Community acquired Pneumonia Dr Yog Raj Khinchi
Introduction• Pneumonia, especially CAP has been a subject of challenge to the medical fraternity despite extensive research since ‘Antiquity’
Introduction – Contd..• It is tragedy that in this era of easy vaccine availability millions of children die across the globe, particularly in developing countries due to vaccine preventable ‘Lower Respiratory Tract Infections’
PneumoniaCongenital Acquired Opportunistic AspirationNosocomial Community Acquired Pneumonia (CAP)
Disease Burden - CAP• Global Scenario : - 100 million cases per year < 5 yrs - 80% OPD cases with 1% mortality - 20% IPD cases with 10 -12 % mortality - 2 – 2.3 million deaths / year, 90% in developing countries
Disease Burden – CAP Indian Scenario :CAP contributes 13% of deaths(< 5 years of age) 24% National Burden of Disease (NBD) 7.5 million total cases .37 to .46 million deaths per year.[Estimates on different studies done at Delhi – Pune – Kolkatta – Varanasi –Rajasthan – Maharashtra - Haryana & Tripura [Source S.K.Kabra - National consensuson child survival & development]
Risk Factors Comorbid Pul. Illnesses Comorbid extra pul.Rampant use of antibiotics conditions particularly B-lactames in viral URTIs Low Birth WeightPoor Socio Economic Status CAP Lack of Breast Feeding Immunosuppressed conditions Malnutrition, Vit A, D & Zinc def. Viral URTIs Air Pollution & Passive Smoking [Study by Burman et al -Epidemiology of ARI in children of developing countries Rev. Inf. Dis. (1991)
Q : Do I need to chase an aetiological diagnosis in CAP before starting antimicrobial treatment?? A : NO ! Q : WHY ?A : It is not only “difficult” but often “not possible” to document Aetiological factor by lab diagnostics (> 60%) THM: It is Prudent and Rational to start “EmpericalAntimicrobial” therapy before establishing microbial aetiology Diagnosis per se is always - almost clinical
Diagnosis Q : Then how do I make the diagnosis ?A : Clinically – Triad of fever, cough, tachyponea With or without Chest pain, Sputum, Grunting, Crackles, Bronchial breathing, ↑ Vocal fremitus, Feeding difficulties, Chest recession, Cyanosis. WHO ARI Control Program Tachyponea most sensitive sign New borns > 70/min Infants (upto 2 yrs) > 50/min Children (> 2 yrs) > 40/min
DiagnosisQ : Does ancillary lab investigations support the diagnosis ?A : Yes ! to some extent Non invasive & easily Non invasive but not easily Invasive & not cost accessible accessible effective CBC X-rays BAL ESR Blood culture Lung Biopsy CRP Sputum and gastric aspirate CT Scan culture Mx Serology PCRGram stain of sputum & Pleural Tap Rapid Antigen naso pharyngeal detection test secretionsLess specific Some what specific More specific
Q : How do I decide whether it is bacterial or viral ?A : There are no definite markers to differentiate between bacterial or viral.Features suggestive of bacterial pneumonia :• Fever > 38.5oC. Toxic look• Respiratory rate > 50 breaths / min• Chest recession (Respiratory distress)• Radiologically Lobar consolidation, Segmental consolidation and Round consolidation.
Features suggestive of viral pneumonia• Infants and young children• Fever < 38.5oC• Mucosal congestion• Wheeze• Hyperinflation• Marked recession• Respiratory rate normal or raised• Radiologically Hyperinflation, Diffuse infilterates & Segmental collapse.
Features suggestive of Pneumonia by Atypical organisms• School Age children• Cough• Wheeze• Chest pain• Respiratory distress• Anemia and reticulo cytosis• Radiologically Lobar consolidation and hilar adenopathy, Interstitial infiltrates
CAPTHM:1. ‘S pneumoniae’ is the commonest causative organism of CAP in Infancy & childhood, accounting for 1 million deaths annually out of a total 1.9 million estimated deaths, particularly in developing countries.2. Viruses are commonest cause in infants and young children (14-35% of CAP)3. Significant proportion of CAP is due to mixed infections (8-40%)4. In 20-60% cases pathogen is not identified. Source – British Thoracic Society guidelines for the diagnosis and management of Community Acquired Pneumonia in children.
