Pneumonia in children: etiology, diagnosis and treatment Prof. Galyna Pavlyshyn

Pneumonia is an acute infectious inflammatory disease of various nature with involving of lower respiratory tract into pathologic process and intra-alveolar inflammatory exudation;

Possible causes of Pneumonia Bacterial – streptococcus pneumonia, mycoplasma (atypical) And any other Viral – RSV (respiratory syncytial virus) In children younger than 2 years, viral infections were found in 80% of children with pneumonia; in children older than 5 years, viral infections were detected only 37% of the time. Aspiration Depends on patient age, immune status, and location (hospital vs. community) S. Pneumo = streptococcus pneumonia RSV = respiratory syncytial virus

Etiology Age-dependent Neonates: Group B Streptococci GN Enterics - Esherichia coli, Klebsiella pneumoniae, Listeria monocytogenes rare St. aureus 2 w- 2mo: Chlamydia Viruses Str. Pneumoniae, St. aureus, H. influenzae

6 mo -6 yrs Strep. Pneumoniae - 50 % Viruses - RSV, parainfluenza, influenza, adenovirus, rhinovirus, coronavirus, herpesvirus, human metapneumovirus Hemophylus inf. type β - 10 % Mycoplasma pneumoniae - 10 % Rare St. aureus, Chlamydia pneumoniae

Infectious causes of pneumonia Age Causative organisms Perinatal + 4 weeks Group B haemolytic streptococci E. coli and other gram negative enteric organisms, Chlamydia trachomatis Infancy Viruses - RSV Pneumococcus Haemophilus influenzae

CLASSIFICATION: 􀂙 Etiology 􀂙 Morphological class - Bronchopneumonia - Lobar pneumonia - Interstitial pneumonia 􀂙 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia 􀂙 Non complicated pneumonia complicated pneumonia

right upper lobe pneumonia jjj right upper lobe pneumonia

Congenital pneumonia Tachypnea Irregular respiratory movements (paradoxic) Apnea Flaring of alae nostril Grunting (expiration sound) Involving chest muscles Temperature may be present in some term babies

Congenital pneumonia Poor feeding Lethargy or irritability Temperature instability Poor color, cyanosis Abdominal distention tachycardia

Congenital pneumonia Late onset of CP (after 7-14 days of life). Mainly Chlamidia or Urea- and Mycoplasma Onset usually is preceded by upper respiratory tract symptoms and/or conjunctivitis Nonproductive cough Fever is absent “afebrile pneumonia syndrome”

Physical sings The sings such as dullness to percussion, change in breath sounds, and the presents of rales or rhonchi are virtually to appreciate in a neonate Weakened breathing during auscultation Moist or bubbly sounds, crepitating Respiratory failure develops gradually

Viral pneumonia Respiratory syncytial virus is the most common viral cause; other common causes include parainfluenza virus, adenovirus, enterovirus; Clinical features- begin with several days of rhinitis, cough, followed by fever and more pronounced respiratory tract symptoms, such as dyspnea, intercostal retraction.

Viral pneumonia Diagnosis Laboratory findings – preponderance of lymphocytes observed on CBC; Diffuse or bilateral infiltrates visible on chest ragiograph; Rapid test for viral antigen, culturing nasopharyngeal specimens for viruses;

CXR in Aspiration: opacification in right upper lobes of infants and in the posterior or bases of the lung in older children Specific testing: barium swallow pH probe, and flexible endoscopic evaluation of swallowing and sensory testing

Plan of examination CBC - so called “septic investigation” - blood analysis (↑ WBC more than 20*109/l or ↓WBC less than 5*109/l) Increased WBC with left stiff strongly suggests bacterial process; Pneumococcus associated with marked leukocytosis; Leukocyte index > 0.2 (immature forms: general count of neutrophils) Trombocytopenia (< 150000)

Examination: Laboratory Biochemical blood test – acidosis, hypoproteinemia Increased inflammatory markers (C-reactive protein); Bacteriological examination of sputum (tracheal), blood (gold standard); Blood culture rarely give organism, but this test is necessary; Examination for viruses

Examination: Radiology X-ray Infiltrates, bilateral involvement or pleural effusion - suggest more serious disease Focal or diffuse interstitial pneumonitis may reveal Infiltrates may be less obvious in dehydrated patients;

Interstitial pneumonia

CXR in Bacterial PNA

CXR in Bacterial PNA                     Right lower lobe consolidation in a patient with bacterial pneumonia

Acute community-acquired pneumonia with complicated parapneumonic effusion

Treatment • Bacterial 1 month Ampicillin 75–100 mg/kg/day and Gentamicin 5 mg/kg d 1–3 months Cefuroxime (75–150 mg/kg/day) or co-amoxiclav (40 mg/kg/day) 3 months Benzylpenicillin or erythromycin (change to cefuroxime or amoxycillin if no response)

Treatment Supportive for atypical pneumonia • Chlamydia and mycoplasma should be treated with erythromycin 40–50 mg/kg/day usually orally. • If pneumocystis carinii pneumonia is suspected co-trimoxazole 18–27 mg/kg/day IV should be prescribed.

Treatment Patients are treated as an outpatient: Children < 5 yo: - high dose amoxicillin (80-90 mg/kg/d) for 7-10 d Children > 5 yo: - increased prevalence of M. pneumoniae and C. pneumoniae - macrolide is reasonable choice Older children with signs most consistent with S. pneumoniae infection (lobar infiltrate, increased wbc or inflammatory markers) – AMOXICILLIN may be used;

Treatment Children with more severe disease: Consider other organisms including Methicillin-resistant S. aures (MRSA) 3-rd generation cephalosporin, plus Clindamycin or Vancomycin;

Treatment Age Start Alternative Ampicillin 100 mg/kg/day 6 mo.-6 yr Ampicillin 100 mg/kg/day Or amoksiklav 20-40 mg/kg (Amoxicillin/clavulanate) Cefotaxime (Claforan) Cefuroxime (Zinacef) 100-150 mg/kg/day Clarithromycin Azithromycin

Treatment Age Start 6 mo.-6 yr Complicated Ceftazidime 150 mg/kg/day or Cefotaxime or ceftriaxone + netilmicin (6-7.5 mg/kg) (amikacinum 15 mg/kg)

Treatment Age Start 6 mo – 6 yo atypical -Clarithromycin 15-30 mg/kg/day or Azithromycin 10 mg/kg 6 mo – 6yo atypical complicated Rovamycine 1500000 IU per 10 kg