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PNEUMONIA LA COPIL

PNEUMONIA
cauza de deces (20% din decesele la copii <5 ani)
infectie respiratorie grava
letalitate crescuta (mai ales la sugar)
PIDS si IDSA ghid management al
pneumoniei comunitare
92 recomandari grupate pe puncte de interes

PNEUMONIA

= inflamatie a parenchimului pulmonar datorata


unui agent infectios
comunitara la copii anterior
sanatosi, cu agent infectios din afara spitalului
pneumonie nosocomiala
pneumonie

agenti infectiosi
virusuri
bacterii
fungi

paraziti

ETIOLOGIE
!! pneumonia poate fi precedata de bronsite acute virale
virusurile faciliteaza infectiile cu ag patogeni care
colonizeaza nazo-faringele : S. pneumoniae, H.
influenzae, M. catarrhalis
colonizarea cu S. mitis, coci anaerobi - efect protector
impotriva tulpinilor patogene
agenti virali :

30-67%,

frecvent

sub 2 ani
VSR, rhinovir bacterie,
adenovir, influenza, parainfluenza, metapneumovir si
bocavir uman
enterovirus, varicela, herpes, CMV

ETIOLOGIE

bacteriana :
S.

pneumoniae, M. pneumoniae, C. pneumoniae


H. influenzae, S. aureus, M. catarrhalis, B. pertussis,
S. pyogenes, C. trachomatis
f rar L. pneumophila
Salmonella non-typhi MDR Africa tropicala
zone endemice TBC pneumonii severe

8-40% - cazuri mixte : viral + bact, bact + bact

ETIOLOGIE
in

functie de varsta
1 l-4 ani virala
nou-nascut Strept grup B, E coli,
Klebsiella, Enterobacteriacee, L.
monocytgenes
1-3 luni C. trachomatis
prescolar: S. pneumoniae, H. influenzae,
S. aureus
scolar: M. pneumoniae, C. pneumoniae

FACTORI PREDISPOZANTI
DZ
absenta splinei sau disfunctii ale splinei
boala cardiaca cronica, sdr nefrotic, boala hepatica severa
astm, episoade repetate de wheezing
OM tratata prin timpanocenteza < 2 ani
deficitele imune primare/secundare
disfunctii mucociliare : fibroza chistica
malformatii congenitale ale cailor aeriene, tulburari de deglutitie, boli
neuromusculare
BRGE
tratament cu IPP
tratament antibiotic, infectii virale (microflora bact e distrusa de antibiotice,
virusurile neuraminidaze+ enzime promoveaza aderenta si expresia rec.
pneumocici)
expunere fum de tigara
malnutritia

PNEUMONIA COMUNITARA

etiol bacteriana
febra

> 38.5 C
stare toxica
geamat
tuse productiva
cianoza
modif Rx condensare pulmonara

etiol virala
varsta

mica
febra < 38.5 C
wheezing
modif RX : hiperinflatie, accentuare desen pulm, atelectazie
lobara/segmentara

MANIFESTARI CLINICE
tuse
febra
aspect toxic, cianoza periorala
semne de insuficienta respiratorie

tahipnee
retractii

costale, batai aripi nazale, respiratii


superficiale

durere toracica (la copilul mai mare)


durere abdominala varsaturi
cefalee

CRITERII DIAGNOSTIC

febra + cel putin una dintre


tahipnee

= CEA MAI MARE VALOARE


PREDICTIVA 3ani
tiraj
tuse
senzatie lipsa aer
dificultate respiratorie
durere toracica
MV diminuat
raluri (subcrepitante, crepitante)
cianoza

DIAGNOSTIC DIFERENTIAL
pneum bact de pneum nebact
SDRA
aspiratia de corp strain
chist hidatic pulmonar
intoxicatia cu CO, fum
malformatii cardiace, malformatii pulmonare
decompensare IC
distrofia toracica asfixianta
criza astm
atelectazia pulmonara, formatiuni tumorale
ocluzia intestinala la nou-nascut
hernia diafragmatica congenitala
bronsiectazii, bronsiolite
bronsite acute/ acutizari bronsite cronice
pleurezie, empiem pleural
pneumotorax, hemotorax

