This document provides guidelines for the evaluation and management of pediatric community-acquired pneumonia (PCAP). It defines pneumonia and discusses the etiology, pathogenesis, clinical manifestations, diagnostic criteria, and treatment recommendations for different classifications of PCAP cases. Empiric antibiotic therapy and monitoring response to treatment are also addressed. The document aims to outline best practices for diagnosing and managing PCAP based on classification of the case.

1. Pediatric Community
Acquired Pneumonia
Nelson 20th Ed. Chapter 400
Matthew S. Kelly & Thomas J. Sandora
Philippine Academy Of Pediatric Pulmonologists, Inc.
2012 PAPP Update in the Evaluation and Management of PCAP
Cristan Q. Cabanilla, MD et. al

2. Rajbanshi Deepen
12 sep 2017
Group:13

4. Objectives
1. Definition of pneumonia.
2. To review the etiology and pathogenesis of pneumonia.
3. To know what diagnostic aids that are initially requested if
pneumonia is suspected.
4. To know what treatment should be used with regards to the
etiologic agent.
5. To know when a patient is either responding to the treatment.
6. To know how can pneumonia be prevented
7. To know the when antibiotic therapy should stopped.

5. Pneumonia
Inflammation of the parenchyma of the lungs .
Is a substantial cause of morbidity and mortality in childhood
throughout the world.
Leading cause of death globally among children younger than 5 years
old.
 developing countries, the introduction of measles vaccine has greatly
reduced the incidence of measles-related pneumonia deaths.

7. ETIOLOGY
Most infectious cases are caused by following
Microorganisms.
BACTERIAL
• Streptococcus pneumonia
• Grp. B streptococcus
• Mycoplasma pneumonia
• Chlamydophila pneumonia
• Chlamydia trachomatis
VIRAL
• Respiratory syncytial virus
• Parainfluenza virus 1-3
• Influenza A, B
• Adenovirus
• Human metapneumovirus

9. Noninfectious causes
 Aspiration of food or gastric acid, foreign bodies, hydrocarbons, and
lipoid substances.
Hypersensitivity reactions, and drug- or radiation-induced
pneumonitis.

10. The lower respiratory tract is normally kept sterile by physiologic
defense mechanisms, including mucociliary clearance.
 The secretory immunoglobulin A (IgA), and clearing of the airway by
coughing.
Immunologic defense mechanisms of the lung that limit invasion by
pathogenic organisms include macrophages that are present in alveoli
and bronchioles.
Secretory IgA, and other immunoglobulins. Additional factors that
promote pulmonary infection include trauma,anesthesia, and
aspiration.

12. CLINICAL MANIFESTATIONS
• URTI (cough, rhinitis)
• Fever (Bacteria cause higher fever than virus)
• Tachypnea
• Increase Cyanosis and fatigue in Infants.
• adults and older children typically begins suddenly with a shaking chill followed by a high fever,
cough, and chest pain.
• Lethargy
• Diminished appetite
• Abdominal pain (lower lobe pneumonia)
• Increased work of breathing result in IC,SC,suprasternal retractions.
• Liver may seem enlarged
• Crackles and wheezing

13. submucosa " airway obstruction
• M. pneumonia - attaches to the respiratory epithelium, inhibits ciliary action "
cellular destruction and inflammatory response in the submucosa “and airway
obstruction.
• S. pneumonia - local edema that aids in proliferation of organisms and spread to
adjacent portion " focal lobar involvement.
• Grp. A streptococcus -more diffuse infection with interstitialpneumonia; necrosis
of the tracheobronchial mucosa " exudation,edema, local hemmorhage, with
extension into alveolar septa,lymphatics, pleural involvement.
• S. aureus - confluent bronchonecrosis and irregular pneumonia, unilateral, p
resence of extensive areas of hemorrhagic areas ofcavitation of the lung
parenchyma " pneumatocele, empyema,bronchopumonary fistulas.

15. WHO SHALL BE CONSIDERED AS HAVING COMMUNITY-ACQUIRED
PNEUMONIA?
1.The presence of pneumonia may be considered even without a chest radiograph in a patient
presenting withcough and/or respiratory difficulty the following predictors of radiographic
pneumonia:
At the Emergency Room as the site-of-care,
• Tachypnea a in a patient aged 3 months to 5 years.
• Fever at any age.
• oxygen saturation less than or equal to 92% at room air at any age absence of any co-existing
illness (neurologic, musculoskeletal, or cardiac condition) thatmay potentially affect oxygenation.
At the Out-Patient Clinic as the site-of-care,
• Tachypnea in a patient aged 3 months to 5 years.
• Fever at any age

16. • 2. The presence of pneumonia should be determined using a chest radiograph in
a patient presenting with
cough and/or respiratory difficulty in the following situations:
a.Presence of dehydration aged 3 months to 5 years.
b. Presence of severe malnutrition aged less than 7 years.
High grade fever and leukocytosis aged 3 to 24 months without respiratory symptoms.

