BRONCHIOLITIS

EPIDEMIOLOGYAnnual incidence is 11.4% in children younger than 1

year and 6% in those aged 1-2 years.Incidence peaks in those aged 2-8 months95% have serologic evidence of past (RSV).; presence

of antibodies to RSV does not confer immunity.Incidence of bronchiolitis winter months in

temperate climates and during the rainy season in tropical climates.

Hospitalization -2% of cases under 6 monthsMortality rate is 1-2% of all hospitalized patients and

3-4% for patients with underlying cardiac or pulmonary disease.

EPIDEMIOLOGY

Accounts for 60% of all lower respiratory tract illness in the first year of life!

Bronchiolitisyoung infants, aged 2-24 months.viral infection of the small airways (bronchioles). increased mucus secretion, cell death followed by

a peribronchiolar lymphocytic infiltrate and submucosal edema

debris and edema produce narrowing and obstruction of small airways.

decreased ventilation in the lung causes ventilation/perfusion mismatching and hypoxia.

in expiratory phase of respiration, further dynamic narrowing of the airways produces disproportionate airflow decrease and resultant air trapping.

Pathophysiology

The virus spreads from the upper respiratory tract to the medium and small bronchi and bronchioles, causing epithelial necrosis and initiating an inflammatory response.

The developing edema and exudate result in partial obstruction, which is most pronounced on expiration and leads to alveolar air trapping.

Complete obstruction and absorption of the trapped air may lead to multiple areas of atelectasis

lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions

RISK FACTORS OF SEVERITYPrematurityLow birth weightAge less than 6-12 weeksChronic pulmonary diseaseHemodynamically significant cardiac diseaseImmunodeficiencyNeurologic diseaseAnatomical defects of the airwaysOlder siblingsConcurrent birth siblingsPassive smoke exposureHousehold crowdingHigh altitude

ETIOLOGYTypically caused by viruses

RSV-most commonParainfluenzaHuman MetapneumovirusInfluenzaRhinovirusCoronavirusHuman bocavirus

Occasionally associated with Mycoplasma pneumonia infection

ClinicsEarly symptoms are those of a viral URTI, including

rhinorrhea, cough, and sometimes low-grade fever.

paroxysmal cough and dyspnea develop within 1-2 days.Fever Increased work of breathing Wheezing Cyanosis Grunting Noisy breathing Vomiting, especially post-tussive Irritability Poor feeding or anorexia

ClinicsPhysicalTachypnea, over 50-60 breaths per minute (most

common)Tachycardia Fever, usually in the range of 38.5-39°C Mild conjunctivitis, otitis, pharyngitisDiffuse expiratory wheezing Nasal flaring Intercostal retractions Cyanosis Inspiratory crackles Apnea, especially in infants younger than 6 weeks Palpable liver and spleen from hyperinflation of the

lungs and consequent depression of the diaphragm

DIFFERENTIAL DGAsthmaGastric reflux with aspiration of gastric contents

also may cause the clinical picture of bronchiolitis; multiple episodes in an infant may be clues to this diagnosis.BronchitisCongestive Heart Failure and Pulmonary EdemaMycoplasmaApneaPneumonia

Cystic fibrosisVascular ringLobar emphysemaForeign bodyCardiac diseaseRefluxAspiration

LABORATORY AND IMAGISTICSComplete blood count (CBC) with white blood cell

(WBC) count within normal limits. 2/3 of the children have WBC counts of 10,000 to 15,000/μL. Most have 50 to 75% lymphocytes

Serum chemistries may be affected in dehydration. Arterial blood gases (ABG) in severely ill patients,

with mechanical ventilation.Chest radiographs should include anterior-posterior

(AP) and lateral views. Hyperinflation and patchy infiltrates ;these

findings are nonspecific and may be observed in asthma, viral or atypical pneumonia, and aspiration.

Focal atelectasis Air trapping Flattened diaphragm Increased anteroposterior diameter

RSV rapid antigen testing done on a nasal swab or washing is diagnostic but not generally necessary; it may be reserved for patients with illness severe enough to require hospitalization.