DIAGNOSTIC DIFERENTIAL
atrezia esofag / fistula traheo-esofagiana
histoplasmoza
HIV
inf cu B. pertussis
boala granulomatoasa cronica
coccidioidomicoza
stridor congenital
fibroza chistica
TBC
LMNH cu celula T citemizat
LMH
traumatisme toracice

EXAMEN CLINIC
aspectul toxic : facies incercanat, suferind
sugarul: nu primeste alim po, varsa, agitat
tuse seaca/semiproductiva/productiva
SDRA
auscultator

raluri

crepitante, MV diminuat de partea afectata


sau absent, matitate la percutie sau frecatura
pleurala (pleurezie asociata)
wheezing pneumonii virale sau cu M. pneumoniae
suflu tubar in pneumonii de condensare

pulsoximetrie

CRITERII DGN PT SDRA LA COPII CU


PC

semne de DRA
tahipnee,

FR crescuta (0-2 l> 60 r/min, 2-12 l > 50


r/min, 1-5 ani >40 r/min, >5 ani >20 r/min)
dispnee
tiraj suprasternal/intercostal/subcostal
wheezing
batai aripi nazale
apnee
alterare status mental
hipoxie < 90% in aer atmosferic

!!! SPITALIZARE

INVESTIGATII

Rx torace nu de rutina, dar indicata


copil

< 5 ani + febra + hiperleucocitoza de cauza


necunoscuta
modif clinice de pneumonie sunt incerte
modif clinice de pneumonie severa
suspiciune de pleurezie
evolutia pneum este prelungita si neinfluentata de
antibioterapie

orientare etiol
hemocultura
culturi

lichid pleural

umerous radiographic patterns are consistent with pneumonia and a multitude of other
pathologic processes.[2]A synthesis of all available information and careful consideration of the
differential diagnosis is essential to establishing the diagnosis, although empiric antimicrobial
treatment usually cannot be deferred because of an inability to prospectively exclude the
diagnosis.
Generalized hyperinflation with patchy infiltrates suggests partial airway obstruction from
particulate or inflammatory debris, although the contribution of positive airway pressure from
respiratory support must be considered. Pneumatoceles (especially with air-fluid interfaces)
and prominent pleural fluid collections also support the presence of infectious processes.
Chest radiographs of infants infected with organisms in utero or via the maternal genital tract
may demonstrate a ground-glass appearance and air bronchograms. Diffuse, relatively
homogeneous infiltrates that resemble the ground-glass pattern of respiratory distress
syndrome are suggestive of a hematogenous process, although aspiration of infected fluid with
subsequent seeding of the bloodstream cannot be excluded.
Patchy, irregular densities that obscure normal margins are suggestive of antepartum or
intrapartum aspiration, especially if such opacities are distant from the hilus. Patchy,
irregular densities in dependent areas that are more prominent on the right side are more
consistent with postnatal aspiration.
Except for patients with sickle cell disease, a significant pleural effusion usually indicates a
bacterial etiology. Although these patterns are typical, the etiology cannot be reliably
identified based solely on chest radiography findings. Other typical findings of bacterial
pneumonia include a lobar consolidation with air bronchograms occasionally accompanied by a
pleural effusion. Lobar consolidation and pleural effusion are seen in the images below.

