Pneumonia (peds): Difference between revisions
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[ | [[Group B Streptococcus]] (most common), [[Escherichia coli]], [[Listeria monocytogenes]], [[Haemophilus influenzae]], [[S. pneumoniae]] [[Klebsiella]] species, [[Enterobacter]] aerogenes | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment. | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment. |
Revision as of 17:32, 12 October 2014
Background
- Most common site of infection in neonates
- Fever and tachypnea are Sensitive but not Specific
Causes
Neonatal Pneumonia
Etiology | Clinical Presentation | Management Approach |
---|---|---|
Bacterial Group B Streptococcus (most common), Escherichia coli, Listeria monocytogenes, Haemophilus influenzae, S. pneumoniae Klebsiella species, Enterobacter aerogenes |
Fulminant illness w/ onset w/in 48hr of life, w/ infection likely acquired in utero from contaminated amniotic fluid environment. | Full evaluation for sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative. Two culture samples may increase diagnostic yield fourfold. |
Respiratory distress, unstable temperature (high or low), irritability or lethargy, tachycardia and poor feeding may be present. | A lumbar puncture should be done if there are no contraindications. | |
Hospitalization, supportive care (O2), and parenteral antibiotics (ampicillin and gentamicin, adjusts as per culture and sensitivities when available). | ||
Nosocomial infections in premature infants (Staphylococcus aureus,Pseudomonas aeruginosa) | Same as for common bacterial etiology. | Same as for common bacterial etiology. |
Chlamydia | Develops in 3%–16% of exposed neonates (in colonized mothers). | Sepsis evaluation as indicated. |
CXR may show hyperinflation with interstitial infiltrates. | ||
Usually occurs after 3 wk of age, accompanied by conjunctivitis in one half of cases. Often afebrile, tachypneic, with prominent "staccato" cough. Wheezing uncommon. | Definitive diagnosis by nasopharyngeal swab PCR or cultures. | |
Eosinophilia may be seen on peripheral blood count. | ||
Treatment: macrolide (erythromycin, clarithromycin, or azithromycin). | ||
Bordetella pertussis |
In addition to pneumonia, may causes paroxysms of cough, ± cyanosis and post-tussive emesis in otherwise well-looking infant. Characteristic whoop is not present in neonates. Apnea may be the only symptom. Suspect when adult caregiver also has persistent cough. | Sepsis evaluation as indicated. |
Diagnosis via nasopharyngeal swab for PCR and/or culture. | ||
Lymphocytosis in peripheral blood count is nonspecific but supports the diagnosis. | ||
Macrolides are efficient against B. pertussis but is not approved by the U.S. Food and Drug Administration for infants <6 mo. | ||
No available data on efficacy of azithromycin or clarithromycin in infants <1 mo old, but case series show less adverse effects with azithromycin. | ||
Neonates need to be admitted during treatment and monitored for severe adverse effects. | ||
Mycobacterium tuberculosis |
Half of infants born to actively infected mothers develop TB if not immunized or treated. | Sepsis evaluation as for bacterial pneumonia. |
CXR, culture of urine, gastric and tracheal aspirates. | ||
May be acquired via transplacental means, aspiration/ingestion of infected amniotic fluid, or postnatal airborne transmission. | Skin testing not sensitive in neonates. | |
Routine anti-TB treatment. | ||
Supportive treatment as needed. | ||
Often presents with nonspecific systemic symptoms with multi-organ involvement (fever, failure to thrive, respiratory distress, organomegaly). | ||
Viral pneumonia (respiratory syncytial virus, adenovirus, human metapneumovirus, influenza, parainfluenza) | Initial upper respiratory illness progressing to respiratory distress and feeding difficulty. | Sepsis evaluation as indicated. |
Viral testing (direct antigen detection/PCR/cultures) of nasopharyngeal washings (swab). | ||
Hypoxia and apnea may be present. | ||
Often indistinguishable from bronchiolitis. | Rate of concurrent bacterial infections in confirmed viral infection is low. | |
CXR for significant respiratory distress. | ||
Supportive therapy; monitoring for apnea in young and premature infants. |
Infants and Children
- More likely to have viral cause
- Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
- Pneumococus, H. flu, staph, pertussis
- If age >5 consider mycoplasma (treat w/ macrolide)
- Consider secondary bacterial pneumonia if URI progresses to lower tract symptoms
Diagnosis
- Absence of tachypnea, resp distress, and rales/decr BS rules-out with 100% sp
- Productive cough is rarely seen before late childhood
- Imaging
- CXR is not the gold standard!
- Cannot differentiate between viral and bact (but lobar infiltrate more often bacterial)
- Consider for:
- Age 0-3mo (part of w/u for sepsis)
- <5yr w/ temp >102.2, WBC >20K and no clear source of infection
- Ambiguous clinical findings
- PNA that is prolonged or not responsive to abx
- Consider rapid assays for RSV, influenza
- Blood/nasal culture are low yield
Treatment
- Recommendations from AAP[1]
Age Group | Bacterial Pathogens | Hospitalized Patients | Outpatients |
---|---|---|---|
Newborn | Group B streptococci | Ampicillin | Initial outpatient management not recommended |
Gram-negative bacilli | plus | ||
Listeria monocytogenes | Gentamicin or cefotaxime | ||
1–3 mo | Streptococcus pneumoniae | Afebrile pneumonitis | Initial outpatient management not recommended |
Chlamydia trachomatis | Erythromycin or clarithromycin | ||
Haemophilus influenzae | Febrile pneumonia: | ||
Bordetella pertussis | Cefuroxime | ||
Staphylococcus aureus | ± erythromycin IV or clarithromycin PO | ||
Severe: choose one of | |||
Cefuroxime + erythromycin or clarithromycin | |||
Cefotaxime + erythromycin | |||
Cloxacillin + clarithromycin | |||
3 mo–5 y (majority of PNA in this group is viral) |
S. pneumoniae | Ampicillin IV or cefuroxime IV | Amoxicillin |
S. aureus | or amoxicillin if PO | or amoxicillin-clavulanate | |
H. influenzae type b |
or amoxicillin-clavulanate if PO | or cefuroxime axetil x7-10d | |
Nontypeable H. influenzae | Moderate to severe | ||
C. trachomatis | Add erythromycin or clarithromycin | ||
Mycoplasma pneumoniae | |||
5–18 y | M. pneumoniae | Ampicillin IV | Erythromycinor clarithromycin |
S. pneumoniae | plus | or amoxicillin ± clavulanate | |
C. pneumoniae | Erythromycin or clarithromycin | or cefuroxime axetil x7-10d | |
H. influenzae type b |
Alternative | ||
S. aureus | Cefuroxime | ||
or amoxicillin-clavulanate | |||
or erythromycin | |||
or clarithromycin | |||
Moderate to severe: | |||
Cefuroxime + erythromycin or clarithromycin |
- All Children less than 2 months should be hospitalized[1]
- High dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice for uncomplicated outpatient community acquired pneumonia[1]
- For Inpatient treatment of pneumonia preference is to Vancomycin along with a second- or third- generation Cephalosporins.[1]
Disposition
- Consider admission for:
- Age of birth to 3mo
- History of severe or relevant congenital disorders
- Immune suppression (HIV, SCD, malignancy)
- Toxic appearance/resp distress
- SpO2 <90-93%