By      Dr.Mousa El-shamlyConsultant pulmonology king saud             hospital
 Pneumonia: an acute infection of the   pulmonary parenchyma The term “Lower Respiratory Tract Infection”   (LRTI) may in...
In interstitial pneumonia, patchy or diffuseinflammation involving the interstitium is characterized byinfiltration of lym...
Although in developed countries thediagnosis is usually made on the basis ofradiographic findings, the World HealthOrganiz...
   Pneumonia kills more children under    the age of five than any other illness in    every region of the world.   It i...
United States statisticsPneumonia can occur at any age, although it is morecommon in younger children. Pneumonia accounts ...
   Most cases of pneumonia are caused by the    aspiration of infective particles into the lower    respiratory tract.  ...
EtiologyWhile virtually any microorganism can lead topneumonia, specific bacterial, viral, fungal, andmycobacterial infect...
Age Group                                                 Common Pathogens (in Order of Frequency)Newborn                 ...
Age Group                                                   Common Pathogens (in Order of Frequency)2-5 years             ...
It is not possible to distinguish between bacterial     and viral pneumonia on clinical grounds alone!Suggestive of bacter...
Newborns with pneumonia rarely cough;they more commonly present with poorfeeding and irritability, as well astachypnea, re...
After the first month of life, cough is themost common presenting symptom ofpneumonia. Infants may have a history ofantece...
Infants with bacterial pneumonia are oftenfebrile, but those with viral pneumonia orpneumonia caused by atypical organisms...
Older children and adolescents may alsopresent with fever, cough (productive ornonproductive), congestion, chest pain,dehy...
Travel history is important because it mayreveal an exposure risk to a pathogen morecommon to a specific geographic area (...
Age                    Respiratory     Indication of                       Rate            severe                       (b...
Lower chest wall indrawing: with inspiration,From: Integrated Management of Childhood Illness. Chapter Three: Cough or dif...
Nasal flaring: with inspiration, the side of the                          nostrils flares outwardsFrom: Integrated Managem...
Consider if Diagnosis is otherwise inconclusive To exclude other causes of shortness of breath  (e.g.. foreign body, hea...
Bacteria - WBC count & leukocytosis ,blood cultures (3%-11% in   pneumonia),          CRP, ESR; “sputum “ (Gram stain and ...
   All pt’s should have CXR   Blood culture   CBC   ESR/CRP   Urinary antigen for Pneumococcal infection is    not re...
   RSV is the most common cause of LRTIs in    children less than 1.   Infants and young children typically present    w...
Most common in late winter or early spring during the peak of viral infection   Abrupt onset of fever   Restlessness   ...
Test      Specimen             Sensitivity(%)   Specificity(%)           CommentsCulture  Throat or NP swab,        > 90  ...
Common symptoms of tuberculosis include: Chronic cough that has been present for more  than 3 weeks and is not improving...
   Physical exam findings of children with    pulmonary tuberculosis are similar to those    of a lower respiratory tract...
Age Group                       Indications for Admission to HospitalInfants                         Oxygen Saturation <= ...
Admission
   Consideration must be given to the provision    of adequate hydration, oxygenation, nutrition,    antipyretics and pai...
   Assist ventilation (e.g., bag-mask ventilation)    as needed   Provide oxygen   Continuously monitor oxygen saturati...
   Respiratory failure is the most common indication for    intubation in children with pneumonia   Clinical evidence of...
   Pleural effusion – fluid in the pleural space    as the result of inflammation.   Empyema – bacterial infection in th...
   Necrotizing Pneumonia – necrosis or    liquefaction of lung parenchyma.   Lung Abscess – A collection of inflammatory...
   Pneumatocele – thin walled, air filled cysts of    the lung, often occurs with empyema.   Pneumatoceles often resolve...
   Hyponatremia:     Serum   sodium <135 mmol/L.     Studies in India (1992) revealed that in children      hospitalize...
Outpatient Treatment of Pneumonia Child < 5 years old     Presumed bacterial pneumonia         Amoxicillin, oral (90 mg/...
   Presumed bacterial pneumonia     Oral  amoxicillin (90 mg/kg/day in 2 doses to a      maximum of 4 g/day); for childr...
   Presumed atypical pneumonia     Oral azithromycin (10 mg/kg on day      1, followed by 5 mg/kg/day once daily      on...
