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Community Acquired Pneumonia
common but sometimes deadly
DR AHMAD FADZIL
HTAA/HOSHAS
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Challenges
Significant morbidity and mortality
Identifying etiology
Antibiotic resistant Old microorganism changes severity (PVL-
SA)
New microorganism
Epidemic/pandemic and human behavior
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Burden of Disease
WHO 156 million cases, 1.6 million death
Incidence 0.28 episodes perchild/year in
developing country, 0.05 episodes
perchild/year in developed country (< 5 years
old)
20% under 5 mortality globally.
The decrease incidence and mortality much
less than that diarrhea disease.
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In developing country
Etiology Virus
Sreptococcus pneumonie
30-50 %Heamophilus influenzae type B/nontypeable
Staphylococcus (in severe pneumonia
2nd common cause)
Klebsiella pneumonie
Significant mortality and morbidity
WHO1) Protecting child by providing low risk environment2) Preventing children developing the disease
3) Effectiveness case management at community and
health care facility
HOSHAS
meliodosis, PTB
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In developed country
Issue still high morbidity but low
mortality
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New pattern
HIB nontypable
Pneumococcus nonvaccine strain
Staphylococcus PVL Increase in mortality in influenzae strain
New isolated Human metapneumovirus,
Bocavirus. Recogniton of dual infection: pneumococcus-
viral
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Risk factors
Malnutrition, younger age, low immunization rate, early respiratory damage
Fatmi Z et. al Int J Infec Dis 2002: 6; 294-301
Delayed weaning , overcrowding
Shah N et al J Tropical Paed 1994: 40; 201-206
ETS, solid fuel cooking
Rahman MM et al Bangladesh Med Res Counc Bull 1997
Severity large family size, lateness in the birth order, overcrowding, LBW,
malnutrition, vitamin A def. , lack breastfeeding, pollution, young age.
Berman et all Rev Inf Dis 1998 157, Tupasi TE et al J Infec Dis 1988 157
LBW, lack breast feeding, incomplete immunization, unwell sibling, overcrowding
Azizi et al 1995, Choo et al 1998
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Mortality - below 1 year, unable to feed, loose stool,severe malnutrition, coexisting measles
Sengal V et all Indian Paed 1997, Deivanayagam N et all Ind Paed 1992: 29
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EFFECTIVENESS
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IMCI
Assumption all are bacteria
Meta-analysis 9 studies
Total mortality
27% (CI 18
35%)
neonates 42% (22-57)
Infant 36 % (20 48)
0
4 yrs. 36 % (20
49)Sazawal S et. Al. Lancet infec Dis 2003.
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Type
Infection
Non infection
Origin X-ray finding aetiology
Community acquired Lobar Bacteria
nosocomial Bronchopneumonia viral
Interstitial Mix
Atypical fungi and others
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Age & pneumonia
Causal
Severity, mortality
Taiwan 2007Jokinen C 1993
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Etiology
Bacteria
Strep.pneumoniae (10
50%)H. influenzae (5 -21 %)
Staphylococcus aureus
M. pneumoniae (8
21 %), newer study had shown the meanage now younger mean (5 years old) . Older children
Mycoplasma 50 70 %
Michelow IC Paediatric 2004.
Viral PCR (n = 4279) 7 developed country & 2 undevelopedcountry:
Viral (49 %) : RSV (11%), influenzae virus (11%),
Parainflunzae (8%), adenovirus (3%) , Bocavirus (5%),
Human metapneumovirus (8%), Rhinovirus (18 %).
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Malaysia
Liam CKet al. KL
2001
127 K.Pneumo.
10.2
S.Pneumo.
12
H.Infuen.
5.5
M.Pneumo.
3.9
Ps.aeroginosa
3.9
Meliodosis
1.6
Unknown
58.3
Hooi LN
et al
Penang2001
98 M.
Tuberculosi
s15.3
K.
Pneumo.
7.2
Ps.
aeroginosa
S.
aureus.
4.2
S.
Pneumo.
3.0
Acinetobacter
3.0
57.1
Liam 2003 352 K.
Pneumo.
11.4
S.
Pneumo.
6.3
M.
Tuberculosis
4.8
S
aureus
3.7
S.
Pneumo.
3.0
H.
Influen.
3.1
59.1
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Malaysian Children
40/170 (23.5%), 1 month 15 years old,
M. pneumoniae Chan PW et al 2001
22 % viral ALRTI (RSV 84%, Parainf. 8%, Inf.