A positive culture or direct fluorescent antibody test result can confirm the diagnosis of RSV infection

COURSEDepends on co-morbiditiesUsually self-limitedSymptoms may last for weeks but

generally back to baseline by 28 daysIn infants > 6 months, average

hospitalization stays are 3-4 days, symptoms improve over 2-5 days but wheezing often persists for over a week

Disruption in feeding and sleeping patterns may persist for 2-4 weeks

Prognosis

Prognosis is excellent. Most children recover in 3 to 5 days without

sequelae, although wheezing and cough may continue for 2 to 4 wk.

Mortality is < 1% when medical care is adequate. Bronchiolitis has been identified as a risk factor for asthma, but the association is controversial and the incidence seems to decrease as children age.

TreatmentSupportive therapyO2 supplementation as neededIV hydration as neededIndications for hospitalization include accelerating respiratory distress, ill appearance (eg, cyanosis, lethargy, fatigue), apnea by history, hypoxemiainadequate oral intake. children with underlying disorders such as cardiac

disease, immunodeficiency, or bronchopulmonary dysplasia, which put them at high risk of severe or complicated disease, also should be considered candidates for hospitalization

In hospitalized children, 30 to 40% O2 by tent or face mask is usually sufficient to maintain O2 saturation > 90%.

Endotracheal intubation is indicated for severe recurrent apnea, hypoxemia unresponsive to O2 therapy, or CO2 retention or if the child cannot clear bronchial secretions.

Hydration maintained with frequent small feedings of clear liquids. For sicker children, fluids should be given IV initially, and the level of hydration should be monitored by urine output and specific gravity and by serum electrolyte determinations.

There is little evidence that systemic corticosteroids are beneficial

Antibiotics should be withheld unless a secondary bacterial infection (a rare sequela) occurs.

Bronchodilators are not uniformly effective some children may respond with short-term improvement. This is particularly true of infants who have wheezed previously. RIBAVIRINactive in vitro against RSV, influenza, and measles, is toxic

RSV immune globulin has been triedPrevention of RSV infection by passive

immunoprophylaxis with monoclonal antibody to RSV ( palivizumab ) SYNAGIS decreases the frequency of hospitalization but is costly and is indicated primarily in high-risk infants

RESPIRATORY PHYSIOTHERAPYNEBULISATIONS WITH: Epinephrine:

0.01 mL (ie, 0.01 mL/kg of 1:1000 solution [1 mg/mL]) SC q15-20min, not to exceed 0.3 mL/doseRacemic epinephrine:<2 years: 0.25 mL of 2.25% solution via nebulizer diluted in 3 mL NS>2 years: 0.5 mL of 2.25% solution via nebulizer diluted in 3 mL NS

ALBUTEROL, VENTOLINE 90 mcg; 4-8 inhalations q 20min up to 4 h, then q 1-4h prn; use with a spacer device

NONSTANDARD THERAPIESHeliox

Mixture of helium and oxygen that creates less turbulent flow in airways to decrease work of breathing

Only small benefit in limited patientsAnti-RSV preparations RSV-IGIV or

PalivizumabNo improvement in outcomes

SurfactantMay decrease duration of mechanical

ventilation or ICU stay

COMPLICATIONSHighest in high-risk childrenApnea

Most in youngest children or those with previous apnea

Respiratory failureAround 15% overall

Secondary bacterial infectionUncommon, about 1%, most in children

requiring intubation

PNEUMONIA

•The WHO Child Health Epidemiology Reference Group estimated an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission.

95% of all episodes of clinical pneumonia in young children worldwide occur in developing countries

PATHOPHISIOLOGYInflammation of the alveolar space and may

compromise air exchange. Often complicating other lower respiratory

infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also occur via hematogenous spread or aspiration.

Most commonly, this inflammation is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of chemical injury or may follow direct lung injury

PATHOLOGYBronchopneumonia is a patchy consolidation

involving one or more lobes. The neutrophilic exudate is centered in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli.

In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages. The alveoli do not contain a significant exudate

Bacterial superinfection of viral pneumonia can also produce a mixed pattern of interstitial and alveolar airspace inflammation.

Four stages of lobar pneumonia 1.In the first stage, within 24 hours of infection,

microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present.

2.The stage of red hepatization (2-3 d) similar to the consistency of liver: presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli.

3.In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of red cells, and hemosiderin.

