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- 1. CAP in children is classified as pneumonia, (agerelated tachyypnca)severe pneurmonia (tachypneaand recessions) and very severe pneumonia (severe pneumonia with hypoxemia, dullness orinability to drink). Severe or very severe pneumonia are ideally treated asinpatients. There issome data that severe CAP can alsobe treated on an outpatient basisincertain situations. No investigations including CXR are needed for outpatients. Bloodcultures and CXR should be performedfor inpatients. CBC and CRP may not alwayshelp differentiate bacterial from viral CAP. Other investigations todetermineetiology arenotroutinely indicated. Empiricantimicrobial therapyis discussed inTable 2. Salient difference from adult CAP is the sclectiveuse of macrolidesonly if clinical features suggest mycoplasma. Complications such as empyema shouldbe watchedout. Duration oftherapy foroutpatientsis 5 days and for uncomplicated pneumonia ininpatients is 7 days. Choice of empiric antimicrobial therapyinadult CAP Type of CAP Preferred drug Alternative Comments Outpatients without Co amoxiclav Macrolides** Beta lactam preferred over co-morbidities Cefuroxime macrolidesdue tohigh Cefpodoxime prevalenceof macrolide resistance inS.pneumoniae in India. Doxycyclinemonotherapy not recommended Outpatients with Co-amoxiclav Cefuroxime co-morbidities* or and cefpodoximeand use ofantimicrobialmacrolide doXyey macrolidedoxyeycline in 3 months cline If there is hypersensitivity to Inpatient., nonICU Ceftriaxone with CefotaXImeamox clav macrolide doxyeywith beta lactams: respiratory Ime macrolide doxyeycline fluoroquinolones (exeludeTB
- 2. first) Inpatient ICU Ceftriaxone with Cefotaxime, macrolide/doxycypiperacillin-tazobactam clinewithmacrolide Inpatient IC with Piperacillin Cefepime/imipenem The useofcarbapenems is risk factors for tazobactam/ with preferred overbetalactam beta Pseudomonas macrolide/doxycymacrolide/doxycycline combinations inpatients with lactamase inhibitor aeruginosal other cline enteric gram septic shock negative bacteria" The empiric addition ofoseltamivir inpatients withCAP shouldbe considered inthesetting of an influenza outbreak |IfCA MRSA issuspectedthenvancomycinorteicoplanin may be added *Chronic heart, liver, renal orlung disease, diabetesmellitus, malignancies, alcoholism oruse ofimmunosuppressive drugs Empyema •Empyema is a common complication of bacterial CAP. The common pathogens causing empyema include PneumococCUs, S.aureSs. S. pogenes and sometimes Klebsiella orothergram negative bacilli. It shouldbe suspectedif thereis persistent fever, leukocytosis and effusion on the CXR. USG can be done to confirm the diagnosis. The pleural fluid should be tapped andifit is purulenthas organisms onthe gram stain or culture, empvema is confirmed. Itshould also be suspectedin complicated para-pncumonic effusions (pll < 7.0 sugar<40 mg dl LDH> 1000 IUA lactate> 45 mg dil).
