recurrent pneumonia

1. RECURRENT PNEUNOMIA
Presenter:
Dr. Subash K.C.
Junior Resident
Moderators:
Dr. Shipra Chaudhary
Dr. Arun Kumar Singh
Dr. Lalan Rauniyar
Dr. Sagun Khanal

2. CASE SENARIO
A 6 months male child presented to a Pedia ER with complain of:
• Cough for 3 days
• Fever for 3 days
- Cough was associated with feeding and there was history of choking during the
feed
- History of bluish discoloration of face, lips, hands and feet during the event
- Fever was not documented

3. • Past history:
-History of admission on 2nd day of life with pneumonia for 10 days
-History of chest infection on 1 and ½ month and 4 months of age for which he was
treated with iv medication
• Family history was unremarkable
On examination: Systemic examination: Invetigations
GC: Ill looking, PILCCOD: nil
RR: 64 /min,
Temperature: 101 F,
SpO2: 90 % under RA, 95% under FM
HR: 140/ min
CP/PP: ++/++
Chest: Crepitation heard
over right mid axillary
region
CVS, Per abdomen and
CNS: WNL
CBC: Leucocytosis
Chest X-ray

5. OVERVIEW
• Introduction
• Etiology
• Approach
• Investigation
• Management

6. INTRODUCTION
• Pneumonia: Inflammation of the lung parenchyma
• Recurrent pneumonia : 2 or more episodes in a single
year or 3 or more episodes ever, with radiographic
clearing between occurrences

7. ETIOLOGY- RECURRENT PNEUNOMIA
A. Congenital Malformations
B. Aspirations
C. Defects in the clearance of airways secretions
D. Disorders of local/systemic immunity

8. ETIOLOGY- RECURRENT PNEUNOMIA
A. Congenital Malformations
• Airways: Cleft Palate, Tracheoesophageal fistulae, Tracheomalacia
• Lungs: Pulmonary hypoplasia, Pulmonary sequestration, Congenital adenomatoid
malformation of the lung, Bronchogenic cyst
• Cardiovascular: Congenital heart disease especially L - R shunts, Vascular ring
B. Aspiration
• Gastro-esophageal reflux, Swallowing abnormalities, Foreign body, Anomalies of
the upper airways

9. C. Defects in the clearance of airways secretions
• Cystic fibrosis
• Abnormal clearance secondary to infections: Broncheictasis
• Airway compression : Mediastinal tubercular lymphadenopathy
D. Disorders of local/systemic immunity
• Primary immunodeficiencies
• Acquired immunodeficiencies
• Immunosuppressive therapy
• Malnutrition

10. 1. Aspiration pneumonia (21.6%): Most common GERD (37.5%), FB aspiration and
cerebral palsy (31.2 % each)
2. Immunodeficiency (16.2 %): Primary (66.66%) and secondary (33.33%)
3. Bronchial Asthma (12.1 %)
4. Congenital heart disease (13.5 %): VSD (60 %), ASD (20%), PDA (10 %)
5. Congenital malformation of respiratory tract (10.8%): TEF (37.5%)
Nepal Med Coll J 2019; 21(1): 65-9

11. ETIOLOGIC AGENTS
AGE GROUP FREQUENT PATHOGENS
Neonates
(< 3 weeks)
Group B streptococcus, Escherichia coli, other Gram-negative bacilli,
Streptococcus pneumoniae, Haemophilus influenzae (type b, nontypeable)
3 weeks- 3months Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable); if patient is afebrile, consider Chlamydia trachomatis
4 months- 4 years Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable), Mycoplasma pneumoniae, group A streptococcus
≥5 yr M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae
(type b,nontypeable), influenza viruses, adenovirus, other respiratory viruses,
Legionella pneumophila
Nelson, 21e

12. ETIOLOGIC AGENTS
• Aspiration pneumonia: Mixed anaerobes
• Cystic fibrosis: Pseudomonas aeruginosa
• Immunodeficiency: Viral, Mycobacterium avium complex, Fungal
• HIV: Pneumocystis jiroveci

13. APPROACH- CLINICAL HISTORY
Age of onset
• Onset of symptoms soon after birth: hereditary/congenital disorder.
• Congenital malformations present early in life
• Disorders of humoral immunity : late infancy.
• History of possible foreign body aspiration followed by recurrent episodes
of pneumonia tends to occur in the 1-5 years age.

