Community Acquired Pneumonia (CAP) – Pediatrics | Lecturio

Community Acquired Pneumonia (CAP) – Pediatrics | Lecturio


[Music] in this lecture we’re going to discuss pediatric pneumonia pediatric pneumonia is a an infection of the lower Airways of children it typically presents with respiratory distress hypoxemia cough and fever in the entire world it’s actually the third leading cause of death of children and it’s a common cause in the United States of hospitalization most community-acquired pneumonia is viral it’s not usually caused by a bacteria but distinguishing between viral and bacterial disease is almost impossible 98% of blood cultures in children who we suspect of having bacterial disease are in fact negative and 1/4 of infants who are healthy will test positive for a virus by nasal PCR which means that if we use a viral nasal PCR as a test we’re gonna get a lot of false positives so what are the organisms that are most likely to cause pneumonia in children well under 3 months of age it’s still likely strep pneumo but in those children who are just a few weeks of age it could be chlamydia – crow Modest from the mother also from the mother it could be group B strep or ecoli or less common but it can absolutely happen is staph aureus pneumonia in infants and children the organisms are a little bit different still among the bacterial strep pneumo is the most common followed maybe by H flu and staph aureus and mycoplasma pneumoniae can happen in kids over five is a little bit less common in kids under five however there are exceptions to that rule there are a couple special circumstances we have to keep track of though children who’ve traveled and have a long lingering disease might have tuberculosis children with cystic fibrosis might have Pseudomonas species children who have been exposed to Legionella could have that and also fungal diseases are popular especially in children with T cell deficiency also we’re not sure but perhaps chlamydia psittacosis coxiella various parasites these can very rarely arise under very special circumstances but generally the bug were most concerned about in terms of bacteria across the board is strep pneumonia let’s look at how children present based on their age neonates are more likely to present with nonspecific symptoms like fever lethargy or just apnea compared to infants who often have two kidney a fever cough and very commonly abdominal pain these children tend to have minimal upper respiratory infections so minimal upper respiratory infections in the setting of pulmonary disease is more concerning for a bacterial illness as opposed to a viral illness if a child has a lot of runny nose it’s more likely to be a virus so what do we see on exam that’s specific to community-acquired pneumonia well the first and most important thing is rails rails which is also sometimes called crackles is that high-pitched sound we hear on inhalation and exhalation in a focal point over some infected lung patients on percussion may have dullness to percussion patients may have areas where there’s decreased aeration you can’t hear those breath sounds so well and wheezes are more common in viral disease than they are in true lobar bacterial pneumonias a chest x-ray in a well appearing infant increases the risk of unnecessary antibiotics and does not necessarily distinguish between bacterial and the vastly predominant viral disease what I’m saying is if you believe an infant who’s relatively well appearing has pneumonia based on your exam you should not get a chest x-ray just treat the pneumonia if that child has a question of pneumonia but you have a reassuring exam getting a chest x-ray increases antibiotic use we out benefit in other words probably safe to assume they do in fact have a viral illness the white count on a CBC in no way distinguishes between viral viral and bacterial disease it does not help at all so there’s really no role for a white count in distinguishing between viral and bacterial disease viral swabbing on the nose has a high false positive rate so it’s unclear that a child couldn’t have a bacterial illness even if they have a positive no swab so that test is somewhat useless as well so what is useful well if a child is being hospitalized it is important to get a chest x-ray that’s because there is an increased rate of complicated pneumonia or pneumonia with effusion that’s going on and the chest x-ray can help you decide if you need to get in fact a chest tube in addition to your antibiotics so it distinguishes between complicated pneumonia and uncomplicated pneumonia it also distinguishes between bronchopneumonia and lobar pneumonia a lobar pneumonia is very much likely to be a bacterial pathogen whereas scattered patchy disease that’s diffuse is more likely to be viral occasionally the x-ray will pick up this complicated pneumonia we talked about this is where pus has accumulated in the wall between the chest wall and the lung in the pleural space and this x-ray right here