   Presumed bacterial pneumonia     Ampicillin  or penicillin G;     alternatives: ceftriaxone or      cefotaxime;    ...
   Presumed atypical pneumonia     Azithromycin (in addition to ß-lactam,      if diagnosis of atypical pneumonia is in ...
   Presumed bacterial pneumonia:     Ceftriaxone or cefotaxime;      addition of vancomycin or      clindamycin for susp...
   Presumed atypical pneumonia     Azithromycin (in addition to ß-lactam,      if diagnosis in doubt);     alternatives...
   Preferred: ceftriaxone (100 mg/kg/day every 12–24 hours);   Alternatives: ampicillin (300–400 mg/kg/day every 6 hours...
   Preferred: intravenous azithromycin (10    mg/kg on days 1 and 2 of therapy;    transition to oral therapy if possible...
Suspect MRSA in:“Patients with severe pneumonia,particularly during influenza season,in patients with cavitary infiltrates...
Moderately severe (non-ICU) pneumonia:Erythromycin, or azithromycin, or doxycyclinePLUSCeftriaxone or cefotaximeComplicate...
   Few evidence-based data to guide duration of therapy   Parenteral: Generally preferable to switch to oral antimicrobi...
   It is estimated that hand washing, when    combined with improved water and    sanitation could lead to a 3% reduction...
   Adequate nutrition throughout the first five    years of life, including adequate    micronutrient intake. Impact 6% r...
   Tachypnea and respiratory distress are    considered the most important signs in the    diagnosis of pneumonia.   Onl...
   Reducing indoor air pollution, by changing    to cleaner gas or liquid fuels or high-quality,    well maintained bioma...
Cp5
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
Pediatricpneumonia
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  • References: Global Action Plan for Prevention and Control of Pneumonia (GAPP). Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2009. Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006. Global Coalition Against Child Pneumonia. Baltimore, MD: International Vaccine Access Center (IVAC) at Johns Hopkins Bloomberg School of Public Health, 2011.
  • Reference: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
  • Reference: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
  • Reference: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
  • 2/9/2011 S. Alter, MD Current management of complicated pneumonia in children
  • Reference: Up To Date. Clinical features and diagnosis of community-acquired pneumonia in children. [www.utdol.com] Accessed on December 9, 2011.
  • Reference: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000” https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm . Accessed February 2, 2012
  • Reference: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000” https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm . Accessed February 2, 2012
  • Reference: Up To Date. Clinical features and diagnosis of community-acquired pneumonia in children. [www.utdol.com] Accessed on December 9, 2011.
  • Notes: Right Upper Lobe Pneumonia. Chest xray provided by Dr. Roberta Hood
  • Notes: Right Middle Lobe (RML) Pneumonia. Chest xray provided by Dr. Roberta Hood Instructions: This is a good x-ray to review anatomy. Discuss that RML pneumonia can obscure right heart boarder. The lateral chest xray is helpful to distinguish upper, middle and lower lobe pneumonias.
  • Reference: Up To Date. Respiratory Syncytial Virus infection: Clinical features and diagnosis. [www.utdol.com]. Accessed on December 9, 2011.
  • Reference: Up To Date. Tuberculosis Disease in Children. [www.utdol.com]. Accessed on December 9, 2011.
  • Reference: Up To Date. Tuberculosis Disease in Children. [www.utdol.com]. Accessed on December 9, 2011.
  • Reference: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24.
  • Reference: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24.
  • Reference: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24.
  • Reference: Pediatric Life Support Provider Manual. Dallas,Tx: American Heart Association. 2006.
  • Reference: Up To Date. Emergent endotracheal intubation in children. [www.utdol.com]. Accessed on December 9, 2011.
  • Reference: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24.
  • References: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24. Up To Date. Inpatient treatment of pneumonia in children. [www.utdol.com] Accessed on December 9, 2011.
  • Reference: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax . 2002;57: i1-i24.
  • Reference: Singhi S et al. Frequency and significance of electrolyte abnormalities in pneumonia. Indian Pediatr . 1992;29(6):735-40.
  • References: GAPP. Geneva: WHO/UNICEF, 2009. Niessen, L et al. Comparative impact assessment of child pneumonia interventions. Bulletin of the World Health Organization . 2009;87:472-480.
  • Reference: GAPP. Geneva: WHO/UNICEF, 2009.
