Neonatal sepsis Pneumonia in children

1. Dr: ALI ALLAHABI
Pediatric specialist
Pnumonia in children diagnosis and
management

2. Diagnostic and management of pneumonia
Definition
Epidemiology
Classification
Clinical presentation
Diagnosis referrence
Treatment
Prevention
Reverence

3. Definition
Pneumonia is an infection of one or both of the lungs caused by
bacteria , viruses or fungi . It is a serious infection in which the air sac is
filled with pus and other liquid.
Pneumonia is an infection of the lower respiratory tract that
involves the airways and parenchyma, with consolidation of
the alveolar spaces.
Pneumonia could be localized in the lung or may extend systemically.

4. Epidemiology
-Childhood pneumonia is the leading single cause of mortality in children aged
less than 5 years.
- Pneumonia accounts for 14% all death of children under 5 years old
-pneumonia is a common lung infection that effects millions of people worldwide
-pneumonia is most often caused by the bacterial streptococcus pneumonia,
but infection Can be also due to viruses, fungi.
-the approximately 8,7% of children with pneumonia required hospitalization .
-The approximately 4 million occurred in developed countries .

5. Classification
1- community acquired: pneumonia not acquired in hospital setting or in a
long term care facility.
2-hospital acquired : pneumonia that accurse after 48 h or mor of
hospitalization that was absent on admission.
a- healthcare-associated : pneumonia in patient hospitalized within
90 days of infection residents of long-term care facility, pt receiving
parenteral ATB and chemotherapy within 30 days of infection.
b–ventilatory associated : P. occurs 48 h or mor after endotracheal tube.
3-aspiration pneumonia : occurring after inhalation oropharyngeal
material.

6. Classification
LESS COMMON
PATHOGENS
AGE GROUP
Cytomegalovirus
herpes simplex virus
Listeria monocytogenes
Treponema pallidum
Hemophilus influenzae
(type b, non-typeable)
Neonates (up
to 1month of
age)
Group B streptococcus
Escherichia coli
Other gram negative bacilli
Streptococcus pneumonia
COMMON PATHOGENS
IN APPROXIMATE ORDER OF FREQUENCY

7. Classification
LESS COMMON
PATHOGENS
AGE GROUP
COVID-19
1–3months
Febrile
Pneumonia
Respiratory syncytial virus
other respiratory viruses
(parainfluenza viruses,
influenza viruses, adenoviruses)
S. Pneumoniae
H. influenzae (type b, non-typeable)
COMMON PATHOGENS
IN APPROXIMATE ORDER OF FREQUENCY

8. Classification
LESS COMMON
PATHOGENS
AGE GROUP
1–3months
Afebrile
pneumonia
Chlamydia trachomatis
Mycoplasma hominis
Ureaplasma
urealyticum
cytomegalovirus
Bordetella pertussis
COMMON PATHOGENS
IN APPROXIMATE ORDER OF FREQUENCY

9. Classification
LESS COMMON
PATHOGENS
AGE GROUP
C . trachomatis,
Mycoplasma pneumoniae
Chlamydophila pneumoniae,
group A streptococcus
(S. aureus)
Mycobacterium tuberculosis.
COVID-19
3mo to 5yr
Respiratory syncytial virus,
other respiratory viruses
(parainfluenza viruses, influenza viruses,
human metapneumovirus adenoviruses)
S. pneumoniae, H. influenzae
(type b, non-typeable)
COMMON PATHOGENS
IN APPROXIMATE ORDER OF FREQUENCY

10. Classification
LESS COMMON
PATHOGENS
AGE GROUP
H. influenzae
(type b, non-typeable)
influenza virus
adenoviruses
coronaviruses
other respiratory viruses
5–18yr
M. pneumoniae
S. pneumoniae
C. pneumonia
COMMON PATHOGENS
IN APPROXIMATE ORDER OF FREQUENCY

11. Classification
Other cause related to
causes of recurrent
pneumonia
cause related to
no infectious
-localized :
TFE, sequestration, CAM
- systemic:
immunodeficient, cystic fibrosis
immotile cilia S
-Aspiration pneumonia
-Hypersensitive
pneumonia
-Resistance or atypical bacteria as TB
-Empyema or abscess
Couse related to bacterial
organism

12. Clinical presentation
The clinical signs and symptoms depend primarily on the age
of the patient, the causative organism, and the severity of the disease
Neonates
Infants
Toddler or Young Child
Older Children and Adolescents

