Pediatric Community

Acquired PNEUMONIA
JANINE ROVY ANNE A. FUTOLAN
CLINICAL CLERK

PNEUMONIA
Inflammation of lung
parenchyma due to
infectious agents that
stimulates a response
resulting in damage to
lung tissue

Resolution of damage
may be complete or
partial.

EPIDEMIOLOGY
Pneumonia is the
leading killer of
children worldwide
in children <5 yr in
2010

ETIOLOGY
most cases are caused by microorganisms
noninfectious causes
aspiration (of food or gastric acid, foreign bodies,
hydrocarbons, and lipoid substances),
hypersensitivity reactions
drug- or radiation-induced pneumonitis

ETIOLOGY
3 wk 4 y.o
Streptococcus pneumoniae
(pneumococcus)
>5 y.o
Mycoplasma pneumoniae and
Chlamydophila pneumonia

<2 y.o
Respiratory syncytial viruses
(RSV)

PATHOPHYSIOLOGY
Viral pneumonia
1. Spread of infection along the airways

2. Direct injury of the respiratory epithelium

a. airway obstruction from swelling
b. abnormal secretions

c. cellular debris
*The small caliber of airways in young infants
makes such patients particularly susceptible to
severe infection.

PATHOPHYSIOLOGY
Bacterial pneumonia
1. Colonization of the trachea or direct seeding of lung
tissue from bacteremia

2. Bacterial infection is established in the lung

parenchyma (pathologic process varies according to
the invading organism)

Mycoplasma Pneumoniae
Mycoplasmas: smallest self-replicating prokaryotes

150-250 nm
fastidious double-stranded DNA bacterium with a
small genome (800,000 base pairs) and long
doubling time
Complete absence of a cell wall
(1) Dependence to host cells for obtaining essential
nutrients
(2) Intrinsic resistance to -lactam agents
(3) Pleomorphic shape and lack of visibility on Gram
staining

Mycoplasma Pneumoniae (cont.)

attaches to the respiratory epithelium

inhibits ciliary action

leads to cellular destruction and an
inflammatory response in the submucosa.

As the infection progresses, sloughed cellular

debris, inflammatory cells, and mucus cause
airway obstruction, with spread of infection
occurring along the bronchial tree, as it does
in viral pneumonia

Streptococcus Pneumoniae
local edema that aids in the proliferation of
organisms and their spread into adjacent
portions of lung
resulting in the characteristic focal lobar
involvement

Group A Streptococcus
more diffuse infection with interstitial pneumonia
necrosis of tracheobronchial mucosa
formation of large amounts of exudate, edema,
and local hemorrhage, with extension into the
interalveolar septa
involvement of lymphatic vessels
increased likelihood of pleural involvement

Staphylococcus Aureus
manifests in confluent bronchopneumonia
often unilateral
hemorrhagic necrosis
irregular areas of cavitation of the lung
parenchyma (pneumatoceles, empyema,

bronchopulmonary fistulas)

Clinical Manifestation
History
Upper respiratory tract infection: rhinitis and
cough
Diminished appetite

Abrupt onset of fever (viral vs bacterial)

Restlessness
Increased work of breathing

GI disturbances
High fever, cough and chest pain (older
children)

Clinical Manifestation
Physical assessment
Tachypnea (most consistent)

Respiratory distress: grunting, nasal flaring,

supraclavicular, intercostal, and subcostal
retractions; tachypnea; tachycardia; air
hunger; and often cyanosis
Cyanosis and lethargy (severe infection)

Clinical Manifestation
Early findings on affected lung field:

diminished breath sounds

scattered crackles
Rhonchi

Clinical Manifestation
Increasing consolidation and complication:
dullness on percussion

breath sounds may be diminished

lag in respiratory excursion
Abdominal distention

Abdominal pain is common in lower-lobe

pneumonia

DIAGNOSIS
World Health Organization: solely on the basis of
clinical findings and timing of the respiratory rate

An infiltrate on chest radiograph (not diagnostic,

other clinical features must be considered)