18. WHO WILL REQUIRE ADMISSION?

19. WHO WILL REQUIRE ADMISSION?

20. DIAGNOSTIC AIDS
1.PCAP-A AND PCAP-B(Chest xray,CBC,CRP,,ESR,procalcitonin,blood culture)
2.PCAP-C(gram stain, culture and sensitivity pleural fluid,ABG,oximetry)
Chest xray,CBC,CRP,gram stain of sputum,sputum
smear,Mantoux text,electrolytes and glucose.
3.PCAP-D(Consult a spcialist)

21. WHEN IS ANTIBIOTIC RECOMMENDED?

22. 1. For pCAP A or B, an antibiotic may be administered if a patient is
 beyond 2 years of age or
with high grade fever without wheeze.
2. For pCAP C, an antibiotic
A.should be administered if alveolar consolidation on chest x-ray is present .
B.may be administered if a patient is with any of the following:
• Elevated serum C-reactive protein.
• Elevated serum procalcitonin level .
• Elevated white cell count .
• High grade fever without wheeze.
• Beyond 2 years of age .
3.For pCAP D,
a specialist should be consulted.

23. WHAT EMPIRIC TREATMENT SHOULD BE ADMINISTERED IF A
BACTERIAL ETIOLOGY IS STRONGLY CONSIDERED?

24. 1. For a patient who has been classified as pCAP A or B without previous antibiotic,
A. Amoxicillin [40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses
for at most 7 days] is the drug of choice.
 Amoxicillin may be given for a minimum of 3 days .
 Amoxicillin may be given in 2 divided doses for a minimum of 5 days.
B. Azithromycin [10 mg/kg/day OD for 3 days or 10mg/kg/day at day 1 then
5mg/kg/day for days 2 to 5 maximum dose of 500mg/day], .
C.Clarithromycin [15 mg/kg/day, maximum dose of 1000 mg/day in 2 divided doses
for 7 days] given to those patients with known hypersensitivity to amoxicillin.

25. 2. For a patient who has been classified as pCAP C, without previous antibiotic,
Requiring hospitalization
A .Has completed the primary immunization against H. influenza type b,penicillin
G [100,000 units/kg/day in 4 divided doses] administered as monotherapy is the
drug of choice.
B. Has not completed the primary immunization or immunization status
unknown against H. influenza type b, ampicillin [100 mg/kg/day in 4 divided doses]
administered as monotherapy is the drug of choice.

26. Above15 years of age ,
• A parenteral non-antipseudomonal β-lactam (β-lactam/(BLIC), cephalosporin or
carbapenem] + extended macrolide, or a parenteralnon-antipseudomonal β-
lactam [β-lactam/ BLIC],cephalosporin or carbapenem + respiratory
Fluoroquinolone administered as combination therapy may be given.
• and who can tolerate oral feeding and does not require oxygen support,
amoxicillin [40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses
for at most 7 days] may be given on an outpatient basis.

27. For a patient classified as pCAP C who is severely malnourished or suspected to
have methicillin-resistant Staphylococcus aureus, or classified as pCAP D, referral
to a specialist is highly recommended.
 For a patient who has been established to have Mycobacterium tuberculosis
infection or disease, antituberculous drugs should be started.

28. WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL ETIOLOGY
IS STRONGLY CONSIDERED
1. Oseltamivir
30 mg twice a day for ≤15 kg body weight,
45 mg twice a day for >15-23 kg,
60 mg twice a day for >23-40 kg,
and 75 mg twice a day for >40 kg ,remains to be the drug of choice for laboratory
confirmed, or clinically suspected cases of influenza.

29. WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO THE
CURRENT
ANTIBIOTIC?
Decrease in respiratory signs and/or defervescense within 72 hours after
initiation of antibiotic are predictors of favorable response.
If clinically responding, further diagnostic aids to assess response such as chest x-
ray, C-reactive protein and complete blood count should not be routinely
requested.

30. WHAT SHOULD BE DONE IF A PATIENT IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as either pCAP A or pCAP B is not responding to the
current antibiotic within 72 hours, consider any of the following,
1. Coexisting illness.
2. Conditions simulating pneumonia. .
 Other etiologic agents for which C-reactive protein, chest x-ray or complete
blood count may be used to determine the nature of the pathogen.
1. May add an oral macrolide if atypical organism is highly considered.
2. May change to another antibiotic if microbial resistance is highly considered.

31. If an inpatient classified as pCAP C is not responding to the current antibiotic
within 72 hours, consider any of the following:
1. Coexisting illness
2. Conditions simulating pneumonia.
Consider other etiologic agents for which C-reactive protein, chest x-ray or
complete blood count may be used to determine the nature of the pathogen.
1. May add an oral macrolide if atypical organism is highly considered.
2. May change to another antibiotic if microbial resistance is highly considered.
3 . May refer to a specialist.
For pCAP D immediate consultation with a specialist should be done.

32. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE STARTED?
For pCAP C,
1. Responsive to current antibiotic therapy.
2. Tolerance to feeding and without vomiting or diarrhea
3. Without any current pulmonary or extrapulmonary complications; and
4. Without oxygen support.
For pCAP D,
referal to a specialist should be considered.

33. HOW CAN PNEUMONIA BE PREVENTED?
Vaccine against,
1. Streptococcus pneumonia
2. ,Influenza ,
3. Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus Influenzae type b,
 Micronutrient,
1. Elemental zinc for ages 2 to 59 months to be given for 4 to 6 months.
2. Vitamin D3 supplementation.
Vitamin A should not be given to prevent pneumonia:

34. COMPLICATIONS
1. Pleural effusion,
2. Empyema
3. Pericarditis
4. Meningitis
5. Suppurative arthritis
6. Osteomyelitis