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

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

3. 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

4. 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

5. 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

6. 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

8. 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

9. right upper lobe pneumonia
jjj
right upper lobe pneumonia

10. 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

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

12. 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”

13. 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

14. 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.

15. 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;

16. 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

17. 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 (< )

18. 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

19. 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;

20. Interstitial pneumonia

21. CXR in Bacterial PNA

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

23. Acute community-acquired pneumonia with complicated parapneumonic effusion

24. 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)

25. 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.

26. 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;

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

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

29. 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)

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