- 3. •Drainage oftheinfected fluid is paramount and canbe done by chesttube withor without fibrinolytics. VATS or thoracotomy may benceded in certain cases with organized empyema. Antimicrobial therapyfor Pediatric CAP Outpatient |Inpatient Newboms <l month Cefotaximeand gentamicin, add macrolides if Chlamydia Suspected(afebrile, staccato cough) Age less than 5 years Amoxicillin Ceftriaxone Co-amoxiclav Cefotaxime Cefuroxime Co-amoxiclav Age more than 5 Amoxicillin Ceftriaxone years Macrolide only ifclinical| Ampicillin features Suggestive of Co-amoxiclav mycoplasma with without macrolide Suspected MRSA:add vancomycin' teicoplanin /(linezolid only ifTB ruledout) Suspectedinfluenza: Addoseltamivir
- 4. Drugdoses,duration and route Drug Adult dosePediatric dose Penicillin V 500 mg twice daily 250 mg twicedaily Benzathine 27kg6,00,000 units IMsingle dose penicillin >27 kg1.2 million units IMsingle dose |Amoxicillin 500– 1000 mg thrice daily (POor| 15-20 mgkgtwice daily oral IV) 30-35mgkg thrice daily IV Co-amoxicavI gm twice daily 625 mg thrice 15-20 mgkg of amoxicillin daily oral twice daily P0 12 gm IVq8h 25-30 mgkg of amoxicillin component thrice daily IV Azithromycin 500 mg daily (POor1V) 10 mg kg oncedaily Clarithromycin 500 mg twicedaily |7.5 mgke twicedaily Oseltamivir 75 mg tWice daily PO SISkg 30 mg twicedaily 16-34 kg45 mg twicedaily 35-44 kg 60 mg twicedaily 45 kgand more 75 mg twice daily Doxveveline 100mg twice daily 1.5-2 mykg twice daily
- 5. Clindamycin 300 mgfour timesa dayPO 600 mg thrice daily IV Cepnhalexin 750 mg twicedaily PO Cefadroxil I gm oncedaily Levofloxacin 750 mg once daily PO orIV Moxifloxacin 400 mg once daily PO orIV Cefpodoxime 200 mg twicedaily roxime Cefuroxime 500 mg twicedaily oral 1.5gm twicedaily IV Ceftriaxone 2 gm once daily IV Cefotaxime 2 gm thrice daily IV Cefepime 2gm twicedaily IV Piperacllin 45gm thrice daily tazobactam Cctoperazone3 gm twCe daily sulbactam |7mgkgthrice daily |20 mgkgtwicedaily PO 30 mg kgonce daily 10-15 mpkg in one or two divided doses PO orIV | 10 mg kgoncedaily PO orIV 5 mg kgtwicedaily 1O mg kgtwice daily oral 35 mg kgtwice daily IV S0 mg kgtwicedaily 30-35 mg kgthrice daily IV 50 mg kgtwicedaily 100 mg kgpieracillin thrice daily S0 mg kg of cetoperazone tWIcedaily
- 6. Imipenem Meropenem Vancomycin Teicoplanin Linezolid gm thrice dailyor 500mg four 15-25 mg/kg fourtimnes daily times daily IV IV 1gm thrice daily IV 20-40 mg/kgthrice daily 1gm twice daily 10 mg/kg four timesdaily 400 mg twicedaily for 3 doses and 12 mg/kg twice dailyfor 3 then400 mg oncedaily doses and then 12 mg/kg once daily 600 mg twice daily PO orIV 10 mg/kg thrice daily PO orIV References 1.Gupta D,Agarwal R,Aggarwal AN,Singh N.MishraN,Khilnani GC etal (2012).Pneumonia Guidelines Working Group. Guidelines for diagnosisand management of community- and hospital-acquired pncumonia in adults:Joint ICSNCCPT) recommendations.Lung India 29(Suppl2):S27-62. 2. Mandell LA, Wunderink RG,Anzucto A, Bartlett JG, Campbell GD, Dean NC etal (2007). Infectious Diseases Society of America/ AmericanThoracicSocietyconsensusguidelines on the management of community-acquired pneumonia inadults. Clin InfectDis 44(Suppl 2):S27 72. 3. JayaramanR,VargheseR.Kumar JL, Neeravi A,Shanmugasundaram D, Ralph R, Et al (2018). Invasive pneumococeal diseaseinIndian adults: 11years' experience.JMicrobiol Immmunot nfeet pi: Si684-1182(18)30113-0. 4. Singh J,SundaresanS,Manoharan A,Shet A (2017). Serotype distribution and antimierobial susceptibility patterrnin childrenESyears with invasivepneumococcal disease in India A systematicreview. laCcine 35(35 Pt B):4501-4509. 5. VergheseVP,Veeraraghavan B,JayaramanR.VargheseR,NeeraviA, Jayaraman Y et al(2017). Increasing incidence of penicillin- andcefotaxime-resistant StrptococcUs pneumoniae causing meningitis n India: Time for revision ef treatment guidelines ndiazn Aled Microbio 35(2):228-236. Names ofthecontributors: 1. Dr. Tanu Singhal Consultant Pediatrics andInfectious Disease KokilabenDhirubhai Ambani IHospital and Medical Researeh Institute. Mumbai 2. Dr. Pallab Ray Professor, Department of Medical Microbiology, PGIMER, Chandigarh