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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
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