Community acquired pneumonia is a major cause of childhood morbidity and mortality worldwide, especially in developing countries. In India, acute respiratory infections account for 24% of the disease burden and 13% of deaths in children under 5 years of age. Pneumonia is commonly caused by pathogens like Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Clinical features include fever, cough, difficulty breathing, and fast breathing. Chest x-rays are not always needed for diagnosis. Severity is assessed using WHO criteria to determine appropriate treatment setting and antibiotics. Supportive care includes oxygen and fluids. Antibiotics are typically given for 5-7 days but longer for severe or staphylococcal pneumonia

1. COMMUNITY ACQUIRED
PNEUMONIA
DR MANDAR HAVAL
MBBS DCH DNB
FELLOW IN NEONATOLOGY

2. MAGNITUDE OF THE PROBLEM
• Acute respiratory Infections (ARI) in children
less than 5 years old are the leading cause of
childhood morbidity and mortality in the
world.
• Recent WHO estimates suggest the median
incidence of clinical pneumonia is 0.28
episodes per child per year.
• More than 95% of all episodes of clinical
pneumonia in young children worldwide occur
in developing countries.

3. RECENT ESTIMATES FROM INDIA
• ARI in children under 5 years of age
constitutes 24% of the National Burden of
disease and 13% of deaths
• Mortality estimates suggest that 2.3 million
children less than 5 years of age die every year
in India and 20% of these deaths are due to
ARI.

4. IDENTIFICATION OF ETIOLOGICAL
AGENTS
• The Identification of the etiological agent / agents
responsible for pneumonia remains a challenge.
This is primarily because of difficulty in obtaining
adequate samples for culture, differentiating
infection from colonization and lack of reliable
diagnostic tests.
• The gold standard would be lung puncture
samples taken directly from the infected area of
the lungg. However this is an invasive test and
not routinely preferred

5. WHAT IS COMMUNITY ACQUIRED
PNEUMONIA?
• Community acquired pneumonia is an acute
infection of the pulmonary parenchyma in a
previously healthy child, acquired outside of a
hospital setting.
• The patient should not have been hospitalized
within 14 days prior to the onset of symptoms
or
• Has been hospitalized less than 4 days prior to
onset of symptoms.

6. WHAT ARE THE COMMON
PATHOGENS INVOLVED?
• Age is a good predictor of the likely pathogen of
pneumonia and can help narrow the list of
etiological agents.
• While Gram negative agents are common under
3 months of age.
• S. pneumoniae is common at all ages thereafter
• H. influenzae is a common organism upto 2 years
of age.
• Staphylococcus though not very common is an
important formidable enemy

10. HOW DOES ONE DIAGNOSE
PNEUMONIA IN A CHILD?
A. Children with suspected pneumonia can present
with symptoms like
1. Fever
2. Cough, may or may not be productive
3. Chest pain and/or abdominal pain
4. Difficulty in breathing (dyspnea) / rapid
breathing (tachypnoea)
5. Constitutional symptoms: malaise, lethargy,
headache, nausea / vomiting

11. 2. Signs that suggest a high probability
of pneumonia and need for antibiotic
treatment
• Rapid respiration identifies children who have
a very high probability of having pneumonia
and are therefore candidates for antibiotic
therapy
• Age< 2 months - 60 or more
2 months upto 12 months- 50 or more
12 months upto 5 years - 40 or more
breaths/min.