6%, adenov. 2% (5691 < 2years old)
Chan PW et al 1999
222 sample LRTI 23.2 % viral. Zamberi et al 2003
26 (3.9 %)/170 Mycoplasma 2005 Institute
paediatic /PJ Yun-Fun Ngeow et al Int J infec Dis. 2005
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Bacteria
Streptococcus pneumoniae
Haemophilus influenazae b or
nontypeable
Staphylococcus aureus
Gram negative
Mycobacterium tuberculosis
Burkholderia pseudomallei
Mycoplasma pneumonia
Clamydia trachomatis
Clamydia pneumoniae
Legionella pneumophila
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Mix infection
Already recognized phenomena.
Clinical significant?
> 1 virus in 10 20% children (Bocavirus, Influenzae, RSV)
More wheezing episode, more severe pneumonia.Cilla G J Med Virol 2008, Soderlund-vernermo M. et al. Emerg. Infec. Dis. 2009
Viral bacterial up to 45%
Strep. pneumoniae other virus.
Staph. aureus - measles, influenza virus
Poorer diagnosis
avian flu, H1N1.?failure treatment Juven T Eur J Pediatr 2004
Mycoplasma pneumococcus?
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Diagnosis
Technically histology diagnosis
Clinically fever, symptoms and sign of
respiratory distress with chest x-ray
WHO suspected pneumonia no chest x-ray
Respiratory rate and lower chest insertion (LCI)
Infant; PPV 45 %, NPV 83% Harare M. et al Lancet 1991
< 5 years old; sensitivity 74 %, specificity 67 %Palafox M. et al.Arch Dis Child 2000
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Severity
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Diagnosis
Chest x-ray
gold standard?
necessary in all cases?
impractical
Intraobserver and interobserver
sensitivity? In younger children
Malaysian chest x-ray quality?
Rotated, expiratory film, under or overpenetration, baby gram, abdominal x-ray
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Indications for x-ray
Done because of the
study
Many didn't change
management
Unable differentiate
aetiology
Inversely related toclinical experience
- Clinically ambiguous
- Suspected complication
- Prolong and unresponsive to
antibiotics or severe cases
-< 5 years old with high temperature
and WBC and unsure the sources.
-Suspected TB, severe malnutrition, co-
infect HIV
Do all admitted patient need chest x-
ray?
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Chest x-ray
Viral bilateral, hyperinflation, peribronchiol
opacity, subsegmental atelectasis
Donelly LF Radio. Clin North American 2005
Bacteria - Alveolar or air space opacity, pleural
effusion/empyema, cavity
pneumothorax/pneumocele
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Other investigations
Blood investigation wbc, CRP, Pro-calcitonin,blood c/s
Nasopharyngeal swab or aspirate
Throat swab
Ultrasound of chest
CT-thorax
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Bacteria vs. virus
Ruuskanen O et al
Lancet 2011
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BTS guideline 2002
Fever >38.5 0C
RR > 50/min
Chest recession
Wheeze is not a sign of primary bacterial LRTI
(other than mycoplasma)
Clinical and radiological signs of consolidationrather than collapse.
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Management
Save to treat as outpatient? Severity, age
Bacteria?, viral?, atypical? assumption
Antibiotics
what, mode, how long?
Nebulizer?
Physio?
Nutrition?
Oxygen?
History, physical examination, x-ray. experience
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Outpatient/inpatient
Indication admission:
Children aged < 3 months
Fever (>38.5 C), refusal to fed andvomiting
Fast breathing with/out cyanosis Associated systemic manifestation
Recurrent pneumonia
Severe underlying disorder.
Failure of oral antibiotics
Sa < 93%, Intermittent apnea, grunting,unable to provide appropriate
observation.
Majority treated
as outpatient
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Antibiotics
Age
Likely organism history, clinical examination,
Clinical severity
Local pattern and resistant Investigation outpatient minimal
Inpatient Chest x-ray, WBC, CRP,
Preferable oral
Response to initial therapy. Prior antibiotic ? partially treated/undertreated
Duration 3 days vs. 5 days vs. 7 days
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Other diagnosis
Bronchioliotis
Asthma and recurrent wheeze (viral related) Heart failure pulmonary oedema.
Mass
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Taiwan 2007
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National
antibiotic
guideline
2008
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Virus
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Recurrent pneumonia
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Summary
CAP and mortality
Holistic management
Treat early
Pneumococcus vaccination
Socio-economic development with equaldistribution of wealth.
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TQ
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