  • Reference: Pneumonia The Forgotten Killer of Children. Geneva: WHO/UNICEF, 2006.
  • References: GAPP. Geneva: WHO/UNICEF, 2009. Niessen, L et al. Comparative impact assessment of child pneumonia interventions. Bulletin of the World Health Organization . 2009;87:472-480.
  • Pediatricpneumonia

    1. 1. By Dr.Mousa El-shamlyConsultant pulmonology king saud hospital
    2. 2.  Pneumonia: an acute infection of the pulmonary parenchyma The term “Lower Respiratory Tract Infection” (LRTI) may include pneumonia, bronchiolitis and/or bronchitisBronchopneumonia, a patchy consolidation involving oneor more lobes, usually involves the dependent lungzones,Miliary pneumonia is a term applied to multiple, discretelesions resulting from the spread of the pathogen to thelungs via the bloodstream
    3. 3. In interstitial pneumonia, patchy or diffuseinflammation involving the interstitium is characterized byinfiltration of lymphocytes and macrophagesThe alveoli do not contain a significant exudate,but protein-rich hyaline membranes similar tothose found in adult respiratory distress syndrome(ARDS) may line the alveolar spaces congenital pneumonia, presents within the first 24 hours after birth.Pneumonia may originate in the lung or may be a focalcomplication of a contiguous or systemic inflammatoryprocess
    4. 4. Although in developed countries thediagnosis is usually made on the basis ofradiographic findings, the World HealthOrganization (WHO) has definedpneumonia solely on the basis of clinicalfindings .
    5. 5.  Pneumonia kills more children under the age of five than any other illness in every region of the world. It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumonia Approximately 98% of children who die of pneumonia are in developing countries.
    6. 6. United States statisticsPneumonia can occur at any age, although it is morecommon in younger children. Pneumonia accounts for 13%of all infectious illnesses in infants younger than 2 years. In alarge community-based study conducted by Denny andClyde, the annual incidence rate of pneumonia was 4 casesper 100 children in the preschool-aged group, 2 cases per100 children aged 5-9 years, and 1 case per 100 childrenaged 9-15 years.[16]
    7. 7.  Most cases of pneumonia are caused by the aspiration of infective particles into the lower respiratory tract. Organisms that colonize a child’s upper airway can cause pneumonia. Pneumonia can be caused by person to person transmission via airborne droplets.
    8. 8. EtiologyWhile virtually any microorganism can lead topneumonia, specific bacterial, viral, fungal, andmycobacterial infections are most common inpreviously healthy children. pathogen was identified in 79% of children,Pyogenic bacteria accounted for 60% of cases, ofwhich 73% were due to Streptococcuspneumoniae, while the atypical bacteria Mycoplasmapneumoniae andChlamydophila pneumoniae weredetected in 14% and 9%, respectively. Viruses weredocumented in 45% of children.
    9. 9. Age Group Common Pathogens (in Order of Frequency)Newborn Group B Streptococci Gram-negative bacilli Listeria monocytogenes Herpes Simplex Cytomegalovirus Rubella1-3 months Chlamydia trachomatis Respiratory Syncytial virus Other respiratory viruses3-12 months Respiratory Syncytial virus Other respiratory viruses Streptococcus pneumoniae Haemophilus influenzae Chlamydia trachomatis Mycoplasma pneumoniae From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
    10. 10. Age Group Common Pathogens (in Order of Frequency)2-5 years Respiratory Viruses Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae Chlamydia pneumoniae5-18 years Mycoplasma pneumoniae Streptococcus pneumoniae Chlamydia pneumoniae Haemophilus influenzae Influenza viruses A and B Adenoviruses Other respiratory viruses From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
    11. 11. It is not possible to distinguish between bacterial and viral pneumonia on clinical grounds alone!Suggestive of bacteria: Rapid onset (tachypnea, cough, retractions) Likely to appear very sick Higher temperatures (>39º C)Suggestive of virus: Low-grade fever, irritable but not toxic (usually!) Associated complaints: sore throat, myalgias, GI complaints Longer prodrome (2-3 days or longer) Concomitant URI symptoms at times
    12. 12. Newborns with pneumonia rarely cough;they more commonly present with poorfeeding and irritability, as well astachypnea, retractions, grunting, andhypoxemia. Grunting in a newborn is dueto vocal cord approximation as they try toprovide increased positive end-expiratorypressure (PEEP) and keep their lowerairways open
    13. 13. After the first month of life, cough is themost common presenting symptom ofpneumonia. Infants may have a history ofantecedent upper respiratory symptoms.Grunting may be less common in olderinfants; however, tachypnea, retractions,and hypoxemia are common and may beaccompanied by a persistent cough, fever,irritability, and decreased feeding.
