CPG Pneumonia

IntroductionIntroduction Pneumonia is defined as the inflammation

of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms.

It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired)

Who shall be considered as

having community-

acquired Pneumonia?

For ages 3 months to 5 years are tachypnea and/or chest indrawing

For ages 5 to 12 years are fever, tachypnea, and crackles

Who shall be considered as

having community-

acquired Pneumonia?

Beyond 12 years of ages are the presence of the following features:Fever, tachypnea, and tachycardiaAt least one abnormal chest findings of

diminished breathing sounds, ronchi, crackles or wheezes

Tachypnea is still the best predictor of pneumonia

Who will require

admission? A patient who is at moderate to high risk

to develop pneumonia-related mortality should be admitted

A patient who is minimal to low risk can be managed on an outpatient basis

Risk Classification of

PneumoniaVariables PCAP A Minimal risk

PCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Co-morbid illness None Present Present Present

Compliant caregiver Yes Yes No No

Ability to follow up Possible Possible Not possible Not possible

Presence of dehydration None Mild Moderate Severe

Ability to feed Able Able Unable Unable

Age >11 mos >11 mos <11 mos <11 mos

Respiratory rate 2-12mos 1-5years >5 years

≥50/min≥40/min≥30/min

>50/min>40/min>30/min



Risk Classification of

PneumoniaVariables PCAP A Minimal risk

PCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium

NoneNoneNoneNoneNone

Awake

NoneNoneNoneNoneNone

Awake

Intercostal/SubcostalPresentPresentNoneNone

Irritable

Supraclavicular/Intercostal/Subcostal

PresentPresentPresentPresent

Lethargic/Stuporous/Comatose

Complication(effusion, pneumothorax)

None None Present Present

Action Plan OPD follow up at end of treatment

OPD follow up after 3 days

Admit to regular ward Admit to ICURefer to specialist

The presence of retraction on admission was the best single predictor of death

Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia

Diagnostic Tools

Chest X-Ray PA-lateral White cell count Acute Phase Reactants

ESR and CRP have not been demonstrated to differentiate viral from bacterial infection

Diagnostic Tools

MicrobiologyBlood C/SPlueral fluid C/STracheal aspiration C/SSputum C/S

Oxygen saturation and/or Blood GasTo help the clinician in deciding the

appropriate intervention

What diagnostic aids are requested

for a patient classified as PCAP

A or PCAP B? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting

What diagnostic aids are initially requested for a

patient classified as either PCAP C or

PCAP D? The following should be routinely requested:

Chest x-ray PA-lateralWhite blood cell countCulture and sensitivity of

○ Blood for PCAP D○ Pleural fluid○ Tracheal aspirate upon initial intubation○ Blood gas and/or pulse oximetry

What diagnostic aids are initially requested for a

patient classified as either PCAP C or

PCAP D? The following may be requested:

Culture and sensitivity of sputum for older children

The following should not be routinely requested:Erythrocyte sedimentation rateC-reactive protein

When is antibiotic

recommended? For a patient classified as either PCAP A or B and is:Beyond 2 years of ageHaving high grade fever without wheeze

For a patient classified as PCAP C and is:Beyond 2 years of ageHaving high grade fever without wheezeHaving alveolar consolidation in the CXRHaving WBC > 15,000

For a patient classified as PCAP D

Etiology First 2 years: viruses

As age increases bacterial pathogens become more prevalent

PCAP managed as an outpatient:Bacterial pathogen is more commonStreptococcus pneumoniae is the pathogen in

more than half (Others: M. pneumoniae, C. pneumoniae)

PCAP managed as an inpatient:Bacterial pathogen is more commonStreptococcus pneumoniae is the pathogen in

little more than half (Others: H. influenzae b, M. pneumoniae, C. pneumoniae)

Haemophilus influenzae type b should be given in patient below 5 years of age who has not completed the primary series of Hib immunization

Bacterial vs Viral

Features Bacterial Viral

Fever T>38.5°C T<38.5°C

Wheeze Absent Present

Alveolar infiltrates in Chest Xray or an elevated white cell count favors bacterial pathogen

What empiric treatment should be

administered if a bacterial etiology is strongly considered? For a patient classified as PCAP A or B

without previous antibiotic, oral Amoxicillin (40-50mg/kg/day in 3 divided doses) is the DOC

For a patient classified as PCAP C without previous antibiotic who has completed primary immunization against H.Influenza type b, Penicillin G (100,000units/kg/day in 4 divided doses) is the DOC

What empiric treatment should be

administered if a bacterial etiology is

strongly considered?If a primary immunization againts Hib has not

been completed, intravenous Ampicillin (100mg/kg/day in 4 divided doses) should be given

For a patient classified as PCAP D, a specialist should be consulted

What treatment should be given if a viral etiology is

strongly considered? Ancillary treatment should be given

Oseltamivir (2mg/kg/dose BID for 5 days) or Amantadine (4.4-8.8mg/kg/day for 3-5days) may be given for influenza that is either confirmed by laboratory or occurring as an outbreak

When can a patient be

considered as responding to the current antibiotic? Decrease in respiratory signs (particularly

tachypnea) and defervescence within 72hours after initiation of antibiotic

Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation

End of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic

What should be done if a patient is not responding

to current antibiotic therapy?

If an outpatient classified as either PCAP A or B is not responding within 72hours, consider any one of the following:Change the initial antibioticStart an oral macrolideReevaluate diagnosis


to current antibiotic therapy?

If an inpatient classified as PCAP C is not responding within 72hours, consider consultation with a specialist because of the following possibilities:Penicillin resistant Streptococcus pneumoniaePresence of complication (pulmonary or

extrapulmonary)Other diagnosis


to current antibiotic therapy? If an inpatient classified as PCAP D is

not responding within 72hours, consider immediate re-consultation with a specialist

When can switch therapy in bacterial

pneumonia be started?Switch from intravenous antibiotic

administration to oral from 2-3 days after initiation is recommended in a patient who:

Is responding to the initial antibiotic therapy Is able to feed with intact gastrointestinal

absorption Does not have any pulmonary or extra

pulmonary complication

What ancillary treatment can be

given? Among inpatient, oxygen and hydration

should be given if needed Cough preparations, chest physiotherapy,

bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in community-acquired pneumonia

What ancillary treatment can be

given? In the presence of wheezing, a

bronchodilator may be administered

How can Pneumonia be

prevented? Vaccines recommended by the Philippines Pediatric Society should be routinely administered

Zinc supplementation may be administered

Vitamin A, Immunomodulators, and Vitamin C should not be routinely administered as a preventive strategy

CPG Pneumonia

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