4.The final stage of resolution :resorption and restoration of the pulmonary architecture. Fibrinous inflammation may extend into the pleural space, causing a rub heard by auscultation, (resolution or to organization and pleural adhesions)

ETIOLOGYBacteria accounted for 60%, of which 73% were

due to Streptococcus pneumoniae; Mycoplasma pneumoniae and Chlamydia pneumoniae were detected in 14% and 9%, respectively.

S pneumoniae, S aureus H influenzae are by far the most common bacterial pathogen in 1-3 years age group

EnterococciNewborns: group B Streptococcus, gram-negative

rods (E.coli, Klebsiella pneumoniae), Lysteria monocytogenes

Chlamydia trachomatis, U urealyticum, Mycoplasma hominis,  Treponema pallidum  Toxoplasma gondi  

Viruses that cause acute pneumoniaViruses that cause acute pneumoniaadenovirusadenovirus

coronaviruscoronavirus

influenza A and B virusesinfluenza A and B viruses

parainfluenza virusparainfluenza virus

respiratory syncytial virusrespiratory syncytial virus

coxsackievirus A21coxsackievirus A21

rhinovirusrhinovirus

BACTERIA THAT CAUSE PNEUMONIAGRAM POSITIVE COCCI 1.Streptococcus Pneumoniae the most common 2. Streptococcus Pyogenes 3. Streptococcus Agalactiae

ETIOLOGY OF BACTERIAL PNEUMONIAS- Pneumoniae generally resides in the

nasopharynx and is carried asymptomatic in approximately 50% of healthy individuals. A strong association exists with viral illnesses, such as influenza. Viral infections increase Pneumococcal attachment to the receptors on activated respiratory epithelium. Once aerosolized SP go from the nasopharynx to the alveolus,

Pneumococci infect type II alveolar cells,multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus to alveolus through the pores of Kohn, thereby producing inflammation and consolidation along lobar compartments

Patients with pneumococcal pneumonia may produce bloody or rust-colored sputum

Streptococcus agalactiae is a commensal organism in the genital tract and it can cause pneumonia in newborns which inhale fluid containing the bacteria during its journey down the birth canal and develops pneumonia soon after birth.

Staphylococcus aureus is gram positive organism,affecting children and old people. as well as extreme ages.it can produce thin walled air filled cavities ("pneumatoceles")

Staphylococcal pneumonia is diagnosed by finding typical clusters of Gram-positive cocci by microscopy and subsequently a growth of Staphylococcus aureus in a purulent sputum that often appears creamy and bloodstained.

Staphylococcal pneumonia and bronchopneumonia ( cont’)

Commonly following influenza in debilitated patients and in those with cystic fibrosis.

Abcess formation is very common.The abcesses are thin walled,multiple and

commonly bilateral giving rise to patchy bronchopneumonia.

Some strains of staphylococcal bacteria produce toxins (poisons) when they grow and reproduce on food.

Contaminated food with staphylococcal bacteria and these toxins can cause staphylococcal food poisoning. The toxins can also cause scalded skin syndrome and, very

occasionally, toxic shock syndrome

Bacteria gram positive rods1. Bacillus anthracis

2. Nocardia sp3. Actinomyces sp. Bacteria Gram Negative cocci1. Neisseria meningitidis2. Moraxella catarrhalis Bacteria gram negative rods1. Klebsiella pneumoniae

Bacillus anthracis is Anthrax or Wool-Sorters disease Associated with wool sorting, with animal handlers, and veterinarians,produces eschar

Nocardia sp Beaded filamentous rod shaped bacteria,

Pleura and chest wall involvmentActinomyces sp. Beaded filamentous rod shaped bacteria,

causing rib destruction, cutaneous sinuses, cavitation, spreads to pleura and chest wall.

Neisseria meningitidis (meningococci) cause epidemics in schools,adolescents .

Klebsiella pneumoniae produces Current Jelly sputum, more commonly seen in patients with cronic cardiopulmonary ilness, immunocompromised. Also called (friedlanders bacillus)

Severe form of pneumonia with high mortalityUpper lobes being most affected with massive

lobar consolidationSputum is jelly like and blood stained producing

(current jelly sputum).

