Pneumonia

Approach for unresponsive to initial treatment

Retno Asih S
 Contents
The management of children with pneumonia
Unresponsive response to initial treatment
Approach for unresponsive to initial treatment
Case presentation
Take home message
 The management of children
with pneumonia

Straightforward in most cases approriate antibiotics

and supportive therapy
Significant proportion die after having the sought
treatment management remains a major problem
The initial treatment (empiric therapy) is undertaken
without knowlegde the causative organisme
Not all the children respond to initial treatment
Follow up is important

Mulholland K. Fundamental of Pneumonia Management, 2016. 1st ed. London; Pinter & Martin ltd:
 The main reasons for admitting a child to a hospital
The need for parenteral antibiotics
The possibility that the child might deteriorate
The need for intensive monitoring
The need for oxygen
Feeding support and/or intravenous fluids
The need for invasive procedure
World Health Organization : danger signs

Mulholland K. Fundamental of Pneumonia Management, 2016. 1st ed. London; Pinter & Martin ltd
 Use of empiric antibiotic therapy based on guideline
has been estimated to reduce pneumonia-specific
mortality by 35-40%
The antibiotic should cover the most common
organisms which are likely to be lethal if left
untreated (H. influenzae and S. pneumoniae)
World Health Organization:
Outpatient : Amoxicillin 40mg/kg, 2 times per day
Inpatient : Ampicillin 50mg/kg, every 6 hours AND
gentamycin 7.5mg/kg, once a day.

Mulholland K. Fundamental of Pneumonia Management, 2016. 1st ed. London; Pinter & Martin ltd
 The progress of treatment should be regularly
reassess compare with clinician expectation
Assessment of treatment : clinical signs
Breathing
Fever
Danger signs

Mulholland K.. Fundamental of Pneumonia Management, 2016. 1st ed. London; Pinter & Martin ltd
 Unresponsive response to
initial treatment
There are a number of possibilities response to
treatment (48-72 jam)
1. The child responds to treatment and does not
relapse
2. The child is slow to respond or worsens
3. The child responds but later relapses or re-
presents with a new episode of pneumonia
Very young infants may be slower to respond to
therapy
Mulholland K. Unsatisfactory Response to Treatment, 2016. 1st ed. London; Pinter & Martin ltd
Treatment failure was defined as any of the following
occurring by or at 48 hours:
1. No improvement or worsening of tachypnea or
lower chest indrawing OR
2. New appearance, no improvement or worsening of
danger signs OR
3. Occurrence of complications (empyema,
pneumothorax, lung abscess, meningitis,
septicaemia, respiratory failure).

Jain DJ, et al. Indian Pediatric 2013; 50 (15)

 Approach for unresponsive to
initial treatment

The main areas for the consideration

The causative agents, including differential diagnosis
Underlying conditions
Complications of pneumonia

Mulholland K. Unsatisfactory Response to Treatment, 2016. 1st ed. London; Pinter & Martin ltd
Kelly MS, Smieja M, Luinstra K, et al. Plos One 2015; May 14: 1-12
 Possible other causes

The most common reason of pneumonia being slow

to resolve
Microbiological differential diagnosis
Viral etiology (RSV, adenovirus)
Atypical organisms
Tuberculosis
Staphylococcus aureus/ Klebsiella pneumoniae
True differential diagnosis
Cardiac failure
Foreign body
Diagnosis Points in favour Suggested
investigation
RSV Wheeze, hyperinflation Clinical examination
Young children
Mycoplasma Relatively mild illness with Chest radiograph
pneumoniae severe radiographic changes
C.pneumonia Older child
S. aureus or Severe, downhill course Chest radiograph
H. influenzae Pneumatoceeles or abcess on Blood culture
CXR
Evidence of Sthapylococcus
infection elsewhere
Tuberculosis Cough more than 2 weeks Chest radiograph
Weight loss Mantoux test
History of TB contact Sputum examination
HIV exposed or infected HIV test
 Underlying Conditions

Many conditions can predispose a child to be slow

response to initial treatment
Pulmonary factors
Bronchiectasis
Congenital abnormalities
Cardiac factors
Neurological factors
Immunological disorders
Hematological disorders
 Complication of pneumonia

Thoracic cavity
o Pleural effusion
o Pneumothorax
o Empyema
o Lung Abcess
Bacteremia & hematologic spread
o Meningitis
o Septicemia
 Case 1
A//20 months old/9.4 kg
Cough, fast breathing and fever for 3 days.
Already treated with ceftriaxon (5 days)
Past history: pneumonia
RR 49 times per minute
Temperature : 38 0C
Chest retraction and fine moist rales
-

Chest X-ray, 1 Desember 2016

 Haemoglobin : 10.7 g/dl
WBC : 7920/mm3
Haematocrit: 30.8%
Platelets : 253.000/mm3

Chest X-ray, 30 December 2016

Chest X-ray, 4 January 2017
 Case 2
R//7 months old/6.5 kg
Referred with diagnosis pneumonia and lung
atelectasis
Cough, fast breathing for 2 weeks.
Fever already resolved
Already treated with ampicillin- gentamycin,
ceftriaxon-cloxacillin
Past history : pneumonia when he was 3 months old
RR 54 times per minute
Temperature : 37 0C
 Case 3
I// 6 years old/20 kg
Productive cough and paroxysmal for 2 weeks.
Fever for 10 days
The appetite was normal.
His daily activities were normal.
RR 34 times per minute
Temperature : 38 0C
Already treated with ampicillin sulbactam-amikasin (5
days), meropenem (3 days)
 Haemoglobin : 10.4 g/dl Haemoglobin : 10.9 g/dl
WBC : 9200/mm3 WBC : 6450/mm3
Haematocrit : 30.8% Haematocrit : 31.5%
Platelets : 262.000/mm3 Platelets :
ESR : 58/hour 184.000/mm3
TST induration : 0 mm
Case Report..

23
 Take home message

The follow up of initial treatment (empiric

antibiotics) is important response therapy
Approach for unresponsive to initial treatment
The causative agents, including differential
diagnosis
Underlying conditions
Complications of pneumonia
Thank you