6/17/2014 Guidelines/Guidance/CAP/ Hospitalized Child PHM Boot Camp 2014 Jay Tureen, MD June 19, 2014 CAP in Children: Epi • Greatest cause of death in children worldwide • Estimated > 2 M deaths in children • In developed countries, 3 ‐ 4/100 children < 5y • Hospitalizations using ICD ‐ 9: 200/100,000 – Infants < 1y: 912/100,000 – Adolescents 13 ‐ 18 y: 62/100,000 CAP: Etiology • Viral most common, especially < 2 y/o – RSV, adenovirus, bocavirus, influenza A/B, parainfluenza virus, metapneumovirus, coronavirus, rhinovirus • S. pneumoniae, S. aureus, S. pyogenes • Atypical pathogens: M. pneumoniae, C. pneumoniae, C. trachomatis 1
6/17/2014 CAP: Clinical Questions • Diagnostic testing • Site of care decisions • Anti ‐ infective rx • Adjunctive surgical/fibrinolysis for empyema • Prevention • Discharge criteria CAP: Diagnostic testing ‐ microbiology • Bacteria – Blood cultures not recommended for outpts (1 ‐ 2 %) ; +/ ‐ for inpts, mod to severe PNA (1.4 – 3.4%; 11.4% in one study) or complicated (13.0 ‐ 26.5%) – Sputum : yes if can produce; Tracheal aspirate/BAL for intubated patients – Urine antigen: no ; not correlated with sputum cx in children and + may reflect colonization, not S.p. PNA CAP: Diagnostic testing – microbiology (2) • Viral testing – Yes, but recognize limitations of poor sensitivity. • DFA 50 ‐ 80% for pathogens; PCR 80 ‐ 90% – Advantage is ability to limit antibiotics if alternative dx, but recognize up to 10% have both a resp viral pathogen and bacterium • Atypical organisms – For M. pneumoniae, poor specificity of + cold agglutinins and delay in results of antibody testing; complement fixation rarely timely 2
6/17/2014 CAP: Ancillary Diagnostic testing • CBC ‐ +/ ‐ • Inflammatory markers +/ ‐ acutely; value for followup of complicated cases • CXR ‐ /+ (usually have had as outpt); f/u imaging not usually needed unless… – Parapneumonic effusion present or suspected – U/S preferred over CT as initial additional imaging CAP: Clinical Questions • Diagnostic testing • Site of care decisions • Anti ‐ infective rx • Adjunctive surgical/fibrinolysis for empyema • Prevention • Discharge criteria CAP: Dx criteria • World Health Organization definition – Mild: tachypnea, fever – Moderate: tachypnea, fever, retractions – Severe: tachypnea, fever, retractions, cyanosis or inability to eat 3
6/17/2014 CAP: Site of Care • Mild: Outpatient management • Moderate: Hospitalization – Hypoxemia (< 90% O2 sat) on RA, resp distress*, age < 3 mos, +/ ‐ 3 ‐ 6 mos with suspected bacterial CAP, suspected S. aureus, home considerations • Severe: Intensive Care – Hypoxemia with supplemental O2, BP or HR abnl. AMS, need for PP vent CAP: Clinical Questions • Diagnostic testing • Site of care decisions • Anti ‐ infective rx • Adjunctive surgical/fibrinolysis for empyema • Prevention • Discharge criteria CAP: Rx Age Organisms Inpatient Discharge 1 st line: Amp Amoxicillin Lobar/no prior > 2 mo S. pneumoniae Rx H. influenzae Alternative: M. catarrhalis Cefttriaxone S. aureus 1 st line: Lobar/prior Rx > 2 mo S. pneumoniae Amoxicillin ‐ H. influenzae Ceftriaxone clavulanate M. catarrhalis Alternative: or S. aureus Amp ‐ Cefdinir Sulbactam Complicated > 2 mo S. pneumoniae Vanco + Based on S. aureus Ceftraixone culture and or sensitivity Clindamycin Atypical > 5 yr Mycoplasma Azithromycin Continue x 5d Chlamydia or levofloxacin Influenza Any age Flu A, Flu B Oseltamivir Continue x 5d 4
