Severe pneumonia in childhood. Robert Gie Department Paediatrics and Child Health Stellenbosch University.

3 month old infant Doing well after birth Onset of cough and fast breathing Severely hypoxic with rapid progression of disease Started on PJP treatment HIV infected Proven PJ pneumonia Initially improves then deteriorates Proven CMV co-infection

2 month old ex-premature Presented with cough and progessive respiratory distress Required ventilatory support Due to hypercarbia Culture proven PTB. Source case CXR:

10 year old child Previous well Develops the symptoms of an influenza like disease Rapid progression of respiratory failure H1N1 proven

Predominant cause of pneumonia by age and HIV status HIV-uninfected childrenAdditional organisms HIV-infected children For children 2-12 months:  S. pneumoniae  H. influenzae  S. aureus  Gram-negative bacteria  Viruses For children 12 – 59 months:  S. pneumoniae  H. influenzae  S. aureus  Viruses. For children 2-12 months  Pneumocystis jiroveci  Cytomegalovirus  M Tuberculosis  Co-infections For children months  M Tuberculosis  Gram-negative bacteria  Co-infections P Enarson 2010

Table 3 WHO standard antibiotic regimens for low and high HIV prevalent settings Child months Low HIV prevalence setting High HIV prevalence setting HIV infected or HIV suspected Very severe pneumo nia Ampicillin 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily OR if ampicillin unavailable replace with benzylpenicillin units/kg The total course of treatment is 10 days Ampicillin (OR PENICILLIN) 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily (10 days) AND High-dose cotrimoxazole (8 mg/kg trimethoprine/40 mg/kg sulfamethoxazole IV 8 hourly or orally 3 times a day for 3 weeks Severe pneumo nia Benzylpenicillin units/kg 6 hourly for at least 3 days when improved switch to oral amoxicillin 25mg/kg twice daily The total course of treatment is 5 days Ampicillin 50 mg/kg IM 6 hourly plus gentamicin 7.5 mg/kg IM once daily (10 days) AND High-dose cotrimoxazole (8 mg/kg trimethoprine/40 mg/kg sulfamethoxazole) IV 8 hourly or orally 3 times a day for 3 weeks [1] World Health Organisation. Management of Children with Pneumonia and HIV in low-resource settings. Report of a consultative meeting. Harare, Zimbabwe,Jan 30–31, Geneva: World Health Organisation/Boston University, 2004.)

Further adaptation: Consider PJP CMV co-infection in infants Less than 6 months Add Gancyclovir for 21 days

Surgical enucleation of obstructing glands. Indication: hypercapnea and not able to wean

Zinc supplementation 10mg/day Micronutrients

Predicting for failure

Child lung Health Project: Malawi In 5 years in hospital children treated for pneumonia Age –52%2-11 months –37%12-59 months Severity of disease –62.8% severe pneumonia –25.2%very severe pneumonia Mortality –Decreased from 18.6% to 8.4% P Enarson