Q : What are other ‘Clues’ and ‘Parameters’ to catch aetiologocal diagnosis ?‘CLUES’ Associated co-morbid conditions Otitis media S pneumoniae Purulent sinusitis S pneumoniae Pyoderma S aureus Empyema S aureus Measles S aureus Watery rhinorrhoea viral Meningitis S Pneumonia / HIB
Parameters : Age is a good predictor of the likely pathogens Pathogens in infants < 3 months . Group B Steptococcus Gram negative enterococci & klebseilla Staph aureus Chlamydia trachomatis
Pathogens in Children 3 months to 5 yrs of age• More Common : - ‘S’ pneumoniae - Viruses (RSV, PIV3, Adenovirus) - H influenzae b Less Common : - M.catarrhalis - Staph aureus - Group A streptococci
Pathogens in Children > 5 yrs of age• Mycoplasma pneumoniae• Chlamydia pneumoniae• Streptococcus pneumoniae• Leigonella species
Diagnostic Difficulties1. No specific markers to differentiate viral from bacterial.2. Sputum samples are not often obtainable3. Nasopharyngeal secretions are unreliable due to high asymptomatic carriage rates.4. Some common organisms like M pneumoniae, C pneumoniae & H influenzae cannot be cultured easily.5. Bactec culture facilities are not available everywhere6. Invasive tests which are more specific are not practical in practice and are not cost effective.7. Infection may be polymicrobial
Q : How do I manage a case of CAP ? Principles of Management a) Evaluation Diagnosis Grading of severity Mode of managementb) Stabilization Supportive treatment ICU Management c) Specific Agents Antimicrobials
Severity Assessment Mild Moderate Severe OPD Management IPD Management ICU Management Indicators Indicators IndicatorsFever < 38.5oc, Fever > 38.5oc on two Altered sensoriumMild cough occ. at 8 hrs apart Cyanosis / Pso2 < 92R.R< 50 / min Moderate to severe Pao2 < 60%No dehydration, cough Pco2 > 40%Adequate intake Tachyponea pH > 7.3 R.R.> 50 / min Systolic BP<60 mmHg Resp. distress BUN > 20 mg% Pso2 92% Exp. Grunt Grunting Severe Resp. Distress Refusal of feeds & dehyderation As per BTS & ATS guidelines on CAP management
Mode of ManagementA) OPD - Appropriate oral Antibiotics for 3-5 days - Analgesics & Antipyretics - SymptomaticB) IPD - IV antibiotics for 3 - 5 days – switch to oral - IV fluid therapy & Electrolyte maintenance - Pulse oxymetry monitoring - Maintenance of Nutrition - Oxygen if requiredC) ICU - All of the above + ABG monitoring + Ventilatory life support if required
Specific AntimicrobialsWhich antibiotic ? Which Route ?Duration ? When to switch to oral? “Age is a good predictor of the likely pathogen & choice of antibiotic is based on suspected pathogen”
CAP Treatment AGE OPD IPD ICUBirth to 3 IV Ampicillin / Amoxycillin IV Ampicillin / Amoxycillinmonths 100-200 mg / kg / day + IV Aminoglycoside + IV Aminoglycoside with or without with or without IV Ceftazidime 3rd Generation Cefalosporin 50-100 mg / kg / day 100-150 mg / kg / day or Vancomycin / Teicoplanin 10- 15 mg / kg / day or Imipenem / Meropenem or Pipracillin / Tazobactum
CAP Treatment AGE OPD IPD ICU3 months Oral Amoxycillin IV Amoxycillin IV Ampicillin + Cloxacillinto 5 yrs 50-100 mg/kg/day 100-200 mg / kg / day 200 mg/kg/day or or Co-amoxiclav with or without IV B-Lactames 50-100 mg/kg/day a) co-amoxiclav or a) Cefotaxime b) Cefuroxime Cefaclor 100-150 mg/kg/day c) Ceftriaxone 25-30 mg/kg/day b) Ceftriaxone or 100-150 mg/kg/day with or without Cefuroxime or 15-25 mg/kg/day B-Lactames Aminoglycoside And / Or a) Co-amoxiclav or Macrolide 100-150 mg/kg/day Vancomycin / Teicoplanin a)Azithromycin b) Cefuroxime 10mg/kg/day 50-100 mg/kg/day b) Clarithromycin with or without 15mg/kg/day Oral Macrolide