6/17/2014 CAP: Clinical Questions • Diagnostic testing • Site of care decisions • Anti ‐ infective rx • Parapneumonic effusions and Empyema/VATS/fibrinolysis • Discharge criteria CAP: Parapneumonic Effusions • 2 ‐ 12% • Small (1 cm) can be managed conservatively with antibiotics alone • Moderate (< ½ of hemithorax) 27% required drainage • Large (> ½ hemithorax) usually require drainage • Empyema – fibrinolytic or VATS + drainage + antibiotics PNA: PPE – Empyema 3 Phases • Exudative – Free flowing, cytochemical changes minimal (normal glucose, pH, cell count low) • Fibrinopurulent – +/ ‐ loculated, U/S shows fibrin stranding, septations – Light Criteria : pH < 7.2, glucose, 40, LDH > 1000, + GM stain, + U/S • Organized , Loculated, ‘pleural peel’ 5
6/17/2014 PNA with PPE: Suggested approach • Dx early • Establish free ‐ flowing and differentiate exudative vs fibrinopurulent • Diagnostic thoracentesis • Pleural fluid analysis combined with U/S Empyema: Med vs Surg • When empyema diagnosed, earlier rx leads to shortened hospital stay. • Intrapleural fibrinolytics (tPA, urokinase) + antibiotics • Video assisted thorascopic surgery (VATS) + antibiotics – Can be primary rx or follow fibrinolysis if rx fails (17%) Empyema: VATS vs Fibrinolytic Rx St. Peter 2009 Sonappa 2006 Kurt 2006 VATS/CT + 18/18 30/30 10/8 fibrinolytic (# pts) LOS (days) 6.9/6.8 6/6 5.8/13/2 Cost ($) 11,700/7600 11.379/9127 19,714/21,947 Fever after 3.1/3.8 2.5/2.5 3.6/6.2 intervention (days) 6
6/17/2014 Empyema: Approach CAP: Clinical Questions • Diagnostic testing • Site of care decisions • Anti ‐ infective rx • Adjunctive surgical/fibrinolysis for empyema • Prevention • Discharge criteria PNA: Discharge criteria • Recommendations made by expert opinion, often with little or no clinical trial evidence • No substantially incr WOB, incr RR, incr HR • Overall clinical improvement >24h (decreased WOB, activity, appetite) • Pulse ‐ ox >90% for >24h • If CT placed, no air leak > 24h • Able to tolerate home PO ABX regimen 7
6/17/2014 References The management of Community ‐ Acquired Pneumonia in Infants and Children • Older than 3 months of Age: Clinical Practice Guidelines by the PIDS and the IDSA. Bradley JS et al; Clin Infect Dis , 8/2011, Epub. Time to clinical stability in patients hospitalized with community ‐ acquired • pneumonia; implications for practice guidelines. Halm EA et al. JAMA ,1998:279:1452. Video ‐ Assisted Thoracoscopic Surgery vs Chest Drain with Fibrinolytics for the • treatment of Pleural Empyema n Children: A systematic review of Randomized Controlled Trials. Mahant S et al. Arch Pediatr Adol Med ., 2010; 164:201 ‐ 3. Influenza ‐ associated pediatric mortality in the United States: increase of • Staphylococcus aureus co ‐ infection. Finelli L et al. Pediatrics 2008; 122:805 ‐ 11. The diagnosis and management of empyema in children: a comprehensive reviwe • from the APSA Outcomes and Clinical Trials Committee Islam S et al. J Pediatr Surg 2012; 47:2101 ‐ 2110. Decline in invasive pneumococcal disease after the introduction of protein ‐ • polysaccharide conjugate vaccine. Whitney CG et al. N. Engl J. Med 2003; 348:1737 ‐ 46 8
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