14. Details of the episodes
• A detailed account of the first episode of pneumonia and subsequent episodes
should be obtained:
-Onset, nature and duration of cough, occurrence of fever
-Type and duration of antimicrobial therapy (adequate/appropriate), response
to therapy and need for hospitalization.
• Respiratory distress at birth followed by recurrent pneumonia and persistence
wet cough : primary ciliary dyskinesia or cystic fibrosis

15. Past history
• Occurrence of repeated infections at other sites : systemic immunodeficiency.
• Foreign body inhalation
• Tuberculosis
• Frequent nebulization or use of MDI inhaler
• Sleep disturbances : gastroesophageal reflux and obstructive lesions, especially of
upper respiratory tract.
• Symptoms suggestive of malabsorption : cystic fibrosis
• Easy fatiguability, sweating over the forehead on feeding: CHD

16. Perinatal history
• Low birth weight and/or premature neonates : asthma, bronchiectasis, and
recurrent chest infections.
• Prematurity and neonatal respiratory distress syndrome: BPD
• History of prolonged exposure to oxygen therapy
• Occurrence of delayed passage of meconium: cystic fibrosis

17. Family history
• H/O similar illness in other siblings :cystic fibrosis, primary ciliary
dyskinesia, or immune deficiency disorders
• Family history of tuberculosis
• History of unexplained death in the family
• Maternal HIV

18. Feeding history
• Choking during feeding: aspiration.
• Excessive crying during feeding or abdominal
distension: H-type TE fistula. Vomiting after
feed or coughing at the end of feeding: GERD
Socioeconomic History and Environmental Exposures
• Overcrowding
• Exposure to inhaled pollutants, irritants and passive tobacco smoking.
Drug and Allergy History
• Use of immunosuppressant drugs.
• History of allergy to dust, smoke, cold

19. If ≥ 2 of the following warning signs are present, there is possibility of an
underlying primary immunodeficiency
• ≥4 new ear infections within 1 year.
• ≥ 2 serious sinus infection within 1 year.
• ≥ 2 months on antibiotics with little effect.
• ≥ 2 pneumonia within 1 year.
• Failure of an infant to gain weight or grow normally.
• Recurrent, deep skin or organ abscesses.
• Persistent thrush in mouth or fungal infection on skin.
• Need for intravenous antibiotics to clear infection.
• Two or more deep seated infection including septicemia.
• A family history of primary immunodeficiency.
European society of Immunodeficiencies

20. PHYSICAL EXAMINATION
• A general and systemic examination
• Oral thrush and fungal infection : Phagocytic defect.
• Generalized lymphadenopathy: Tuberculosis or HIV
infection
• Phlyctenular conjunctivitis: Tuberculosis
• Absence or atrophic tonsil, Purulent conjunctivitis :
B-cell disorder agammaglobulinemia.
• Presence of cleft plate : Aspiration pneumonia.

21. • Situs inversus, Chronic otitis media : Immotile cilia syndrome
• Multiple recurrent pustules: Immunodeficiency
• Chronicity and severity of illness is indicated by growth retardation,
persistent respiratory difficulty, hypoxia, clubbing, hyperinflammation or
reduced volume of hemithorax
• Observation during feeding: Nasal regurgitation, Coughing or choking
(anatomical defect of oral, nasal or pharyngeal wall)

22. History Extrapulmonary examination findings
Delayed passage of
meconium, passage of bulky,
oily stools, salty to kiss
-Growth failure
-Stigmata of fat-soluble vitamin deficiencies like
rachitic rosary, wrist widening, dry eyes, Bitot
spots.
-Nasal polyps in older children, rectal prolapse,
absence of vas deferens in males, digital
clubbing
Probable diagnosis
Cystic fibrosis

23. History Extrapulmonary examination findings
Unexplained neonatal
respiratory distress,
Recurrent middle ear
discharge, persistent or
recurrent nasal discharge
Persistent mucopurulent nasal discharge, serous
discharge from middle ear, , dextrocardia, male
infertility
Probable diagnosis
Primary ciliary
dyskinesia

24. History Extrapulmonary examination findings
• Recurrent episodes of
sinopulmonary infection
• Recurrent skin abscesses, deep-
seated abscesses
• Recurrent diarrhea, oral or
cutaneous candidiasis
• Persistent infections after
receiving live vaccines
Coarse facial features, absence of
tonsils and lymph nodes,
oculocutaneous albinism, ocular
telangiectasia, eczema, features of
thrombocytopenia
Probable diagnosis
Primary
immunodeficiency
disorders

25. History Extrapulmonary examination findings
Feeding difficulties in infancy,
forehead sweating while feeding,
suck-rest-suck cycles, palpitations
Displaced location of apex beat, cardiac
murmur(s), palpable heart sounds
Probable diagnosis
Congenital heart
disease with left-to-
right shunts

26. A Child with Recurrent Pneumonia, Journal of Postgraduate

27. Approach to a child with recurrent pneumonia Sudan J Paediatr.

28. INVESTIGATIONS
Diagnosis
RECURRENT PNEUNOMIA
• Is the chest X-ray abnormal
between pneumonia episode?
• Specific imaging findings?
• Chest X-ray
• Review previous films
Single lobe
involvement
Multiple lobes
involvement

29. Single lobe involvement
• Chest CT with or without contrast
• MRI chest (if mediastinal disease suspected)
• Tuberculin test (if Lymphadenopathy present)
• Echocardiogram
Fibreoptic bronchoscopy + BAL
• Surgical excision
• Lymph node biopsy
• Mediastinoscopy
If inconclusive
If inconclusive
Recurrent pneumonia in children, IJMS

