonia in children. 1990; 5: 183 - 203. Donowits GR, Mandell GL. Acute pneumonia. In : Mandell GL, Douglas RG, Bennet JE, editors. Principles and practice of infectious diseases. New York Churchill Livingstone, 1990 : 540-54 Hickey RW, Burman MJ, Smith GA. Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Ann Emergency Med 1996 27:721-5 Chan PWK, Lum LCS, Ngeow YF, Yasim YM. Mycoplasma pneumoniae infection in Malaysian children admitted with community acquired pneumonia. Southeast Asian J Trop Med Public Health 2001; 32: 375 - 401 Shann F, Barker J, Poore P. Clinical signs that predict death in children with severe pneumonia. Pediatric Infect Dis J 1989; 8: 852 5 WHO Pneumonia [online]: http://www.who.int/mediacentre/factsheets/fs331/en/index.html Joseph T.Dipiro et al. (2008) Pharmacotherapy. A Pathophysiologic Approach. 7th Edition. Chapter 111; pp1801 1810 Intrapleural Tissue Plasminogen Activator for Parapneumonic Effusion: Conclusion http://www.medscape.com/viewarticle/726343_10 Pediatric Pneumonia Treatment & Management http://emedicine.medscape.com/article/967822-treatment#aw2aab6b6b1aa