12. Continue
• The presence of grunt, crackles, bronchial
breathing is suggestive of pneumonia but are
not so common
• Often there may be presence of signs of the
complications of pneumonia like para-
pneumonic effusions/ empyema,
pneumothorax

13. HOW DOES ONE ESTABLISH THE
DIAGNOSIS?
• Diagnosis of CAP can be established with a fair
degree of accuracy by judicious use of the
clinical signs detailed above.
• There are few clinical features to suggest
probable etiology yet some clues like presence
of skin boils, rapid progression /
deterioration, empyema or pneumothorax or
radiological evidence of pneumatocele
strongly incriminate Staphylococcus

14. Clinical differentiation of viral and
bacterial pneumonias is difficult

15. DIAGNOSING PNEUMONIA
AIMED AT
• Recognizing signs that suggest a high
probability of Pneumonia and need for
antibiotic treatment
• Assess severity of pneumonia to identify
patients requiring hospital care

16. STUDY

17. DIFFERENTIAL DIAGNOSIS

18. CONSIDER BRONCHIOLITIS-WALRI
• Age 1month-1year
• Presence of upper respiratory catarrh
• Progressive increase in resp distress
(tachypnea, retractions)
• Wheeze ± crackles
• Clinical and radiological evidence of
hyperinflation

19. CONSIDER LTB-CROUP
• Hoarseness of voice and barking/brassy cough
• Stridor
• Mild to marked respiratory distress
• Sonorous rhonchi
• Fever usually mild (or spiking as in tracheitis,
however this disease entity is rare)

20. CONSIDER ASTHMA
• Recurrent afebrile episodes, 3 or more
• Wheeze
• Good response to bronchodilator
• Hyperinflation
• Family/personal history of atopy

21. INVESTIGATION

22. RADIOLOGY
• Not a very reliable diagnostic tool due to wide
inter- and intra-observer error in reading
radiographs
• Those needing domiciliary care usually do not
benefit from radiographs
• Those sick enough to need hospitalization
may benefit

23. INDICATIONS FOR CXR IN EITHER
PRIMARY CARE OR HOSPITAL CARE
• For diagnosis of child under 5 years with fever
of 39 C of unknown origin,If complications
suspected, (for example, pleural effusion as
suggested by diminished air entry),
• Ambiguous features, Unresponsive to
treatment after 48 hrs of treatment /
deteriorates

24. MICROBIOLOGICAL TESTS ARE OF
NO USE ROUTINELY

25. ACUTE PHASE REACTANTS
• TLC, DLC, CRP are not diagnostic but may be
useful to monitor the response to treatment.
• A normal test may be more useful in
EXCLUDING the diagnosis as compared to
confirmation on the basis of a positive test

26. ASSESSING PNEMONIA

27. ASSESSING SEVERITY OF PNEUMONIA
• WHO criteria of assessment of severity is
simpler and useful at all levels of care

28. WHY AND HOW DOES ONE ASSESS
SEVERITY?
• Assess for severity to decide the level of
facility at which to treat and also to
determine the choice of treatment including
antibiotics.

31. Note..
• Hypoxaemia is a good indicator of the severity
of Pneumonia, and pulse oxymetry should
therefore be performed on every child
deemed ill enough to be admitted.

32. Indications For Admission To Hospital In
Pneumonia Among Children?
1. Mild to moderate cases do not need
admission (refer to ‘FACTS’)
2. Infants less than 3 months of age are best
treated as inpatients.

34. THE INDICATIONS FOR TRANSFER TO
PEDIATRIC INTENSIVE CARE UNIT
(PICU)
• There is failure to maintain SaO2 >92% in FiO2
>0.6
• The patient is in peripheral circulatory failure
• There are rising respiratory and pulse rates
with clinical evidence of severe respiratory
distress and exhaustion with or without raised
PaCO2
• There is recurrent apnoea or slow irregular
breathing.

36. HOW DOES ONE TREAT SUCH CASES?
• The components of management are
(a) Oxygen as indicated by pulse
oxymetry and/ or clinical signs of hypoxia
(b) Supportive therapy
(c) Antibiotic

37. USING ANTIBIOTICS FOR CAP -
GENERAL PRINCIPLES
• Empiric therapy should be based on knowing
the most likely pathogen in each community.
S. pneumoniae is an important causative
agent for Community Acquired Pneumonia at
all ages.