    14. 14. Infants with bacterial pneumonia are oftenfebrile, but those with viral pneumonia orpneumonia caused by atypical organisms mayhave a low-grade fever or may be afebrile.The childs care takers may complain that thechild is wheezing or has noisy breathing.Toddlers and preschoolers most often presentwith fever, cough (productive ornonproductive), tachypnea, and congestion.They may have some vomiting, particularlyposttussive emesis. A history of antecedentupper respiratory tract illness is common
    15. 15. Older children and adolescents may alsopresent with fever, cough (productive ornonproductive), congestion, chest pain,dehydration, and lethargy. In addition to thesymptoms reported in younger children,adolescents may have other constitutionalsymptoms, such as headache, pleuritic chestpain, and vague abdominal pain. Vomiting,diarrhea, pharyngitis, and otalgia/otitis areother common symptoms.
    16. 16. Travel history is important because it mayreveal an exposure risk to a pathogen morecommon to a specific geographic area (eg,dimorphic fungi). Any exposure to TB shouldalways be determined. In addition, exposure tobirds (psittacosis), bird droppings(histoplasmosis), bats (histoplasmosis), or otheranimals (zoonoses, including Q fever,tularemia, and plague) should be determined.
    17. 17. Age Respiratory Indication of Rate severe (breaths/min) infection (breaths/min)< 2 months > 60 >702 to 12 months > 5012 months to 5 years > 40 >50Greater than 5 years > 20
    18. 18. Lower chest wall indrawing: with inspiration,From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
    19. 19. Nasal flaring: with inspiration, the side of the nostrils flares outwardsFrom: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
    20. 20. Consider if Diagnosis is otherwise inconclusive To exclude other causes of shortness of breath (e.g.. foreign body, heart failure) To look for complications of pneumonia unresponsive to treatment (e.g.. empyema, pleural effusion) To exclude pneumonia in an infant less than three months with fever
    21. 21. Bacteria - WBC count & leukocytosis ,blood cultures (3%-11% in pneumonia), CRP, ESR; “sputum “ (Gram stain and culture), urine pneumococcal antigen (good sensitivity, poor specificity)Viral - viral isolation, antigen detection, molecular diagnostics, serology limited.Mycoplasma – serology (IgM has poor specificity ~60%), paired serology, PCR (limited sensitivity in children; poor sputum sample)Chlamydophila – Serology (poor sensitivity , limited specificity in children),Legionella – Urinary antigen (sensitivity ~80%, specificity ~100%)Radiology – to follow.
    22. 22.  All pt’s should have CXR Blood culture CBC ESR/CRP Urinary antigen for Pneumococcal infection is not recommended Sputum samples Rapid tests for Influenza and viruses should be used Mycoplasma pneumoniae should be tested for if suspicious No reliable test for Chlamydophila pneumoniae
    23. 23.  RSV is the most common cause of LRTIs in children less than 1. Infants and young children typically present with pneumonia or bronchiolitis. Older children may have upper respiratory tract infection symptoms. RSV is associated with apnea in infants. Wheezing is common.
    24. 24. Most common in late winter or early spring during the peak of viral infection Abrupt onset of fever Restlessness Respiratory distress following URI
    25. 25. Test Specimen Sensitivity(%) Specificity(%) CommentsCulture Throat or NP swab, > 90 50-90 Not routinely available; sputum, bronchial slow-growing organism washing tissuePCR Throat or NP swab, 95 95-99 Not commercially available sputum, potencially useful for rapid broncial washings, diagnosis test tissueSerology cold agglutinins 50 < 50 Nonspecific;takes several wks to develop Serum 75-80 80-90 Paired acute-convalescent Complement sera preferred;takes 4-9wks fixation for seroconversion Elisa Diagnostic criteria Definite: 4-fold increase in titer
    26. 26. Common symptoms of tuberculosis include: Chronic cough that has been present for more than 3 weeks and is not improving Fever greater than 38°C for at least two weeks, not attributable to other common causes Weight loss or failure to thrive
    27. 27.  Physical exam findings of children with pulmonary tuberculosis are similar to those of a lower respiratory tract infection. In children less than age five tuberculosis can progress rapidly from latent infection to active disease and serve as a sentinel case in the community. Consider the diagnosis of tuberculosis, especially in those children who fail to respond appropriately to routine treatment for pneumonia.