Single or multiple prominent air bronchograms 2 or more generations beyond the mainstem bronchi reflect
dense pulmonary parenchyma (possibly an infiltrate) highlighting the air-filled conducting airways. A welldefined, dense lobar infiltrate with bulging margins is unusual. Lateral or oblique projections may help to
better define structures whose location and significance are unclear.
Although unilateral and/or lobar infiltrates are often seen in bacterial pneumonia (see the image below),
several studies have found that the pattern of radiologic features cannot accurately distinguish a bacterial
etiology from a viral etiology.[3, 4]
In contrast, a large Finnish series concluded that an alveolar (equivalent to a lobar) infiltrate is an insensitive,
but reasonably specific, indication of bacterial infection.[5]Thus, a lobar infiltrate can be seen with viral
infections, foreign body aspirations, and mucous plugging that results in atelectasis. Furthermore, pleural
effusions, although usually parapneumonic (80%), may be observed in numerous disease processes.
At either extreme (from typical bronchiolitis with scattered infiltrates to dense lobar pneumonia with a large
pleural effusion), the level of diagnostic certainty provided by radiologic findings increases.
Pneumatoceles and abscesses are less commonly found but may indicate aStaphylococcus aureus,gramnegative, or complicated pneumococcal pneumonia. Round pneumonia on chest radiographs should raise
suspicion that the disease has a bacterial etiology, and particularly, thatStreptococcus pneumoniaeorS
aureusis the causative agent. Round pneumonia is shown in the radiograph below.

The radiographic appearance ofMycoplasmainfection varies. Early in the infection, the pattern tends to be
reticular and interstitial; as the infection progresses, patchy and segmental areas of consolidation are noted,
along with hilar adenopathy and pleural effusions.
ForM pneumoniae, 3 radiographic patterns may be observed: peribronchial and perivascular interstitial
infiltrates, patchy consolidations, and homogeneous acinar consolidations like ground glass. [6]The lower fields
of the lungs are most often affected, and enlargement of the hilar glands is common.

Although no radiographic findings are specific forChlamydophilapneumoniae(formerlyChlamydia


pneumoniae),a combination of the clinical and radiographic findings strongly suggests the
diagnosis before laboratory diagnosis is available.
In a study of 125 cases ofChlamydophilapneumonia, Radkowski et al demonstrated that most
chest radiographs showed bilateral hyperexpansion and diffuse infiltrates with various
radiographic patterns, including interstitial, reticular nodular, atelectasis, coalescence, and
bronchopneumonia. Pleural effusion and lobar consolidation were not seen. [7]
Chest radiography findings in children with tuberculous pneumonia may include hilar or
mediastinal lymphadenopathy, atelectasis, or consolidation of a segment or lobe (usually right
upper lobe), pleural effusion, cavitary lesions (in adolescents and adults only), or miliary disease.
In viral pneumonias, 4 common radiographic findings are generally detected: parahilar
peribronchial infiltrates, hyperexpansion, segmental or lobar atelectasis, and hilar adenopathy. [8]
Asthma differentiation
Children with an asthma exacerbation often have abnormalities visible on chest radiographs; in
an undiagnosed asthmatic child, these abnormalities, most commonly appearing in the right
middle lobe can occur in any part of the lung, are frequently interpreted as pneumonia.
The overall presence of radiographic pneumonia among children with wheezing is uncommon.
[9]Historical and clinical factors, such as fever and hypoxia, may be used to determine the need for
chest radiography for wheezing children. Wheezing responsive to bronchodilators, a history of
atopy, a family history of asthma, and a history of cough or wheeze with exercise may be helpful in
differentiating these patients from those with pneumonia. The authors discourage the routine use
of chest radiography for children with wheezing but without fever.

