Post on 09-Feb-2018
transcript
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.
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
Pneumoniaisaclinicaldiagnosis.• CXRfindingsarenotrequiredtomakethediagnosisofpneumonia.Consistenthistoryandfocalcracklesonexamaresufficient.
• However,giventhehighincidenceofchroniclungdiseaseinourpopula>on,physicalexamfindingsarenotalwaysreliable.– Achildcanhaveclearlungswithaninfiltrate.– AchildcanhavefrankcrackleswithaclearCXR.
• Thus,wehavealowthresholdtoorderCXRsinourpa>entsandinterprettheresultsinlightoftheen>reclinicalpicture.
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
Streppneumo
• Historically,theYKDeltahashadhighresistanceratesofSpneumoforpenicillins.
• Asaresult,weusedce\riaxoneasthefirst-linetreatmentforpneumonia.
• However,resistanceratesaredecreasing.
LowpenicillinresistanceforSpneumo
• Ampicillinandamoxicillinarenowthefirst-linedrugsofchoiceforCAP.
• DosingonguidelineisbasedonlocalMIC:– Ampicillin50mg/kg/doseIVQ6h– Amoxicillin45mg/kg/dosePOQ12h
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)
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.”
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
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.