    28. 28. Age Group Indications for Admission to HospitalInfants Oxygen Saturation <= 92%, cyanosis RR > 70 breaths /min Difficulty in breathing Intermittent apnea, grunting Not feeding Family not able to provide appropriate observation or supervisionOlder Children Oxygen Saturation <= 92%, cyanosis RR > 50 breaths /min Difficulty in breathing Grunting Signs of Dehydration Family not able to provide appropriate observation or supervision From: British Thoracic Society (BTS) of Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.
    29. 29. Admission
    30. 30.  Consideration must be given to the provision of adequate hydration, oxygenation, nutrition, antipyretics and pain control. Monitoring should include:  Respiratory rate  Work of breathing  Temperature  Heart rate  Oxygen saturation (if available)  Findings on auscultation.
    31. 31.  Assist ventilation (e.g., bag-mask ventilation) as needed Provide oxygen Continuously monitor oxygen saturation Consider use of CPAP or BIPAP Prepare for endotracheal intubation as needed Administer medications as needed
    32. 32.  Respiratory failure is the most common indication for intubation in children with pneumonia Clinical evidence of respiratory failure:  Poor or absent respiratory effort  Poor colour  Obtunded mental status Oxygen saturation and end-tidal carbon dioxide can be used to support the decision to intubate, but intubation should not be delayed if there is clinical evidence of respiratory failure
    33. 33.  Pleural effusion – fluid in the pleural space as the result of inflammation. Empyema – bacterial infection in the pleural space. Parapneumonic effusions develop in approximately 40% of patients admitted to hospital with bacterial pneumonia. If an effusion is present and the patient is persistently febrile, the pleural space should be drained.
    34. 34.  Necrotizing Pneumonia – necrosis or liquefaction of lung parenchyma. Lung Abscess – A collection of inflammatory cells leading to tissue destruction resulting in one or more cavities in the lungs. A rare complication. Treatment of both Necrotizing Pneumonia and Lung Abscess involves long term parenteral antibiotics for 2-4 weeks, or 2 weeks after the patient is afebrile, and has clinically improved.
    35. 35.  Pneumatocele – thin walled, air filled cysts of the lung, often occurs with empyema. Pneumatoceles often resolve spontaneously, but may lead to pneumothorax.
    36. 36.  Hyponatremia:  Serum sodium <135 mmol/L.  Studies in India (1992) revealed that in children hospitalized with pneumonia, 27% had hyponatremia and 4% had hypernatremia.  SIADH was the most common cause of hyponatremia.  Hyponatremia is associated with increased hospital stay, complications and increased mortality, however most cases were found to be mild.
    37. 37. Outpatient Treatment of Pneumonia Child < 5 years old  Presumed bacterial pneumonia  Amoxicillin, oral (90 mg/kg/day in 2 doses) Alternative: oral amoxicillin clavulanate (amoxicillin component, 90 mg/kg/day in 2 doses)  Presumed atypical pneumonia  Azithromycin oral (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2–5);  Alternatives: oral clarithromycin (15 mg/kg/day in 2 doses for 7-14 days) or oral erythromycin (40 mg/kg/day in 4 doses) IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    38. 38.  Presumed bacterial pneumonia  Oral amoxicillin (90 mg/kg/day in 2 doses to a maximum of 4 g/day); for children with presumed bacterial CAP who do not have clinical, laboratory, or radiographic evidence that distinguishes bacterial CAP from atypical CAP, a macrolide can be added to a b-lactam antibiotic for empiric therapy;  alternative: oral amoxicillin clavulanate (amoxicillin component, 90 mg/kg/day in 2 doses to a maximum dose of 4000 mg/day, eg, one 2000-mg tablet Pediatric Community Pneumonia Guidelines. CID 2011;53:e25 IDSA twice daily)