Viral pneumonia
Hyperinflation with bilateral interstitial infiltrates
and peribronchial cuffing

Pneumococcal pneumonia
Confluent lobar consolidation

Definitive Diagnosis
Viral infection: a virus or detection of the viral
genome or antigen in respiratory tract secretions

Bacterial infection: isolation of bacteria in blood,

pleural fluid, or lung
Blood cultures: recommended for those who fail to
improve or have clinical deterioration

COMPLICATIONS
Result of direct spread of bacterial infection within
the thoracic cavity:
Pleural effusion, empyema, pericarditis
Rare hematologic spread:

Meningitis, suppurative arthritis, osteomyelitis

Most common cause of parapneumonic effusions

and empyema:
S. Aureus, S. Pneumoniae, S. Pyogenes

- MANAGEMENT -

2012 Summary of
Recommendations
for PCAP

1. Cough and/or respiratory difficulty plus any of the

following predictors of radiographic pneumonia:
ER:
Tachypnea (based on WHO) for 3 months to 5 years old

Fever at any age

<92% O2 sat at any age in the absence of coexisting
illness
OPD:
tachypnea (based on WHO) for 3 months to 5 years old

Fever at any age

2. Presence of pneumonia should be determined

with CXR if:

i. Cough and respiratory difficulty with:

Presence of dehydration (3mos 5 years)
Severe malnutrition (<7yr)
3. High grade fever with leucocytosis (3 24 mos)
without respiratory symptoms

Can be managed initially on an outpatient basis:

PCAP-C px <5 years old & >5 years old
CXR without: effusion, lung abscess, air leak or
multilobar consolidation,

oxygen saturation is > 95% at room air

Chest x-ray may be requested to rule out

pneumonia-related complications or pulmonary
conditions simulating pneumonia
It should not be routinely requested to predict end-oftreatment clinical outcome

CXR, CBC, CRP, ESR, procalcitonin, or blood culture

should not be routinely requested to determine
appropriateness of antibiotic usage

PCAP-C
SHOULD BE DONE:

to determine etiology:
Gram stain and/or culture and sensitivity of pleural fluid
when available
To assess gas exchange
Oxygen saturation using pulse oximetry

ABG

MAY BE DONE:

to confirm clinical suspicion of multilobar consolidation, lung

abscess, pleural effusion, pneumothorax or
pneumomediastinum

Chest x-ray PA-lateral

to determine appropriateness of antibiotic usage
C-reactive protein (CRP)
Procalcitonin (PCT)

Chest x-ray PA-lateral

White Blood Cell (WBC) count

Gram stain of sputum or nasopharyngeal aspirate

 to determine etiology:
Sputum culture and sensitivity

Blood culture and sensitivity

to predict clinical outcome:
Chest x-ray PA-lateral
Pulse oximetry
to determine the presence of tuberculosis if clinically
suspected:
Mantoux test (PPD 5-TU)

Sputum smear for aid fast bacilli

 to determine metabolic derangement:

Serum electrolytes
Serum glucose

PCAP-D :Referral to a specialist should be done

1. For PCAP-A or B
beyond 2 years, or

high grade fever without wheeze

2. For PCAP-C, an antibiotic

Should be given if (+) alveolar consolidation on CXR
May be given if with CRP, PCT, WBC, high grade fever
without wheeze, beyond 2 years of age
3. For PCAP-D, a specialist should be consulted

For PCAP A/B without prior antibiotic:

AMOXICILLIN (drug of choice)
40-50 mg/kg/day
max dose: 1500 mg/day in 3 divided doses, at
most 7 days

May be given for minimum of 3 days

May be given in 2 divided doses for minimum of 5
days

With known hypersensitivity to Amoxicillin:

AZITHROMYCIN
10 mg/kg/day OD x 3days or
10mg/kg/day on day1 then 5mg/kg/day day 2-5
Max dose: 500mg/day
CLARITHROMYCIN
15mg/kg/day

Max dose: 1000mg/day in 2 divided doses for 7 days

For PCAP C without previous antibiotic:

