This document discusses community-acquired pneumonia (CAP) in children. It defines CAP and provides epidemiological data, noting that CAP affects over 450 million people annually worldwide, with over 150 million new cases in children under 5, most in developing countries. Mortality is also discussed, with over 2 million child deaths from pneumonia each year, mostly in developing nations. The document then covers etiology, risk factors like HIV, and interventions to control childhood pneumonia. It concludes by outlining Cuba's national CAP management consensus, including antimicrobial treatment guidelines based on a child's age and the severity and suspected cause of their pneumonia.

1. Community-Acquired Pneumonia
(CAP)
in Children
Prof. RobertoRazon Behar, Dr. Sc.
CUBA

2. DEFINITION
 Community-acquired pneumonia (CAP) is an acute
infection of the lung parenchyma that affects a
previously healthy patient or immunocompetent,
exposed to a micro-organism outside the hospital.
 In Clinical Practice it is a combination of fever,
symptoms and signs of respiratory distress and
inflammatory infiltrates in a chest radiographic
examination.

3. EPIDEMIOLOGY
 CAP affects 450 millions people in the world
annually.
 156 millions new episodes occur in children under 5
years.
 95% in developing countries.
 Children under five years old, are the ones with the
highest mortality rate, and pneumonia is a frequent
cause of death in this age group.

4.  More than 150 million episodes of childhood pneumonia
occur every year in the developing world, accounting for
more than 95% of all new cases worldwide.
 Between 11 and 20 million children with pneumonia will
be hospitalized, and more than 2 million will die every
year.
 South Asia and sub-Saharan Africa together bear the
burden of more than half of all childhood pneumonia
cases worldwide.

 And, three-quarters of all childhood pneumonia cases
occur in just 15 countries.

5. EPIDEMIOLOGY
 8.7% of these pneumonias are serious and life-
threatening, and as a result, 2 millions children die in
developing countries every year.
 Bacteria, mainly Streptococcus pneumoniae and
Haemophilus influenzae type b, cause 90% of them.
 In children < 1 year Respiratory Syncytial Virus
(RSV) is a frequent cause of CAP.
 55 to 65% of African children admitted in hospitals
with severe pneumonia have co-infection with HIV
and two-thirds of them die. Mortality is 3 to 6 times
higher than in those without HIV.

7. The Lancet Respiratory Medicine DOI: (10.1016/S2213-2600(15)00028-4)
Copyright © 2015 Elsevier Ltd Terms and Conditions
South Asia and sub-Saharan Africa together bear the
burden of more than half of all childhood pneumonia cases
worldwide
2012

8. Pneumonia: the leading killer of
children
Pneumonia kills
more children
than any other
illness—
more than AIDS,
malaria, and
measles
combined.

9. Rudan I,. et. al. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. May 2008; 86(5): 408–416.

10. Children under 5 years old.
Pneumonia in relation to total deaths
The Americas
< 5 %
Canada and USA 1
Argentina 3
Cuba and Costa Rica 4
≥ 15 %
Bolivia 17
Haiti 20
5 a 9%
Uruguay 5
Venezuela y Chile 6
México 8
Jamaica 9
10 a 14 %
Panama 11
Ecuador and Paraguay 12
Brasil and El Salvador 13
Rep. Dominicana,
Guatemala, Honduras,
Nicaragua and Peru 14 UNICEF/WHO.
Pneumonia: The forgotten killer of children, 2006

11. ARI Mortality in Cuba
< 1 year Deaths Rate / 1 000 b a
1970 1202 5,1
2013 27 0,2
1 - 4 years Deaths Rate /10 000 inhab
1970 218 2,2
2013 22 0,4
5 - 14 years Deaths Rate /10 000 inhab
1970 52 2,6
2013 9 0,5

12. ARI Mortality in Cuba
Deaths under 5 years old
Year Deaths % of Total Deaths
Year
Rate / 1 000 born
alive
1970 1550 23,7 10,3
2013 49 4,0 0,4
The rate of under five years old mortality in
Cuba is similar to
Canada and lower than in USA.
It shows that the management of
pneumonia in our country puts us at the
level of developed countries.

13. BRONCHIOLITIS
 Mortality in developed countries is low.
It increases in patients with preexistent
medical conditions.
 Rate x 100 000 in children < 1 year
United Kingdom 2.9
USA 5.3
Cuba (2001-10) 4.1

14. Interventions needed to control childhood pneumonia,
through various programmes and approaches
GLOBAL ACTION PLAN FOR PREVENTION AND CONTROL OF
PNEUMONIA (GAPP). World Health Organization/The United
Nations Children’s Fund (UNICEF), 2009

15. Mean interventions which have
contributed to reduce ARI mortality
in Cuba
 Infant Mortality Programme.
 Maternal-Infant Programme.
 ARI Control Programme.
 Low Born Weight Reduction Programme.
 National Immunization Programme.
 Improve Nutritional Children Conditions.
 National System of Epidemiologic Vigilance.

16.  Health Centres and Specialized Services in Pneumology,
with 20% of total beds in all the Paediatric Hospitals.
 National System of Paediatric and Neonatal Intensive
Cares Unites.
 Family Doctor and Primary Health Care Attention
Programme.
 National, Provincial and Municipal Capacitation Curses.
 Social Communication, Population Information and
Mothers Education.