    39. 39.  Presumed atypical pneumonia  Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2–5 to a maximum of 500 mg on day 1, followed by 250 mg on days 2–5); alternatives: oral clarithromycin (15 mg/kg/day in 2 doses to a maximum of 1 g/day); erythromycin, doxycycline for children >7 years old IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    40. 40.  Presumed bacterial pneumonia  Ampicillin or penicillin G;  alternatives: ceftriaxone or cefotaxime;  addition of vancomycin or clindamycin for suspected CA- MRSA IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    41. 41.  Presumed atypical pneumonia  Azithromycin (in addition to ß-lactam, if diagnosis of atypical pneumonia is in doubt);  alternatives: clarithromycin or erythromycin; doxycycline for children >7 years old; levofloxacin for children who have reached growth maturity, or who cannot tolerate macrolides IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    42. 42.  Presumed bacterial pneumonia:  Ceftriaxone or cefotaxime; addition of vancomycin or clindamycin for suspected CA- MRSA;  alternative: levofloxacin; addition of vancomycin or clindamycin for suspected CA-MRSA IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    43. 43.  Presumed atypical pneumonia  Azithromycin (in addition to ß-lactam, if diagnosis in doubt);  alternatives: clarithromycin or erythromycin; doxycycline for children >7 years old; levofloxacin for children who have reached growth maturity or who cannot tolerate macrolides IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    44. 44.  Preferred: ceftriaxone (100 mg/kg/day every 12–24 hours); Alternatives: ampicillin (300–400 mg/kg/day every 6 hours), levofloxacin (16–20 mg/kg/day every 12 hours for children 6 months to 5 years old and 8–10 mg/kg/day once daily for children 5–16 years old; maximum daily dose, 750 mg), or linezolid (30 mg/kg/day every 8 hours for children <12 years old and 20 mg/kg/day every 12 hours for children ≥12 years old); may also be effective: clindamycin (40 mg/kg/day every 6–8 hours) or vancomycin (40–60 mg/kg/day every 6–8 hours) IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    45. 45.  Preferred: intravenous azithromycin (10 mg/kg on days 1 and 2 of therapy; transition to oral therapy if possible); Alternatives: intravenous erythromycin (20 mg/kg/day every 6 hours) or (16-20 mg/kg/day every 12 hours; maximum daily dose, 750 mg) IDSA Pediatric Community Pneumonia Guidelines. CID 2011;53:e25
    46. 46. Suspect MRSA in:“Patients with severe pneumonia,particularly during influenza season,in patients with cavitary infiltrates,and in those with a history of MRSA infection”Treatment:Vancomycin or linezolid should be used in such patients Med Lett Drugs Ther 2007; 49(1266):62-64
    47. 47. Moderately severe (non-ICU) pneumonia:Erythromycin, or azithromycin, or doxycyclinePLUSCeftriaxone or cefotaximeComplicated pneumonia/abscess/effusion or severely ill patients requiring ICU admission:Ceftriaxone or cefotaximePLUSVancomycin (trough levels 15-20 ug/mL) or ? clindamycinPLUSAzithromycin
    48. 48.  Few evidence-based data to guide duration of therapy Parenteral: Generally preferable to switch to oral antimicrobial therapy in patients who have received IV medications if (a) afebrile for 24-48 hours and (b) able to keep food down. Uncomplicated cases: 7-10 days combined IV/PO for routine pathogens in uncomplicated infection. Consider continuing PO therapy until one week beyond resolution of fever Complicated cases: Necrotizing pneumonia or abscess – likely 4 weeks and patient improving.
    49. 49.  It is estimated that hand washing, when combined with improved water and sanitation could lead to a 3% reduction in all child deaths. Promote exclusive breast feeding for 6 months. Impact 15-23% reduction in pneumonia incidence. 13% reduction in all child deaths. Shown to be cost effective.
    50. 50.  Adequate nutrition throughout the first five years of life, including adequate micronutrient intake. Impact 6% reduction in all child deaths for adequate complementary feeding (age 6-23 months). Reduce incidence of low birth weight.
    51. 51.  Tachypnea and respiratory distress are considered the most important signs in the diagnosis of pneumonia. Only 1 in 5 caregivers know that fast breathing and respiratory distress are a reason to seek care immediately.
    52. 52.  Reducing indoor air pollution, by changing to cleaner gas or liquid fuels or high-quality, well maintained biomass stoves, may reduce the incidence of pneumonia by 22 to 46% in appropriate settings. This intervention may be cost-effective in low-income settings.
    53. 53. Cp5
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