30. Multiple lobes involvement
• Sweat chloride test
• Immune work up
• Swallowing evaluation
Chronic aspiration/ GERD
Diagnosis
Asthma Bronchiectasis Structural or anatomical
abnormalities
• Upper GI study
• Barium swallow study
• 24 hour PH monitoring
• Pulmonary function
test with
bronchodilator
response
• Inhaled steroid trial
• HRCT Chest
• Blood testing for
Primary ciliary
dyskinesia
• CT/MRI
• Bronchoscopy
• Echocardiogram
• Barium swallow study
If inconclusive

31. TREATMENT
• Treatment of underlying illness
• Control of current infection with appropriate antibiotics
• To start with broad spectrum antibiotics
• After result of microbiological test, antibiotic can be modified to narrow
spectrum to avoid development of drug resistance
• Nutritional support and chest physiotherapy

33. OUTPATIENT TREATMENT (ORAL THERAPY)
Age First line Second line If S. aureus suspected
< 3 months Always admit and treat in the hospital
3 months- 5 year Amoxicillin (80 mg/
kg/d) BD for 5 days
Amoxicillin (80 mg/ kg/d)
BD for 5 days
Co-amoxiclav Or
Cefuroxime (30 mg/kg/d),
BD for 5 days Or
Linezolid(10 mg/kg/d), TID
for 5 days
> 5 years Same as above Co-amoxiclav or
cefpodoxime (as above)
Or Azithromycin (10
mg/kg/d), OD for 5 days
(empty stomach)
Same as above

34. INPATIENT TREATMENT (PARENTERAL THERAPY)
Age First line Second line If S. aureus suspected
< 3 months Cefotaxime ±
gentamicin (5–7
mg/kg/d, OD) Or
Amikacin (15
mg/kg/d, OD) Or
Ceftriaxone (75–
100 mg/kg/d), BD
Piperacillin-tazobactam
± gentamicin or
amikacin Or
Cefoperazone-
sulbactam ±
gentamicin or amikacin
Ceftriaxone + cloxacillin
(50–100 mg/kg/d, QID) Or
Cefuroxime/or co-amoxiclav
+ gentamicin or amikacin
Second line
Ceftriaxone + vancomycin
(40–60 mg/kg/d, QID) or
linezolid (10 mg/kg/d), TID
for 5 days)

35. INPATIENT TREATMENT (PARENTERAL THERAPY)
Age First line Second line If S. aureus suspected
3 months to 5 years Ampicillin (100
mg/ kg/d, TID or
QID)
Co-amoxiclav
Or
Cefotaxime
Or
Ceftriaxone
Ceftriaxone + Cloxacillin
Or
Cefuroxime or Co-
amoxiclav or cefazolin (50
mg/kg/d, BD or TID)
Second line
Ceftriaxone + vancomycin
or clindamycin (20
mg/kg/d, TID or QID) or
linezolid

36. INPATIENT TREATMENT (PARENTERAL THERAPY)
Age First line Second line If S. aureus suspected
> 5 years Ampicillin (100 mg/
kg/d, TID or QID)
Co-amoxiclav Or
Cefotaxime (150
mg/kg/d, TID) Or
Ceftriaxone Or
Azithromycin
Ceftriaxone + Cloxacillin
Or
Cefuroxime or Co-amoxiclav
or cefazolin (50 mg/kg/d, BD
or TID)
Second line
Ceftriaxone + vancomycin or
clindamycin (20 mg/kg/d, TID
or QID) or linezolid

37. DURATION: 21 DAYS New Insights Into Transmission, Diagnosis, and Drug
Treatment of Pneumocystis carinii Pneumonia

38. • Pseudomonal pneumonia: Piperacillin-tazobactam, ceftazidime,
ciprofloxacin, cefepime, imipenem, meropenem
• Fungal pneumonia: Voriconazole, Posaconazole (Aspergillosis), Liposomal
Amphotericin B (Aspergillosis, blastomycosis, murcoromycosis),
caspofungin, micafungin (candidiasis)

39. TAKE HOME MESSAGE
• Recurrent pneumonia: ≥ 2 episodes in a single year or ≥ 3 episodes ever, with
radiographic clearing between occurrences.
• Common condition predisposing conditions: aspiration syndromes, structural
abnormalities, cystic fibrosis and immunodeficiency disorders
• Detailed history and examination are essential
• Investigation chest x-ray, tuberculin test ,sweat chloride test, bronchoscopy &
Bronchoalveolar lavage, CT chest and immunological studies
• Management consists treating underline causes

40. REFERENCE
• Nelson’s Textbook of Pediatrics, 21st edition
• Ghai Essential Pediatrics, 8th edition
• IAP
• UpToDate

41. THANK YOU