Guidelines/Guidance/CAP/ Hospitalized Child PHM Boot Camp 2014 Jay - - PDF document

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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

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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

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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

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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 Lobar/no prior Rx > 2 mo

• S. pneumoniae
• H. influenzae
• M. catarrhalis
• S. aureus

1st line: Amp Alternative: Cefttriaxone Amoxicillin Lobar/prior Rx > 2 mo

• S. pneumoniae
• H. influenzae
• M. catarrhalis
• S. aureus

1st line: Ceftriaxone Alternative: Amp‐ Sulbactam Amoxicillin‐ clavulanate

• r

Cefdinir Complicated > 2 mo

• S. pneumoniae
• S. aureus

Vanco + Ceftraixone

• r

Clindamycin Based on culture and sensitivity Atypical > 5 yr Mycoplasma Chlamydia Azithromycin

• r levofloxacin

Continue x 5d Influenza Any age Flu A, Flu B Oseltamivir Continue x 5d

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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’

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• 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 + fibrinolytic (# pts) 18/18 30/30 10/8 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 intervention (days) 3.1/3.8 2.5/2.5 3.6/6.2

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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,
• ften 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

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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