you can see that this plural space is remarkably filled with a large amount of pus and it’s going all the way up the side of the chest wall that’s something you want to look out for because this patient here is probably going to be treated differently than a patient who doesn’t have this so you want to know about antibiotics and what antibiotics should we choose in order to make that decision we have to make a few assessments first we need to know how sick is this child if the child is going to the wards or as staying in the outpatient setting we’re gonna do very narrow focused antibiotic we don’t need a broad-spectrum antibiotic and we’re willing to take some risk that maybe it’s not resist where the bacteria is resistant to this antibiotic maybe we need to ramp for antibiotics later but we’re going to start with a narrow spectrum agent if the child is in the ICU and in sepsis we’re going to start with a broad-spectrum agent because we don’t have the the time or the ability to wait and allow this child to get worse if in fact this is the unlikely case of a resistant organism if we’re choosing an antibiotic we want to know is this child likely to take oral medications amoxicillin for example is a good first choice for a pneumonia oral amoxicillin is delicious clindamycin tastes terrible and if you’re a two-year-old who’s being forced to take their medicine that may weigh into your decision you may want to know what the resistance patter and pattern is in your community the reality is right now in the United States we do not have very resistant streptococcal pneumonia this is because of the way we’ve been vaccinating so amoxicillin is working great in most places in the country that’s generally our first-line agent but if you have a lot of resistance you might plan accordingly differently you also need to know what are the side effects of that medication so this is true for any antibiotic we want to know do we need to check levels things like that it might be easier to use a medicine with fewer side effects okay community-acquired pneumonia our number one choice by far and away is high dose amoxicillin or high dose episode and if they are hospitalized this is a penicillin that is very effective against pneumococcus as you may remember from basic science pneumococcus present prevents itself from being killed by the penicillins by altering its penicillin binding protein it does not create beta lactam ASIS so adding sole back dam or amoxicillin plus clavulanic acid does not help in community acquired pneumonia by far and away the best thing to do is to raise the dose and thereby attack those altered penicillin binding proteins if a patient can’t tolerate a penicillin or you’re worried about resistance because of some spectrum of resistance in your community you would maybe start with a third-generation cephalosporin other drugs that have been found to be effective are fluoroquinolones but we were we don’t encourage those because they have a black box warning there are a number of side effects of fluoroquinolones that we want to avoid like lifelong peripheral neuropathy if a patient has a complicated pneumonia that is market or a very very sick appearance or an abscess in their lung we’ll probably add staph aureus coverage this can be done by adding clindamycin or adding vancomycin in a very sick patient for infants we do use broader spectrum agents because remember these infants are prone to other infections like e.coli which can get into lung lastly we often will add as if through mice into infants under six weeks of age for concern over possible chlamydia trachomatis but we’ll test for that too through a Nosal nasal PCR can we prevent pneumonia the answer is absolutely yes so pneumococcal vaccine is an effective prevention against pneumonia and nationwide probably has resulted in a reduction in the rate at which this bacteria is resistant to antibiotics he’ll or the hemolysis influenza type B vaccination has been amazing at preventing very severe pneumonia which used to happen with Moff less influence a type b i’ve never seen a case because of vaccination influenza vaccination is important in preventing pneumonia because it prevents super infection that can happen after influenza same thing with varicella infection it does reduce the likelihood of super infection in the lungs that can happen after varicella and don’t forget the DTaP vaccine does prevent pertussis which can present with a pneumonia like picture so we have many vaccines that can prevent the likelihood of patients developing pneumonia [Music]

2 Comments

  • Mohsin Fareed says:

    Thanks very much for the excellent lectures you deliver and the effort. only 5 hours since the video uploaded I can see already 231 views. It means one thing people are just waiting for the great lectures from you and your colleagues. God bless you all .

  • meteor liu says:

    Thank a lot. It's really an amazing lecture.

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