13. clinical presentation
AGE GROUP Symptoms
Neonates
Infants
Toddler or Young Child
Older Children and
Adolescents
lethargy, irritability, poor feeding, isolated fever
hypothermia, apnea , cough, vomiting,
poor muscle ton , difficulty breathing , shortness of breath
apnea, fever ,cough, gastrointestinal symptoms , vomiting , irritability
Poor feeding , tachypnea , difficulty breathing , , shortness of breath
fever ,cough, gastrointestinal symptoms are common ,Vomiting ,
anorexia are common as is abdominal pain,
difficulty breathing , shortness of breath
the presentation is similar to that of adults with pneumonia.
Cough is often, but not always, present.
Chest pain may occur and is usually pleuritic

14. Diagnostic approach of pneumonia
Local exam
General exam Local examination
Chest Deformity
Chest expansion and asymmetry
Trachea
palpate neck and axillary
lymphadenopathy
Auscultation: air entry (decreased and
equality)
Breath sounds (vesicular, bronchial
Prolonged expiratory phase)
added sounds (transmitted ,wheeze,
rhonchi, crepitations - coarse ,
fine end-inspiratory
Vital signs
General observation :
(Around the child – O2, inhalers , tubing ,
wheelchair, monitors, sputum pot, peak
flow
appearance of child (Pt look well, ill
,toxic or in pain )
respiratory distress with/without
oxygen) Color cyanosis, Pallor, and facial
edema
Dysmorphism Observe
Nutritional status
General examination

15. Diagnostic approach of pneumonia
Investigation
• Rapid influenza test may help to identify the
cause of fever and to reduce unnecessary use of antibiotic
• CBC, chemistry, or serology will not help in identifying etiology or aid in
management
• Blood culture rarely helpful (only 10% of the time organism is recovered)
• ESR and C-reactive protein (CRP) may be elevated but are not specific
• Tuberculin test if there are TB risk factors or TB is being considered
• septum culture identified the type of bacterial pneumonia

16. Diagnostic approach of pneumonia
Image
C X R:- A CXR will not change clinical management for patients
being treated as outpatient
Afebrile children do not need a CXR – CXR always lags behind clinical response.
No need to obtain to confirm response to antibiotics
Obtain a CXR if:
◦ Complicated pneumonia is being considered
◦ Clinical deterioration
◦ Prolonged fever with no obvious source of infection
◦ Abdominal pain with normal appendix
Video swallow study: Aspiration
Ultrasound: Pleural effusion, complicated pneumonia
Chest CT scan : complicated pneumonia

17. Indication for hospitalization
- Suspected sepsis
- severe dehydration
- toxic appearance
- hypoxemia (SpO2 < 90%) , - central cyanosis
- tachypnea:( > 60 c/m in infant <2months)( > 50 c/m in child aged
2m-12months) (> 40 c/m in child aged from 12months to 5 yrs.)
- unresponsive to outpatient therapy
inability to drink
-
- Intravenous fluids and O2 if needed and antibiotics

18. Treatment
Supportive treatment :
-Oxygen therapy
-Analgesic if pain and antipyretic if fever
-If wheeze is present give a rapid acting broncho-dilator
-Gentle suction any thick secretion in the throat which the child cannot clear
-IV fluid if necessary correct dehydration and maintain adequate hydration
-Physiotherapy has no proven role
-Nutritional status during and after hospitalization

19. Treatment of community – acquired pneumonia
1 to 6 months
Age group and suspected
pathogens
Suggested parenteral empiric
agent(s)
Comments
Bacterial
(not chlamydia trachomatis or
staphylococcus aureus)
C. trachomatis
On of the following
Ceftriaxone
-
- cefotaxime
If CA- MARSA is suspected.
ADD
On of the following
- Vancomycin
- clindamycin
Azithromycin

20. Treatment of community – acquired pneumonia
> 6 months
Age group and suspected
pathogens
Suggested parenteral empiric
agent(s)
Comments
Uncomplicated bacterial
(not mycoplasma pneumonia ,
chlamydia pneumonia
or S. aureus)
M . Pneumonia or C. pneumonia
On of the following
Ampicillin or penicillin G
-
Cefotaxime
-
- Ceftriaxone
Cefotaxime and ceftriaxone are
reserved for :
- children with incomplete Hib or
streptococcus .P immunization
Or
- Communities with substantial
prevalence of penicillin resistant
S. Pneumonia(ag. >25%)
On of the following : - azithromycin – erythromycin – levofloxacin

