PHARMACOLOGY CONFERENCE GUIANG, Ada; GUEVARRA, Biancarita; GERONIMO, Cherry; GERONIMO, Maria Angelica; GERONIMO, Ralph

Approach to the diagnosis - Bianca, Cherry History and PE – Ada General Data, History, PE and Salient Features Approach to the diagnosis - Bianca, Cherry Presenting Manifestations Working Impression Differential DX (?) - brief lang Brief Disc of the Final Diagnosis Confirmation of the Working Dx - Ange and Ralph Work-ups Pharma

CONFIRMATION OF THE WORKING DIAGNOSIS

Diagnosis Chest x-ray is considered the gold standard for the diagnosis of pneumonia Confluent lobar consolidation is typically seen with pneumococcal pneumonia Indicates complications PCAP such as a pleural effusion or empyema CXR alone is not diagnostic and other clinical features must be considered Repeat CXR are not required for proof of cure for patients with uncomplicated pneumonia

Diagnosis Pulse oximetry is recommended in any child with signs of tachypnea or clinical hypoxemia CBC Culture of sputum is of little value in the diagnosis of pneumonia in young children Blood cultures are positive in only 10% of children with pneumococcal pneumonia Bacterial Viral WBC 15,000 – 40,000 WBC < 20,000 Granulocytes Lymphocytes

In our patient... CBC & platelet Chest X ray PDD test

CBC

CXR Infiltrates both parahilar and left lower lobe and retrocardiac Air bronchogram Nodular densities with confluence at paratracheal and peribronchial region

PDD Test

Need for Hospitalization of PCAP Age <6 mo    Sickle cell anemia with acute chest syndrome Multiple lobe involvement Immunocompromised state Toxic appearance Severe respiratory distress    Requirement for supplemental oxygen    Dehydration    Vomiting    No response to appropriate oral antibiotic therapy    Noncompliant parents Nelson Textbook of Pediatrics, 18th ed.

Antibiotic Management Choice of antibiotics Age Clinical presentation Local resistance patterns of predominant bacterial pathogens Oral antibiotic therapy provides adequate coverage for most patients with pneumonia treated as out-patients Parenteral therapy is typically reserved for neonates and patients with pneumonia severe enough to warrant admission to hospital

PPS Clinical Practice Guideline for PCAP 2004

PPS Clinical Practice Guideline for PCAP 2004 PCAP A Minimal Risk PCAP B Low Risk PCAP C Moderate Risk PCAP D High Risk What is the recommended antibiotic? > 2 years old; or High grade fever without wheeze > 2 years of age; or High grade fever without wheeze; or Alveolar consolidation in CXR; or WBC >15, 000 ALL What empiric antibiotic should be given for patients without previous treatment Oral amoxicillin (40-50 mg/kg/day in 3 divided doses within 7 days) IV Pen G (100,000 units/kg/day in 4 divided doses) or ampicillin (100 mg/kg/day in 4 divided doses) Consult specialist

PPS Clinical Practice Guideline for PCAP 2004 PCAP A Minimal Risk PCAP B Low Risk PCAP C Moderate Risk PCAP D High Risk What if the patient is not responding to current antibiotic within 72 hours? Change initial antibiotic; or Start oral macrolide; or Reevaluate diagnosis Consider consulting specialist because: Pen resistant S. Pneumoniae; or Presence of complications; or Other diagnosis Consider immediate consultation with a specialist

Empirical Antibiotic of Choice Suspected bacterial pneumonia in a hospitalized child Mainstay - Parenteral cefuroxime (150 mg/kg/24 hr), cefotaxime, or ceftriaxone

Empiric Antibiotic Drugs MOA Pediatric Dose Cefuroxime 2nd gen cephalosporin; about equal activity as 1st gen against gram + cocci; improved activity againt gram negative resistant to first generation agents; no activity against P. aeruginosa Recommended Dose: 50-100mg/ka/day in 3 or 4 doses in 10-14 days Stock dose: Cefotaxime 3rd gen cephalosporin; bactericidal Infections of penicillin resistant pneumococci, beta-lactamase producing orgs. (E.coli, Klebsiella,Proteus) Recommended Dose: 50-200 mg/kg/day in 4-6 doses Ceftriaxone Recommended Dose: 50-100mg/kg/day in 1 or 2 doses

Empiric Antibiotic Drugs Adverse Effects Cefuroxime diarrhea, nausea, vomiting, headaches/migraines, dizziness and abdominal pain Cefotaxime Mild diarrhea (2.7%); mild pain, swelling, or redness at the injection site; nausea; vomiting (<1%). pseudomembranous colitis symptoms may occur during or after antibacterial treatment Ceftriaxone diarrhea; an increase in liver enzymes; and pain, warmth, and/or minor swelling at the injection site. Serious side effects include blood in stools, unexplained bleeding or bruising, and difficulty breathing or swallowing

Empiric Antibiotic DRUGS EFFICACY SUITABILITY SAFETY COST ++++ +++ ++ Cefuroxime ++++ +++ Cefotaxime ++ Ceftriaxone

Management No cough preparations needed

Supportive Care/ Ancillary Treatment Among inpatients, oxygen and hydration may be given if needed No routine chest physiotherapy Nebulization with normal saline solution Bronchodilators Philippine Pediatric Society (PPS). Clinical Practice Guideline in the Evaluation and Management of Pediatric Community Acquired Pneumonia (Immunocompetent Filipino Children Aged 3 months to 19 years). 2004.

In our patient... Cefuroxime 500mg/slow IV infusion initially 15-30minutes then every 8 hours Salbutamol nebulization every 6 hours Paracetamol 250/5mL, 3mL every 4 hours for temperature ≥38.5˚C IVF D5 0.3 NaCl 500mL 11-12 gtts/min 0.65% NaCl drops, 3 drops/nostril every 6 hours then suction of secretions   Preventive plans Watch out for cyanosis, retraction, persistent tachypnea

Monitoring Response Improvement in clinical symptoms (fever, cough, tachypnea, chest pain) within 48–96 hr of initiation of antibiotics Radiographic evidence of improvement substantially lags behind clinical improvement No follow-up laboratory required When a patient does not improve on appropriate antibiotic therapy (slowly resolving pneumonia) Complications Bacterial resistance Nonbacterial etiologies such as viruses and aspiration of foreign bodies or food Bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs Pre-existing diseases such as immunodeficiencies, ciliary dyskinesia, cystic fibrosis, pulmonary sequestration, or cystic adenomatoid malformation ****A repeat chest x-ray is the 1st step in determining the reason for delay in response to treatment.

Streamlining of Antibiotic In selected patients, switch to oral therapy when signs of infection are resolving after 2-3 days Patients with symptom resolution, ability to feed and absence of complications Philippine Pediatric Society (PPS). Clinical Practice Guideline in the Evaluation and Management of Pediatric Community Acquired Pneumonia (Immunocompetent Filipino Children Aged 3 months to 19 years). 2004.

Thank you!!!!