2.Pseudomonas aeruginosa produces green sputum, abscess formation, Common cause of pneumonia in cystic fibrosis and those with severely compromised respiratory defenses.

3. Acinetobacter sp. often found on respiratory therapy equipment and on human skin

very difficult to treat due to multiple drug resistance.4. Burkholderia pseudomallei exposure with

contaminated soil5. Francisella tularensis ,Tularemia Infection is

via tick bite or contact with contaminated rabbits.

6. Hemophilus influenzae more commonly seen in patients with COPD, alcoholics, and the elderly.

7. Bordetella pertussis Whooping cough

ANAEROBIC BACTERIA•Bacteroides •Fusobacterium •Porphyromonas •Prevotella•Actinomyces •Bifidobacterium •Clostridium •Peptostreptococcus •Propionibacterium

Gram-Negative BacteriaE-coli, Salmonella, Pseudomonas, Moraxella,

Helicobacter, Stenotrophomonas, Legionella,Along with the above mentioned bacteria,

there are several other type of Gram-Negative bacteria such as Hemophilus influenzae (also known as Bacillus influenzae), Neisseria Meningitidis, Moraxella Catarrhalis, Neisseria Gonorrhoeae, Acinetobacter Baumanii (which comes under Nosocomical Gram-Negative bacteria group).

Fungal PneumoniaEndemic fungi

HistoplasmosisBlastomycosisCryptococcosisSporotrichosis - primarily a lymphocutaneous disease,

but can involve the lungs as well AspergillusCandidaCoccidiodomycosisHistoplasmosis All Chickens, bats, river valleys Coccidioidomycos All California, Southwest USA

Coccidioides immitis: Pneumonia may develop after travel to the southwestern United States and after exposure to a wind or rain storm in an endemic area.

Blastomyces dermatitidis: Patients may have traveled to the midwestern United States or the Canadian Shield.

Protozoal PneumoniaParasites causing pneumonia are 1.Toxoplasma gondii 2.Strongyloides stercoralis 3.Ascariasis. 4.Cryptosporidia 5.Hookworms A variety of parasites can affect the lungs. These

parasites enter the body through the skin or by being swallowed, they travel to the lungs, usually through the blood. The eosinophils, responds hihgy to parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia.

Rickettsial PneumoniaTyphus fevers (epidemic and endemic)Rocky mountain spotted fever,scrub

typhus, rickettsialpox

Louse-borneflea-borne through rats and mouse fleas

Rickettsial PneumoniaQ fever ranging from multiple segmental

opacities to pleural effusion, lobar consolidation, or linear atelectasis.

Hepatosplenomegaly is a common finding; it usually is accompanied with elevation of liver enzymes

Rickettsia pneumonia cannot be distinguished clinically, radiologically, or histologically from atypical pneumonia.

ATYPICAL BACTERIAThese are the bacteria's that will be called as atypical bacteria

and causing also atypical pneumonias like other viral agents etc.and constitute following organisms

Legionella Mycoplasma pneumoniae Chlamydia trachomatis an afebrile pneumonia,

usually seen in 2 wk to 6 months of ageChlamydia psittaci Chlamydia pneumoniae , Chlamydia trachomatisThis is a sexually transmitted disease that may also cause

pneumonia and bronchitis. It usually is a subacute infection of early infancy producing a sudden cough and eosinophilia without fever that lasts from 1-3 weeks, but it may occur in adults too.

Etiology of Pneumonia inHospitalized Children

– Streptococcus pneumoniae 73% – Mycoplasma pneumoniae 23%– Chlamydia pneumoniae 13%– Mycobacterium tuberculosis 2%

Features of viral PneumoniaStrikes primarily in the fall and winter and tends to be more serious in people

with cardiovascular or lung disease.

Usually starts with a dry (nonproductive) cough fever ,headache, sore throat,dry cough, malaise,running nose,common cold, aches and pains precedes several days before viral pneumonia ;

In viral pneumonia onset is less abrupt Leucocyte count is usually normal or low • On x ray may show features of interstitial or of atypical pneumonia

• Course is mild and self limiting and resolves by 7-10 days time

Diagnosis confirmed by isolation of virus and serological tests

Features of Bacterial PneumoniaOnset is often suddenHigh grade feverRigors and chillsSputum is rusty coloured or blood stained

CLINICS Neonates 

The infant may present with tachypnea; grunting, flaring, and retractions; lethargy; poor feeding; or irritability. Fever may not be present in newborns; however, hypothermia and temperature instability may be observed.