21. Treatment of community – acquired pneumonia
1 to 6 months
Clinical syndrome (any age)
Suggested parenteral empiric
agent(s)
Comments
Sever pneumonia
Combination therapy with
on of the following
Ceftriaxone
-
- Cefotaxime
Plus on of the following
-Azithromycin
-Erythromycin
-doxycycline
Children with sever infection may
benefit from broad – spectrum
therapy that addresses both typica
and atypical pathogens
If S. aureus is a consideration
either: add
Vancomycin or clindamycin
Or
Provide therapy with ceftaroline
PLUS
Azithromycin

22. Treatment of community – acquired pneumonia
1 to 6 months
Clinical syndrome (any age)
Suggested parenteral empiric
agent(s)
Comments
Sever pneumonia
Requiring ICU
admission
Combination therapy with
on of the following
Ceftriaxone
-
- Cefotaxime
Plus
Vancomycin
plus
-Azithromycin
Plus
Antiviral treatment for influenza if
the child is hospitalized during
influenza season
If S. aureus is likely :
add nafcillin or
Substitute :Linezolid
for vancomycin and nafcillin
0r use : ceftarolin
plus Azithromycin
plus
Antiviral treatment for influenza if
the child is hospitalized during
influenza season

23. Treatment of community – acquired pneumonia
1 to 6 months
Clinical syndrome (any age)
Suggested parenteral empiric
agent(s)
Comments
Complicated pneumonia
(e.g. Effusion/empyema
necrotizing process. Abscess)
Combination therapy with
on of the following
Ceftriaxone
-
- Cefotaxime
Plus
Clindamycin
If S. aureus or anaerobic infection is
a consideration
Potential pathogens include
S. Pneumonia , S . aureus and
streptococcus pyogenes
Vancomycin: is alternative to
clindamycin for children with
allergy to clindamycin or high
prevalence of clindamycin
resistance in the community
Monotherapy: with
ceftaroline

24. Doses for parenteral antibiotics for the empiric treatment of pneumonia
in hospitalized children
Regimen
agent
150 to 200mg /kg/day divided to QID
(MAX 12g /day)
ampicillin
10mg /kg /day. once /day for 2 day of therapy .
5mg /kg/day OD . Subsequent days of therapy.
azithromycin
Age >2months <2 yrs. 8mg mg /kg/8h,
Age >2 yrs.<18yrs (BW<33Kg 12mg/kg/8h
if BW >33Kg :400mg/8h or 600mg/ 12h)
Ceftarolin
150 mg /kg /day in 3 or 4 divided doses
MAX 8g/day
cefotaxime

25. Doses for parenteral antibiotics for the empiric treatment of pneumonia
in hospitalized children
Regimen
agent
50 to 1oo mg /kg /day in 1 or 2 divided doses
MAX 4g/day
ceftriaxone
30 to 40 mg /kg /day divided to 3 or 4 doses
Max 2,7g/day
clindamycin
20 mg /kg /day divided to 4 doses
Max 4g/day
Erythromycin
4mg/kg/day divided to 4 doses
Max 200mg /day
Doxycycline

26. Doses for parenteral antibiotics for the empiric treatment of pneumonia
in hospitalized children
Regimen
agent
Age 6 months and <5yrs 20mg/kg/day
divided to 2doses
>5yrs to 16 yrs. 8 to 10mg/kg/day divided to 2 doses
levofloxacin
Age <12 yrs. 10mg /kg/dos/8h (max 600mg/dos)
Age >12 yrs. 600mg/12h
linezolid
2ooooo to 250000 unit/kg/day divided to 4 to 6 doses
Max 24million unit/day
Penicillin G
40 to 60mg /kg/day divided to 3 to 4 doses
Max 4g/day
Vancomycin

27. Prevention
Immunization have had a great impact on reducing the incidence of vaccine-preventable causes of
pneumonia
Zinc supplementation
Exclusive Brest feeding up to 6 month of age
RSV infection can be reduced in severity by use of palivizumab
Reducing the length of mechanical ventilation and using antibiotics treatment only when necessary
can reduce ventilatory – associated pneumonia
Hand washing before and after every patient contact and use of gloves for invasive procedure are
important measure to prevent nosocomial transmission of infection.
Hospital staff with respiratory illnesses or who are carriers of certain organism , such as methicillin –
resistant S. aureus , should use masks or be reassigned to non-patient care duties.

28. Reverence
Nelson book 2022
-
-Pediatric Board Study Guide 2020
-UpToDate image kay =PEDS/56260~PEDS/127763
-WHO organization web sit
-Medscape