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

2. 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

3. CONFIRMATION OF THE WORKING DIAGNOSIS

4. 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

5. 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

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

7. CBC

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

9. PDD Test

10. 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.

11. 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

12. PPS Clinical Practice Guideline for PCAP 2004

13. 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

14. 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

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

16. 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: mg/ka/day in 3 or 4 doses in days
Stock dose:
Cefotaxime
3rd gen cephalosporin; bactericidal
Infections of penicillin resistant pneumococci, beta-lactamase producing orgs. (E.coli, Klebsiella,Proteus)
Recommended Dose: mg/kg/day in 4-6 doses
Ceftriaxone
Recommended Dose:
50-100mg/kg/day in 1 or 2 doses

17. 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

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

19. Management
No cough preparations needed

20. 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)

21. 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 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

22. 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.

23. 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)

24. Thank you!!!!