Cyanosis may be present in severe cases. Nonspecific complaints, such as irritability or poor

feeding, may be the presenting symptoms. Cough may be absent in the newborn period. Early-onset group B streptococci infection usually

presents via ascending perinatal infection as sepsis or pneumonia within the first 24 hours of life. Chlamydia trachomatis pneumonia should be considered in infants aged 2-4 weeks and is often associated with conjunctivitis.

Infants   After the first month of life, cough is the most

common presenting symptom. Infants may have a history of antecedent upper

respiratory symptoms. Depending upon the degree of illness,

tachypnea, grunting, and retractions may be noted. Vomiting, poor feeding, and irritability are also common.

Infants with bacterial pneumonia often are febrile, but those with viral pneumonia or pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The child's caretakers may complain that the child is wheezing or has noisy breathing.

Toddlers and preschool children

A history of antecedent upper respiratory illness is common.

Cough is the most common presenting symptom. Vomiting, particularly post-tussive emesis, may

be present. Chest pain may be observed with inflammation of or near the pleura. Abdominal pain or tenderness is often seen in children with lower lobe pneumonia and replaces chest pain!

The presence and degree of fever is dependent upon the organism involved.

Older children and adolescents

Atypical organisms, such as Mycoplasma, are more common in this age group.

In addition to the symptoms observed in younger children, adolescents may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.

PHISICAL EXAMrespiratory distress, hypoxemia, and hypercarbia grunting, flaring, severe tachypnea, and

retractions assessment of oxygen saturation by pulse

oximetry Visual inspection - respiratory effort and count

the respirations – tachypneaAuscultation -crackles or ralesPercussion -identify an area of consolidation.rashes and pharyngitis

IMAGERYThe typical radiological finding is a

homogenous, non-segmental, circumscribed consolidation of lung tissue. The opacities are situated anywhere in the lungs, although they are located most often in the basal segments, and are unifocal or multifocal. An air bronchogram is often seen and is considered to be characteristic of pneumococcal pneumonia. The affected segments of the lung are not reduced in volume. Pleural involvement (pleural effusion) is not usual

CLINICAL FORMS Broncho-PneumoniaCommon cause is staphylococcal infection.Bronchopneumonia is characterized by patchy

exudative consolidation of lung parenchyma due to terminal bronchiolitis with consolidation of peribronchial alveoli.

Bilateral (less often unilateral), patchy consolidation with intervening normal lung tissue.

Lesion is more extensive at the base of the lung and often fuses together resembling lobar pneumonia (confluent bronchopneumonia).

Transverse thin-section CT scan at the level of the carina in a patient with measles infection shows multiple centrilobular nodules (arrowhead) and bilateral areas of lobular consolidation (arrows).

Franquet T Radiology 2011;260:18-39

©2011 by Radiological Society of North America

Staphylococcal Pneumonia inChildren

• Pneumonia caused by S. aureus associated with high

rate of complications (e.g., pleural effusion orempyema in 55-80%; pneumothorax,pyopneumothorax, and pneumatoceles

frequently observed)• Very high mortality rates reported in

primarystaphylococcal pneumonia

CLINICSTOXIC SYMPTOMS:Toxic shock syndrome is caused by toxins

secreted by Staph aureus. Toxic shock syndrome is characterized by the sudden onset of high fever, vomiting, diarrhea, and muscle aches, followed by low blood pressure which can lead to shock and death. There may be a rash with peeling of skin.

FUNCTIONAL:DyspneaChest discomfortPleuritic painChest splintingCough productive of purulent or blood-tinged

sputumTachypneaTachycardia

In advanced cases you may see:CyanosisConfusion Pain referral to the abdominal region due to

diaphragmatic inflammation

PHYSICAL SIGNSrespiratory distress, hypoxemia, and hypercarbia grunting, flaring, severe tachypnea, and

retractions assessment of oxygen saturation by pulse

oximetry Visual inspection - respiratory effort and count

the respirations – tachypneaAuscultation -crackles or ralesPercussion -identify an area of consolidation.rashes and pharyngitis

IMAGERYINTERSTITIALCONDENSATIONSCONFLUATIONPROGRESSION TO ABCESS, EMPIEMARestitutio ad integrum or pneumatocelae

Gram negative infections

Gram negative infections are caused by Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Haemophilus influenzae, and Proteus.