MANAGEMENT

spitalizare daca
semne

clinice de pneumonie severa (tuse, geamat expirator,


nu primeste alim, cianoza, SDRA, alterarea starii de
constienta)
exista semne de sepsis
sugar < 6 luni
hipoxemie < 90-92%, PaO2 < 60 mm Hg, PaCO2 > 50 mm
Hg, cianoza
MCC, fibroza chistica, displazie bronho-pulmonara, deficite
imune
pneumonie multilobulara, pleurezie (vizibile Rx)
esecul tratamentului ambulator
pneumonie cu MRSA
parinti care nu pot administra tratament corect la domiciliu

MANAGEMENT GENERAL

se recomanda evaluare dupa 48 h de la momentul


diagnosticului
deteriorare,

persistenta febra, posibile complicatii


antibioterapie extinsa
pneumonie MDR

tratament ambulator

masuri clare de administrare antitermice,


hidratare corespunzatoare,
recunoasterea semnelor de agravare a starii copilului
complianta parintilor la tratamentul prescris

COMPLICATII ALE PC

pulmonare
pleurezie

sau empiem pleural


pneumotorax
abces pulmonar
fistula bronho-pleurala
pneumonie necrotica
insuf respiratorie acuta

metastatice
meningita
abces

SNC
pericardita/endocardita
osteomielita
artrita septica

THE MANAGEMENT OF COMMUNITY-ACQUIRED


PNEUMONIA IN INFANTS AND CHILDREN OLDER
THAN 3 MONTHS OF AGE: CLINICAL PRACTICE
GUIDELINES BY THE PEDIATRIC INFECTIOUS
DISEASES SOCIETY AND THE INFECTIOUS
DISEASES SOCIETY OF AMERICA

I.
II.

III.

IV.
V.

VI.
VII.

When does a child or infant with CAP require


hospitalization?
When should a child with CAP be admitted to an
intensive care unit (ICU) or a unit with continuous
cardiorespiratory monitoring?
What diagnostic laboratory and imaging tests should
be used in a child with suspected CAP in an outpatient
or inpatient setting?
What additional diagnostic tests should be used in a
child with severe or life-threatening CAP?
Which anti-infective therapy should be provided to a
child with suspected CAP in both outpatient and
inpatient settings?
How can resistance to antimicrobials be minimized?
What is the appropriate duration of antimicrobial
therapy for CAP?

ADJUNCTIVE SURGICAL AND NON


ANTI-INFECTIVE THERAPY FOR
PEDIATRIC CAP
IX.
X.
XI.
XII.
XIII.

XIV.
XV.

How should a parapneumonic effusion be identified?


What factors are important in determining whether
drainage of the parapneumonic effusion is required?
What laboratory testing should be performed on pleural
fluid?
What are the drainage options for parapneumonic
effusions?
When should VATS or open decortication be considered
in patients who have had chest tube drainage, with or
without fibrinolytic therapy?
When should a chest tube be removed either after
primary drainage or VATS?
What antibiotic therapy and duration is indicated for the
treatment of parapneumonic effusion/empyema?

MANAGEMENT OF THE CHILD NOT


RESPONDING TO TREATMENT
What is the appropriate management of a child
who is not responding to treatment for CAP?
XVII. How should nonresponders with pulmonary
abscess or necrotizing pneumonia be managed?
XVI.

DISCHARGE CRITERIA
XVIII.When
XIX.

can a hospitalized child with CAP be


safely discharged?
When is parenteral outpatient therapy
indicated, in contrast to oral step-down
therapy?

PREVENTION
XX.

Can pediatric CAP be prevented?

TRATAMENTUL PC DE ETIOL BACT

Streptococ cu CMI penicilina 2/ml

ampicilina 150-200 mg/kg/zi la 6h sau


penicilina 200k-250k/kg/zi la 4-6 h
alternativa iv: ceftriaxona 50-100 mg/kg/zi la 12-24 h
sau cefotaxim 150 mg/kg/zi la 8 h, clindamicina 40
mg/kg/zi la 6-8 h sau vancomicina 40-60 mg/kg/zi la
6-8 h
po: amoxicilina 90 mg/kg/zi in 2 doze sau 45
mg/kg/zi in 3 doze
alternativa po: cefpodoxima, cefuroxima, cefprozil,
levofloxacin 16-20 mg/kg/zi in 2 doze (6 l -5 ani) si 810 mg/kg/zi doza unica (5-16 ani), max 750 mg/zi sau
linezolid 30 mg/kg/zi in 3 doze (<12 ani) si 20
mg/kg/zi in 2 doze(>12 ani)
iv:

