Pneumonia in infancy and childhood Mária Adonyi Pediatric Clinic, University of Pécs

Pneumonia Developing countries : the leading cause of death Developed countires : the most common childhood disease under the age of 5 : 3 - 4 / 100 / year 5-14 years of age : 0.4 – 1.6 / 100 / year mortality rate: 0.01 / 100 / year

Social, economic burden Community Acquired Pneumonia ( CAP )

Infection of the lungs Pneumonia Incidence is based on: Age Host defence mechanisms Environmental factors Impaired gas exchange. Pneumonia 4

Pneumonia Viral Lobar Bacterial Bronchial Fungal Interstitial Etiology: Viral Bacterial Fungal Protozoon Morphology: Lobar Bronchial Interstitial Broncho - Pneumonia - Lobar - Young children, and elderly - Staph., Str.Pneum., H.infl, - Patchy consolidation - Inflammation surrounding the small airways - Different areas affected - Two-sided - 2-50 years of age - 95% Pneumococc. (Klebs.) - Affects the lobes, these are completely consolidated - Usually one-sided 5

Lobar pneumonia

Bronchopneumonia

Infection agents of pneumonia Children cannot produce a sputum. Upper respiratory tract is contaminated with a normal flora. Antigen-antibody tests are non-specific, and not sensitive.

Pathogens of pneumonia at different age groups in infancy and childhood At any ages RSV, Parainfl., Infl., Adeno, CMV, HSV, Metapneumovirus, Rhinovirus 0-2 days Group B Streptococcus 1-14 days Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, Group B Streptococcus , Enterobacteriaceae 14 days - 2 months S. aureus, Streptococcus pneumoniae, Haemophilus influenzae, Enterobacteriaceae, S. epidermidis, Candida albicans 2 months - 5 years Haemophilus infl. Streptococcus pneumoniae, S. aureus 5-10 years Streptococcus pneumoniae, S. aureus,Mycoplasm 10-21 years Mycoplasma pneumoniae, Chlamydia pneumoniae, Streptococcus pneumoniae, Legionella pneum.

Viral pneumonias in childhood 30 – 67% Pathogens: Adenovirus Influenza A, B 7-22% Parainfluenza RSV Rhinovirus Coronavirus 1.5-6.5% Metapneumovirus 8-12% Parvo (Boca) virus 4.5-15.2% Combined: viral – bacterial 23-33% Diagnosis: PCR serologic, immunfluorescent methods Diff.dg: bronchitis bronchiolitis Treatment: supportive antibiotics (bacterial coinfection): cefotaxim

Moraxella catarrhalis Bacterial CAP 10% Pathogen: S. pneumoniae S. aureus H. influenzae B Moraxella catarrhalis

Infiltration → Pneumatocele → Abscess → Ptx Bacterial CAP Infiltration → Pneumatocele → Abscess → Ptx Treatment: supportive antibiotics chest tube VATS oxygen ventillation

Pathology and symptoms Early stage Intraalveolar exudate Parenchymal destruction Weakness Loss of appetite Mucus production Low grade fever –fever Chest pain Crepitation Acidosis Cyanosis Reduced pO2 Respiratory distress Sepsis Fever: 38.5 oC Cough Tachypnoe >50/minute, tachycardia Nasal flaring Dull percussion Crepitation, weakened breathing, bronchial sound Toxic symptoms Elevated acute phase reactants

CAP caused by intracellular pathogens Mycoplasma pneumoniae 27-36% Chlamydia pneumoniae (psittaci, trachomatis) 5-14% Legionella pneumophila 10-16%

CAP caused by intracellular pathogens Symptoms: weakness headache sore throat mild temperature – temp. cough – dry, fits chest pain Treatment: supportive macrolides: clarithromycin (2 weeks) azithromycin oxygen ventillation

Pneumonias caused by opportunistic pathogens VZV CMV HSV Pneumocystis carinii Aspergillus fumigatus Candida species Mycobacterium avium Treatment: treatment of underlying disease + acyclovir, gancyclovir amphotericin B, voriconazol trimethoprim + sulfamethoxazol (14-21 days) Diagnosis: culturing, PCR Tracheal aspirates BAL ,biopsy 16

Basic questions : Pneumonia ? Antibiotics ? Hospitalization ? Treatment using the proper dosage of antimicrobial to achieve a minimal effective concentration.

Penumonia caused by Pneumococcus: - invasive infection Penumonia caused by Pneumococcus: - invasive infection - nonivasive infection Invasive infection : - accompanied by bacteremia, - pleural effusion, - other invasive complications. S. pneumoniae resistance to Penicillin

S. pneumoniae Penicillin sensitivity Reduced sensitivity to beta-lactam antibiotics Change of the protein structure in the cell wall. High dosage penicillin, ampicillin, amoxicillin, normal dosage cefotaxim, cetriaxon, meropenem is needed. Coresistance: macrolide, tetracyclin derivates Still sensitive to: - levofloxacin, moxifloxacin - glycopeptides (vancomycin, teicoplanin)

Summary Hospitalization recommended: Admission to ICU: - fever, tachypnoe - respiratory rate! letarghy, depressed state - inability of food, drink intake - pleural effusion - - decreased oxygen sat <92% - young age, multifocal infl. long-lasting disease underlying chronic disease - inappropriate social conditions Admission to ICU: - FiO2 >0,6 → <92% O2 SAT - altered sensorium - shock - exhaustedness, pCO2 ↑ - increasing resp. distress - apnoe, irregular breathing

Summary Streptococcus pneumoniae is the most prominent pathogen causing CAP in childhood. (A) The use of different methods can make its diagnosis more effective. Age is a good predictor of pathogens. (B) Age above 3, fever higher than 38.5, tachypnoe suggest bacterial infection . (B) Routine chest radiographs and lab investigations are not necessary in the absence of complications. (A) Bacterial and viral causes cannot be differentiated based on these.

Summary If bacterial pneumonia is suspected blood culture must be done. (B) Physiotherapy is not recommended in CAP. (B) Under the age of 5 oral amoxicillin, above the age of 5 macrolides are the first line antibiotics. (B) Parenteral amoxicillin, ampicillin, cefuroxim. Excluding severe cases, oral antibiotics in CAP are safe and effective. (A) Immunisation can decrease the incidence of pneumonias.