The radiological picture is identical, and it is not possible to differentiate between bacteria.

Gram negative lung infections are seen in chronically ill patients , chronic lung diseases, diabetes, or different types of cancer.

Aspiration to the respiratory tract is the commonest single cause of Gram negative pneumonia.

Opacities caused by Gram negative bacteria are usually localized in the basal lung segments. It is not possible to differentiate these opacities from those caused by staphylococcus aureus.

Complications such as empyema and lung abscess are frequently seen

Atypical or Interstitial or viral PneumoniaCausesMycoplasmaLegionellaChlamydiaPneumocystis carinni. CoxiellaFungi Histoplasma capsulatum (histoplasmosis) Coccidioides immitis (coccidioidomycosis

Atypical or Interstitial or viral PneumoniaIn atypical pneumonia the x ray finding

usually do not show lobar type of picture but meaning that the affection is restricted to small areas that is interstitial spaces between alveoli, rather than involving a whole lobe. As the disease progresses, however, the look can tend to be lobar pneumonia.

There is also absence of leukocytosis.Extrapulmonary symptoms, give some clue

to the causing organism.

Atypical or Interstitial or viral PneumoniaIn atypical pneumonia :x ray chest

infiltration, commonly begins in the perihilar region (where the bronchus begins) and spreads in a wedge- or fan-shaped fashion toward the periphery of the lung field.

Reticular shadows as small linear striations running in all directions on which may be small white nodular appearance.

Transverse thin-section CT scan at the level of the carina in a patient with measles infection shows multiple centrilobular nodules (arrowhead) and bilateral areas of lobular consolidation (arrows).

Franquet T Radiology 2011;260:18-39

©2011 by Radiological Society of North America

Atypical or Interstitial or viral PneumoniaThe most common pathogen of this group is

Mycoplasma pneumoniae. It ranks second only to S. pneumoniae.

onset is usually more insidious. Mycoplasma pneumoniae can be communicated through

close personal contact via respiratory droplets or contact with poultry or birds chicken etc.

EXTRAPULMONARY MANIFESTATIONS:gastrointestinal musculoskeletal dermatologic cardiac neurologic symptoms hematological

Complications of Pneumonia1. Pulmonary fibrosis.2. Bronchiectasis3. Lung abscess4. Empyema5. Bacteremia with abscess in other organs6.ARDS7.Bacteremia8.Collapse of lung9.Hemoptysis

Complications of PneumoniaParapneumonic effusionsSeptic arthritisEndocarditisPericarditisRespiratory failureMental symptoms

Differential Diagnoses

Acute Respiratory Distress SyndromeAsthmaBronchiolitisEmpyema and AbscessBronchitisForeign Body AspirationPertussis

Investigations of PneumoniaTotal and differential countPBFBlood ,urine,sputum culture/sensitivityGram staining/stain for AFBFiberoptic bronchoscopy with bronchial

washing/ brushing /biopsy

Inflamatory tests: ESR, Fg, CRP, alpha 2 globulin

Pulse oximetry Urine latex agglutination test: antigen

detection assays for S pneumoniae Blood and sputum culturesFluid recovered from the pleural space should be

sent for Gram stain and culture, along with pH, glucose, protein, and lactate dehydrogenase (LDH).

IMAGERY

Anteroposterior radiograph of a child with a bacterial pneumonia

parahilar peribronchial infiltrates

hilar adenopathy

History of Empiric Therapy

Bacterial Pneumonia in Children:• Early 1900’s Serum therapy• 1950’s Penicillin, the miracle drug• 1960’s Ampicillin improves Haemophilus

coverage;semisynthetic penicillins (oxacillin,

nafcillin) provide Staph coverage• 1980’s 2nd and 3rd generation

cephalosporins provide excellent coverage for the “usual suspects”

• 2010Are beta-lactams still reliable?

