JOURNAL READING

Etiology and Response to Antibiotic Therapy of Community-Acquired

Pneumonia in French Children

Pembimbing : dr. Hery Susanto, Sp.A

Lukas Pria Salman
03010162
Abstrack

Objective :
 The aim of this study was to determine the etiologic agents
associated with community-acquired pneumonia in 104 French
children ages 18 months to 13 years.
Subject

 From 1 June 1992 to 1 December 1994,

 All patients between the ages of 18 months and 13 years hospitalized in or
attending the outpatient clinic of Saint-Vincent-de-Paul Hospital in Paris
presenting with communityacquired pneumonia were enrolled in this
study.
 Diagnosis was based on concurrent findings of fever (> 38~ respiratory
symptoms, and presence of a pulmonary infiltrate on chest radiograph.
Children with underlying diseases (including AIDS), lung malformation,
or nonacute pneumonia (i.e., absence of respiratory symptoms and fever in
the preceding days) were excluded. Children were included only once in
the study; those with recurrent pneumonia were excluded.
Tabel Pathogens Identified in 104 French Children
(18 months- 13 years) with Community-Acquired
Pnemonia
pathogen No.of cases
Viruses 30
Respiratory syncytial virus 10
parainfluenza 6
Influenza A or B 4
adenovirus 4
Others 6
S.pneumonia 12
S.aureus 1
Chlamydia 1
M.pneumonia 41
S.Pneumonia + M. Pneumonia 2
No pathogen Identified 17
 Blood samples were drawn from all children at the first examination for
biochemical analysis, complete blood count, and culture.
 A nasopharyngeal swab was obtained during the first visit for viral culture and
fluorescent viral immunoassay.
 Acute and convalescent antibody titers were measured on sera collected at
enrollment and 15 to 20 days later, respectively.
 Antibodies against respiratory syncytial virus (RSV), influenza virus,
parainfluenza virus, and adenovirus were detected by complement fixation; against
Mycoplasma pneumoniae (IgM and IgG), by enzyme immunoassay and against
Chlamydia trachomatis and Chlamydia psittaci, by a micro-immunofluorescent
test
Results and Discussion

 One hundred four children with a mean age of 5.6 years (range, 18
months-13 years) were eligible for the study.
 A potential pathogen was identified in 87 of 104 (84%) children
(Table 1). Thirty (29%) patients (mean age, 4.1 years) were
considered to have a viral infection.
 Viral infection was diagnosed by serological tests, culture, or
fluorescence in 24 patients. In the other six, a high serum level of
interferon- alpha at the initial visit was considered diagnostic of an
acute viral infection (7).
 Pneumonia was caused by Streptococcuspneumoniae in 12
patients (mean age, 4.5 years).
 Blood cultures for Streptococcus pneumoniae were positive in eight
patients; all isolates were susceptible to penicillin.
 In two patients Streptococcus pneumoniae was detected by
examination of pleural fluid. Two other patients were suspected to
have pneumococcal pneumonia based on clinical findings and the
presence of pneumococcal antigens in urine.
 Mycoplasma pneumoniae was determined to be the causative
pathogen in 43 (42%) children (mean age, 6.3 years), based on
detection of specific IgM antibodies against Mycoplasma
pneumoniae in 37 acute and six convalescent serum samples.
 In all cases a threefold or more increase of specific IgG antibodies
between the two serum samples was observed. Two of the 43
patients with Mycoplasma pneumoniae infection had a blood or
sputum culture positive for Streptococcus pneumoniae.
 Children with pneumococcal pneumonia were treated with
amoxicillin (80 to 100 mg/kg/day): defervescence of fever occurred
within 24 h in 11 of 12 children.
 Thirty-two of the 41 children infected with Mycoplasma pneumoniae
were treated initially with amoxicillin, 30 of whom failed to respond
to B-Lactam therapy. Fever persisted for two to 18 days in these
patients, until treatment was switched to macrolide therapy.
 Eighteen of these patients were referred to our hospital by their
family practitioner with suspected penicillin resistant Streptococcus
pneumoniae infection.
 Mycoplasma pneurnoniae was the predominant pathogen
identified in the present study. The incidence found (42%) is higher
than that reported previously.
 It is possible that the rate of Mycoplasma pneumoniae infection was
overestimated because some patients were referred to the hospital
for failure of B-lactam therapy.
 Only one patient with pneumococcal pneumonia was suspected to
be infected with a penicillin resistant strain.
 This patient responded slowly with amoxicillin therapy, but no
organism could be cultured.
 High doses of amoxicillin are effective for treatment of pneumonia
caused by penicillin sensitive strains of Streptococcus pneumoniae
or those exhibiting an intermediate level of penicillin resistance .
 Considering that pneumococcal pneumonia is a life-threatening
illness (92% of our patients required hospitalization), we recommend
high doses of amoxicillin as the treatment of choice for pneumonia
in children in France over the age of 2 years.
 If B-lactam therapy fails after a minimum of two days of treatment,
Mycoplasma pneumoniae is probably responsible and macrolide
therapy is indicated.