1. Requiring hospitalization
Completed primary immunization of Haemophillus
Influenza Type B:
PENICILLIN G(drug of choice)
Monotherapy: 100,000 units/kg/day in 4 divided
doses

Has not completed primary immunization of

Haemophillus Influenza Type B:
AMPICILLIN (drug of choice)
Monotherapy: 100mg/kg/day in 4 divided doses

 Above15 years old administered as combination

therapy given parenterally:

[B-Lactam/B-Lactamase Inhibitors + Cephalosporin or
Carbapenem] plus Extended Macrolide or
Respiratory Fluorquinolone
Macrolide: Azithromycin or Clarithromycin
Fluoroquinolone: Levofloxacin or Moxifloxacin

2. Who can tolerate oral feeding and does not

need 02 supplementation:
AMOXICILLIN [40-50 mg/kg/day], max dose of
1500 mg/day in 3 divided doses for at most 7
days as OPD basis

3. PCAP C with severe malnutrition or

suspected to have Methicillin-resistant
Staphylococcus Aureus, or PCAP D:
referral to a specialist is highly recommended
4. Established to have Mycobacterium
Tuberculosis infection or disease:

Anti TB drugs should be started

OSELTAMIVIR
30 mg BID for <15kg body weight
40 mg BID >15-23 kg

60 mg BID >23-40 kg
75 mg BID >40KG
Use of immunomodulators are not
recommended

72 hours:
Decrease in respiratory signs and/or
defervescence
If clinically responding, further diagnostic aids to
assess response such as chest x-ray

PCAP A/B (OPD) not responding to current

antibiotic within 72H, consider any of the ff:
Other dx (co-existing illness or conditions
simulating Pneumonia)

Other etiologic agents with which C reactive

protein, CXR, and CBC may be used to
determine pathogen
*May add Macrolide if atypical organisms is highly
considered
*May change to another antibiotic if microbial
resistance is highly considered

PCAP C (inpatient) not responding to current

antibiotic within 72H, consider any of the ff:

Other dx (co-existing illness or conditions

simulating Pneumonia)

Other etiologic agents with which C reactive

protein, CXR, and CBC may be used to
determine pathogen
*May add Macrolide if atypical organisms is highly
considered
*May change to another antibiotic if microbial resistance is
highly considered

May refer to a specialist

PCAP D (inpatient) not responding to current

antibiotic within 72H, consider any of the ff:
Immediate consultation with a specialist
should be done

For PCAP-C
Switch from IV to oral form 3 days after initiation of current
antibiotic Who should fulfill ALL of the following:

Responsive to current antibiotic therapy

Tolerance to feeding and without vomiting or diarrhea

Without any current pulmonary (effusion/empyema;

abscess; air leak, lobar consolidation, necrotizing
pneumonia) or extrapulmonary complications
Without oxygen support

Switch 3 days parenteral Ampicillin to Amoxicillin

40-50 mg/kg/day for 4 days

PCAP A/B:
Bronchodilator may be administered in the
presence of wheezing

*Cough preparation, Elemental Zinc, Vitamin D,

Probiotic and Chest physiotherapy should not
routinely be given during the course of illness

PCAP C

O2 and hydration should be administered

Bronchodilator may be administered ONLY in the
presence of wheezing

Probiotic may be administered

Cough preparation, Elemental Zinc, Vitamin D,
and Chest physiotherapy should not routinely be
given

PCAP D : referral to a specialist should be

considered

1. Should be given to prevent Pneumonia:

Vaccine against:
Streptococcus Pneumonia (Conjugate Type)

Influenza
Diphtheria, Pertussis, Rubeola, Varicella,
Heamophillus Influenza Type B

Micronutrients:
Elemental Zinc (2mo-59mo) to be given 4-6
months

2. May be given to prevent pneumonia:

Micronutrients:
Vitamin D3 Supplementation

3. Should not be given to prevent

pneumonia:
Micronutrients:
Vitamin A Supplementation

THANK YOU!