38. • Because it is difficult to distinguish between
bacterial, viral, and mixed infections, most
children with Community Acquired
Pneumonia are treated with antibiotics.
• Selection of antibiotic is dictated by the age
of the child and epidemiological factors and
sometimes the results of the chest
radiography.

41. SIMPLE WAY OF APPROACH

43. When to start second line of drug?
• Deterioration of clinical condition at anytime
on first line antibiotics
OR
• No response even on DAY 4 of antibiotic
therapy

44. QUINOLONES

45. SELECTION OF ANTIBIOTICS

46. UNDERLYING DISEASE
• Children with hemoglobinopathy or nephrotic
syndrome are more susesptible to
Pneumococcal
• Cystic fibrosis – Staphylococcus, H influenza,
Pseudomonas

47. • Immunodeficiency – opportunistic infection
• HIV – Gram negative bacilli, P.jiroveci and
Fungal
NOTE – PROGRESSION IN IMMUNODEFICIENCY
IS RAPID HENCE MORE EFFICIENT ANTIBIOTIC
COMBINATION USED AS A FIRST LINE

48. • Neutropenia – Gram Negative bacilli,
Staphylococcus along with common pathogen
like S.pneumoniae and H. influenzae
• Drug of choice – CEFTAZIDIME with
AMINOGLYCOSIDE
• If no response then add ANTIFUNGAL or
SEPTRAN

49. • History of Hospitalization – Gram Negative
bacilli.
• NOTE – STAPHYLOCOCCAL infection in
hospital setting is Resistance to PENICILLIN
and need VANCOMYCIN or LINIZOLID

50. History of previous antibiotics
• Current episode OR recent past (2-4 week)
should be consider
• Idea of possible RESISTANT ORGANISMS. So
change antibiotic accordingly.

51. NUTRITIONAL STATUS
• The symptoms of pneumonia may be MASKED
in severe malnutrition
• Added predisposition to GRAM NEGATIVE
organisms

52. DURATION OF ILLNESS
• Short duration – possible BACTERIAL etiology
• Prolonged duration – M. TUBERCULOSIS,
ATYPICAL ORGANISM, ADENOVIRUS

53. INDICATION FOR IV ANTIBIOTICS
• SEVERE PNEUMONIA
• DISTURBED CONSCIOUSNESS
• IMPROPER SWALLOWLING
• FREQUENT VOMITING
• MALABSORPTION
• Note – switch to ORAL when child start
accepting orally or clinically improving

54. SUPPORTIVE THERAPY FOR CAP
• Oxygen as indicated by pulse oxymetry and/
or clinical signs of hypoxia
• IV fluids : If dehydrated,If tachypnoea is
severe enough to make the child unable to
drink, or Impending respiratory failure.

55. • Fever management
• Bronchodilators, indicated only in the
presence of wheeze, should be used to
decrease the work of breathing.

56. HOW LONG DOES ONE CONTINUE
TREATMENT?
• Domiciliary cases: Total of 5-7 days
• Admitted cases: Switch to oral as soon as patient
can accept orally. Total 5-7 days.
• However, if on second line therapy, then use IV
antibiotics for 7-10 days.
• If suspected or confirmed Staphylococcal based
disease, treat for 2 weeks at least in
uncomplicated cases and for 4-6 weeks for those
with complications like empyema, metastatic
abscesses etc.

57. HOW DOES ONE MONITOR
RESPONSE?
• Clinical response in the form of absence of
fever, improvement in breathing is a useful
method.

58. The end of treatment X-ray is not
needed in every case except when:
1. The response is delayed or incomplete, or
2. There were any ambiguous signs in initial
film, or
3. There are any associated complications, or
4. Children with lobar collapse or ongoing
symptoms.

59. PREVENTION OF PNEUMONIA
• ROUTEIN IMMUNIZATION against PERTUSSIS,
MEASLES, H.influenzae type B

60. THANK YOU