Worldwide Trends inPneumococcal Resistance

ATBAmoxicillin 80 mg/kg/d PO divided 2-3Penicillin 100 ooo units/kg/d iv divided qid or orallyCefuroxime (Zinacef) IV: 150-200 mg/kg/d IV divided q8h Ceftriaxone (Rocephin) 50-75 mg/kg/d IV/IM qd; not to

exceed 1 gCefotaxime (Claforan) 100-200 mg/kg/d IV/IM divided q6-

8h Erythromycin 30-50 mg/kg/d (base and ethylsuccinate) PO divided q6-8h

Clarithromycin 15 mg/kg/d PO divided q12h

carbapenems, fluoroquinolones, aminoglycosides, vancomycin

Methicillin-resistant Staphylococcus aureus, known as MRSA, is a type of Staphylococcus aureus that is resistant to the antibiotic methicillin and other drugs in the same class, including penicillin, amoxicillin, and oxacillin

Therapeutic choice: vancomycin, targocid ( teicoplanin), linezolid ( zyvoxid)

Empiric Therapy of Children with Pneumonia (I)

• Cefotaxime/Ceftriaxone reasonable empirictherapy for pneumococcus, Haemophilus,Moraxella, MSSA• Add macrolide for coverage of Mycoplasmaand Chlamydia in older patients (? ≥ 2-3 yrs)• Add clindamycin or vancomycin in patientswith severe or complicated pneumonia(clindamycin in most cases if low rates of R;vancomycin if life-threatening)

Need to establish specific etiologicdiagnosis when possible (e.g.,thoracentesis, culture, moleculardiagnostics)• Consider aggressive management ofempyema (e.g., video-assistedthoracoscopic surgery: VATS)

Pneumocystis carinii pneumonitis (PCP) is a common opportunistic disease that occurs almost exclusively in persons who have profound immunodeficiency.

PCP was and still is the most common life-threatening opportunistic infection occurring in patients with HIV disease.

PCP: Clinical FeaturesCough

Usually nonproductive, occasionally whitish sputum.

Dyspnea Fever May be accompanied by night sweats, but

not rigors. Rales

May be present, but are often absent.

Tachypnea and fever Diffuse bilateral alveolar disease can be observed by radiography. Diagnosis requires the identification of P carinii in pulmonary tissue or lower airway fluids. Lung biopsy, inducement of sputum, bronchoalveolar lavage, or needle aspiration of the lung. The Gomori, Giemsa, fluorescence-labelled antibody, or toluidine blue O stains may be used to identify the organism.

PCP: CXR Findings90-95% have pulmonary infiltrates.Combined interstitial & alveolar infiltrates.Predominantly at bases and centrally.Pneumothorax can be present.Lace like appearance.

PA Chest Radiograph

Demonstratesbilateral, perihilar,R > L, ground glassopacities

PA Chest Radiograph

Progressivedisease showingextensive groundglass opacificationwith consolidation

PA Chest Radiograph

Progressivedisease showingextensive groundglass opacificationwith consolidation

Histologic DiagnosisSputum (induced if necessary):

Diagnostic Flexible Bronchoscopy with Bronchoalveolar

lavage to find pnuemocytis carinii in sputum and secretions.

.

Diagnosis continuedGomori methenamine silver (GMS) stain from

BAL specimen showing “crushed ping-pong ball” appearance of cyst wall

Calcofluor white stains the fungal cyst wall for rapid diagnosis

Diagnosis continuedImmunofluorescence showing trophozoites

(arrowheads) and cysts (arrows)

•Four drugs currently available for therapy of P carinii pneumonitis are:

Pentamidine isethionate Trimethoprim-Sulfamethoxazole atovaquonetrimetrevate

Trimethoprim-sulfamethoxazole is preferred because of its low toxicity and greater efficacy.

BACTRIM-DSBactrim DS tablet contains. 160 mg of

trimethoprim and 800 mg of Sulfamethoxazole.

21 days coursePrednisolone 40 mg bid x 5 days, then 40

mg/day x 5 days, then 20 mg/day to completion of treatment

Alternative Treatments: TMP 15 mg/kg/day PO + dapsone 100

mg/day x 21 days Pentamidine 4 mg/kg/day IV x 21 days-Atovaquone 750 mg PO bid with meal x

21 days

PCP is the most frequently identified serious in HIV disease