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

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

3. Social, economic burden
Community Acquired Pneumonia ( CAP )

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

5. 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
years of age
- 95% Pneumococc. (Klebs.)
- Affects the lobes, these are completely consolidated
- Usually one-sided 5

6. Lobar pneumonia

7. Bronchopneumonia

8. 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.

9. 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.

10. Viral pneumonias in childhood 30 – 67%
Pathogens:
Adenovirus
Influenza A, B %
Parainfluenza
RSV
Rhinovirus
Coronavirus %
Metapneumovirus %
Parvo (Boca) virus %
Combined: viral – bacterial %
Diagnosis:
PCR
serologic,
immunfluorescent methods
Diff.dg:
bronchitis
bronchiolitis
Treatment:
supportive
antibiotics (bacterial coinfection): cefotaxim

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

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

13. 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

14. CAP caused by intracellular pathogens
Mycoplasma pneumoniae %
Chlamydia pneumoniae (psittaci, trachomatis) %
Legionella pneumophila %

15. 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

16. 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

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

18. 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

19. 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)

20. 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

21. 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.

22. 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.