CAP Treatment AGE OPD IPD ICU> 5 yrs Oral Amoxycillin IV Co-amoxiclav IV Co-amoxiclav 60-90 mg/kg/day 100 mg / kg / day 100-150 mg/kg/day + and / or and / or IV Ceftriaxone 100-200 mg/kg/day Macrolide IV Cefuroxime + a) Azithromycin 100-150 mg/kg/day IV Macrolide 10mg/kg/day or b) Clarithromycin with or without IV Fluroquinolone 15 mg/kg/day (Newer anti Pneumococcal) or IV Cefotaxime c) Doxycycline 100 mg/kg/day (> 8 yrs) 5 mg / kg / day with or without Oral macrolide
Failure of clinical response !! What should I Do ?A) Check the diagnosis May be wrong diagnosis - Aspiration Pneumonia - Interstitial Lung Disease - Tuberculous Pneumonia - Foreign body AspirationB) Look for underlyingcardio pulmonary conditions like : - Lung Abscess - Empyema - Cystic Fibrosis - Bronchiectasis - L-R shunt - GERD - Asthma
Failure of clinical response !! Cont’d….. What should I Do ?C) Immunosupression in host - PCP Pneumonia - Fungal Pneumonia - Pseudomonal PneumoniaD) Think for drug resistance - Child from day care centre (DRSP/ B-Lactamase producing - Use of corticosteroids & organisms) - B-Lactames in previous 1 monthE) Possibility of Viral + Bacterial Polymicrobial Aetiology or Bacterial + atypical Bacterial
Q : What complications can I expect if not treated properly ?• Empyema• Pneumothorax• Lobar Atelectesis• Septicemia• Bronchogenic dissemination• Osteomylitis• Septic Arthritis• Multiple Systemic Abscesses• Meningitis etc…
Q : How should I follow up & should I chase for follow up x-rays ? “NO”- Follow up should be clinical for 3-4 weeks- No chase for follow up x-rays except in case of - Lobar collapse - Round Pneumonia - Symptomatic child Radiographic resolution 56% - 2 weeks 74% - 4 weeks 98% - 6 weeks
Q : How can I contribute in prevention of CAP in community ?i) Promotion of Immunisation – Measles, Influenza, HIB & Pneumococus vaccinesii) Prevention of passive smoking & air pollutioniii) Judicious use of corticosteroids & antibiotics particularly B-Lactams)iv) Supplementation of Vit A, Vit D & Zincv) Promotion of Breastfeeding & demotion of bottle feedingvi) Treatment of malnutrition
Key points1. Aetiological diagnosis in CAP is not only difficult but not always possible (>60%)2. Emperical Antimicrobial therapy is ‘Rational’ & ‘Prudent’3. Age is a good predictor of likely pathogens4. Streptococcus pneumoniae is the most common cause of CAP in childhood followed by viruses5. Chest radiography though supports the diagnosis – is poor indicator of aetiology.6. Followup x-rays are not required unless in special circumstances
Key Points – Contd..7. Acute phase reactants do not distinguish between viral & bacterial infections8. Pulse oxymetery monitoring should be performed in every admitted child with CAP.9. Blood cultures though desirable yields only 10-20% positivity.10. Amoxycillin is the drug of choice for CAP from infancy to adolescent alternatives are co-amoxiclav, cefuroxime or macrolide11. Child remaining febrile & symptomatic for more than 48- 72 hrs after hospitalization should be re-evaluated for complications, underlying comorbid conditions, co-mimics, immunosuppression or drug resistance.