Cap Mortality Final

7/27/2019 Cap Mortality Final

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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

Documents

Cap Mortality Final