Community Acquired Pneumonia common but sometimes deadly

DR AHMAD FADZIL HTAA/HOSHAS

Challenges
Significant morbidity and mortality Identifying etiology Antibiotic resistant Old microorganism changes severity (PVLSA) New microorganism Epidemic/pandemic and human behavior

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.

In developing country
Significant mortality and morbidity

Etiology Virus Sreptococcus pneumonie 30-50 % Heamophilus influenzae type B/nontypeable Staphylococcus (in severe pneumonia 2nd common cause) Klebsiella pneumonie WHO 1) Protecting child by providing low risk environment
2) Preventing children developing the disease 3) Effectiveness case management at community and health care facility

HOSHAS meliodosis, PTB

In developed country
Issue still high morbidity but low mortality

New pattern
HIB nontypable Pneumococcus nonvaccine strain Staphylococcus PVL Increase in mortality in influenzae strain New isolated Human metapneumovirus, Bocavirus. Recogniton of dual infection: pneumococcusviral

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

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

EFFECTIVENESS

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.

Type
Infection Non infection
Origin Community acquired nosocomial X-ray finding Lobar Bronchopneumonia Interstitial aetiology Bacteria viral Mix Atypical fungi and others

Age & pneumonia

Causal Severity, mortality

Jokinen C 1993

Taiwan 2007

Etiology
Bacteria Strep. pneumoniae (10 50%) H. influenzae (5 -21 %) Staphylococcus aureus M. pneumoniae (8 21 %), newer study had shown the mean age now younger mean (5 years old) . Older children Mycoplasma 50 70 %
Michelow IC Paediatric 2004.

Viral PCR (n = 4279) 7 developed country & 2 undeveloped country:

Viral (49 %) : RSV (11%), influenzae virus (11%), Parainflunzae (8%), adenovirus (3%) , Bocavirus (5%), Human metapneumovirus (8%), Rhinovirus (18 %).

Malaysia
Liam CK et al. KL 2001 127 K. Pneumo. 10.2 S. Pneumo. 12 H. Infuen. 5.5 M. Pneumo. 3.9 Ps. aeroginosa 3.9 Unknown Meliodosis 1.6 58.3

Hooi LN et al Penang 2001

98

M. Tuberculosi s 15.3

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

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

Bacteria Streptococcus pneumoniae Haemophilus influenazae b or nontypeable Staphylococcus aureus Gram negative Mycobacterium tuberculosis Burkholderia pseudomallei

Mycoplasma pneumonia Clamydia trachomatis Clamydia pneumoniae Legionella pneumophila

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?

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

Severity

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 over penetration, baby gram, abdominal x-ray

Indications for x-ray

Done because of the study Many didn't change management Unable differentiate aetiology Inversely related to clinical 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, coinfect HIV Do all admitted patient need chest xray?

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

Other investigations
Blood investigation wbc, CRP, Pro-calcitonin, blood c/s Nasopharyngeal swab or aspirate Throat swab Ultrasound of chest CT-thorax

Bacteria vs. virus

Ruuskanen O et al Lancet 2011

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 consolidation rather than collapse.

Management
Save to treat as outpatient? Severity, age Bacteria?, viral?, atypical? assumption
History, physical examination, x-ray. experience

Antibiotics what, mode, how long? Nebulizer? Physio? Nutrition? Oxygen?

Outpatient/inpatient
Indication admission: Children aged < 3 months Fever (>38.5 C), refusal to fed and vomiting 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

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

Other diagnosis
Bronchioliotis Asthma and recurrent wheeze (viral related) Heart failure pulmonary oedema. Mass

Taiwan 2007

National antibiotic guideline 2008

Virus

Recurrent pneumonia

Summary
CAP and mortality Holistic management Treat early Pneumococcus vaccination Socio-economic development with equal distribution of wealth.

TQ