17. Cuban National CAP Management Consensus
2013
Antimicrobial treatment
 The initial antibiotic treatment of CAP is primarily
empirical.
 The choice of antibiotic should be based on possible
etiology depending on:
 Age of the patient.
 Severity of symptoms.
 Radiologic imaging characteristics.
 Results of clinical laboratory studies
 Co-morbidity.
 Prevalence and local microbial resistance.
 Children immunization.

18. Children between three weeks and less
than three months of age
 Initial empirical treatment
 Combination of a third generation cephalosporin
(ceftriaxone, or cefotaxime) + ampicillin.

An alternative treatment is aminopenicillins with a
beta-lactamase inhibitor.

In cases where is suspected Bordetella pertussis or C.
trachomatis is advisable to use an oral macrolide.
The recommended doses are: azithromycin 10
mg/kg/day or clarithromycin 15 mg/kg/day.

19. Children between three months and five
years old

Patients with mild intensity clinical pictures: oral
amoxicillin at doses between 80 and 90 mg/Kg/day.

In children more than 1 year old, the treatment could
be ambulatory.

20. Children between three months and five
years old

In cases where children not tolerated antibiotic,
clinical symptoms get worse, fever persists after 72
hours of treatment, they should be admitted at the
hospital.

In patients who require hospital admission, with mild
or moderate clinical forms, the indication will be oral
amoxicillin. If not tolerate oral way, it is indicated
penicillin G 200 000-500 000 IU/Kg/day, or alternatively
ampicillin 200 - 400 mg/kg/day

21. Children between three months and five
years old
 In cases of severe pneumonia, including those with
empyema, the first line treatment is Ceftriaxone (80
to 100 mg/Kg/day) or Cefotaxime (150 to 200 /kg/dia.
 Cephazolin 150 mg/kg/day, is indicated at any age
which is suspected or proven CAP caused by MRSA.
Another option is Aminopenicillins with a beta-
lactamase inhibitor (90 and 100 mg/Kg/day).

22. Children between three months and five
years old

In pneumonias with multiple foci, rapidly
progressive, empyema, infected pneumatoceles or
associated with infection of the skin and soft tissues
will be added to the third generation cephalosporins,
vancomycin (45 to 60 mg/Kg/day) or clindamycin (40
mg/kg/day), due to the suspicion of MRSA at any age.

Linezolide (30 mg/kg/day) is another option to
consider if there is unfavourable evolution even with
vancomycin and an adequate surgical treatment, or
shown a Staphylococcus strain resistant to this
antibiotic.

23. Children between three months and five
years old
 In case of CAP with treatment failure, another
possibility is Streptoccoccus pneumoniae high
resistant to penicillin (MIC:8 μg/ml), not common in
our environment
 However, in many cases there is a good response to
the treatment with high doses of penicillin.

24. Children between five and fifteen years old

S. pneumoniae continues the most frequent cause,
and the treatment is the same as in the former group.

In the absence of adequate clinical response after
the first 72 hs. of monotherapy with a β-L, it is also
advisable to add a macrolide.

If there are features of clinical and radiological
atypical CAP it is recommended treatment with
macrolides to the habitual doses whereas M.
pneumoniae and C. pneumoniae are frequent
causes. If the patient is clinically stable the
treatment may be ambulatory.

25. Other considerations
 Oseltamivir.
 If there is an epidemiological evidence of Influenza
virus circulation, treatment is indicated in patients
with CAP and a history of chronic diseases with
recognized risk to gravity evolve.
 It must also be added to any therapeutic scheme
raised previously in epidemic situations when the
possibility of CAP is serious, even without risk
factors or comorbidity.

26. Treatment according to the results of the
microbiological study.
If it is isolated S. pneumoniae with high resistance to
penicillin [Minimal Inhibitory Concentration (MIC) > 8
μg/ml]:

If it is sensitive (MIC < 1 μg/ml) or intermediate
sensitivity (MIC 1-4 μg/ml) to 3rd generation
cephalosporins, it is recommended ceftriaxone
(100 mg/kg/day) or cefotaxime (200 mg/kg/day).

If there is a resistant to 3rd generation
cephalosporins (MIC ≥ 4 μg/ml), treatment
recommendations are vancomycin, clindamycin or
teicoplanin (6-8 mg/kg/day)

27. Midle lobe
pneumonia

28. Retrocardiac
pneumonia

29. Pseudotumoral
pneumonia

30. Child 2 years old with recurrent pneumonia.
It was found a foreign body in the left inferior bronchi

31. Bronchopneumonias

32. Atypical pneumonia in an adolescent

33. Pneumonias with
extense Empyemas

34.  Age: 17 months
 Sex: Masculine
 Extense pneumonia with
empyema
 Pleural Culture:
S. Pneumoniae

35. Pneumonia
Hydropneumothorax

36. Pneumonia
complicated with a
Pulmonar Abscess

37. Lung Abscess

38. Residual pneumonia
with numerous
pneumatoceles

39.  Age: 12 years
 Sex: masculine
 Pneumonia with empyema.
 Blood and pleural effusion
cultures: S. Aureus
methicillin sensible.

40. Left pneumonía with extense
pleural effusion and mediastinal
deviation
After pleurotomy it is observed
air cavities inside the
condensation.
Also, it is observed a
pneumotorax.

41. Age 8 years old
Sex: Masculine
Right pneumonía with empyema.
After pleurotomy it was
observed a big infected tension pneumatocele with
mediastinal deviation

42. Bronchopneumonia
with suspected
bronchiectasis
Bronchography after
treatment

43. 5 years old girl with a
complicated bacterial
pneumonia after
influenza H1N1
2009