TRATAMENTUL PC DE ETIOL BACT

Streptococ rezistent la penicilina

ceftriaxona 100 mg/kg/zi la 12-24 h


alternativa iv: ampicilina 300-400 mg/kg/zi la 6 h sau
levofloxacin 16-20 mg/kg/zi la 12 h (6l -5 ani) si 8-10
mg/kg/zi o data pe zi (5-16 ani) sau linezolid 30
mg/kg/zi la 8 h(<12 ani) si 20 mg/kg/zi la 12 h(>12
ani), clindamicina 40 mg/kg/zi la 6-8 h sau
vancomicina 40-60 mg/kg/zi la 6-8 h
po: levofloxacin 16-20 mg/kg zi 2 doze (6l -5 ani) si
8-10 mg/kg/zi doza unica (5-16 ani) sau linezolid 30
mg/kg/zi in 3 doze (<12 ani) si 20 mg/kg/zi in 2 doze
(>12 ani)
alternativa po: clindamicina 30-40 mg/kg/zi in 3 doze
iv:

TRATAMENTUL PC DE ETIOL BACT

Streptococ de grup A

penicilina 100k-250k U/kg/zi la 4-6 h sau


ampicilina 200 mg/kg/zi la 6 h
alternativa iv: ceftriaxona 50-100 mg/kg/zi la 12-24 h
sau cefotaxim 150 mg/kg/zi la 8 h, clindamicina 40
mg/kg/zi la 6-8 h sau vancomicina 40-60 mg/kg/zi la
6-8 h
po: amoxicilina 50-75 mg/kg/zi 2 doze sau
penicilina V 50-75 mg/kg/zi 3-4 doze
alternativa po: clindamicina 30-40 mg/k/zi 3 doze
iv:

TRATAMENTUL PC DE ETIOL BACT

Stafilococ auriu cu SSB la meticilina

cefazolin 150 mg/kg/zi la 8 h sau oxacilina 150-200 mg/kg/zi


la 6-8 h
alternativa iv: clindamicina 40 mg/kg/zi la 6-8 h sau vanomicina
40-60 mg/kg/zi la 6-8 h
po: cefalexina 75-100 mg/kg/zi in 3-4 doze
alternativa po: clindamicina 30-40 mg/kg/zi in 3-4 doze
iv:

MRSA

vancomicina 40-60 mg/kg/zi la 6-8 h sau clindamicina 40


mg/kg/zi la 6-8 h
alternativa iv: linezolid 30 mg/kg/zi la 8h (<12 ani) si 20 mg/kg/zi
la 12 h(>12 ani)
po: clindamicina 30-40 mg/kg/zi in 3-4 doze
alternativa po: linezolid 30 mg/kg/zi in 3 doze (<12 ani) si 20
mg/kg/zi in 2 doze (>12 ani)
iv:

TRATAMENTUL PC DE ETIOL BACT

Stafilococ auriu rezistent la meticilina si clindamicina

vancomicina 40-60 mg/kg/zi la 6-8 h


alternativa iv: linezolid 30 mg/kg/zi la 8h (<12 ani) si 20
mg/kg/zi la 12 h (>12 ani)
po: linezolid 30 mg/kg/zi in 3 doze (<12 ani) si 20 mg/kg/zi in
2 doze (>12 ani)
alternativa po: nu exista, doar iv
iv:

TRATAMENTUL PC DE ETIOL BACT

H. influenzae

ampicilina 150-200 mg/kg/zi la 6 h (nu prod lact) sau


ceftriaxona 50-100 mg/kg/zi la 12-24 h (prod lact) sau
cefotaxima 150 mg/kg/zi la 8 h
alternativa iv: ciprofloxacin 30 mg/kg/zi la 12 h sau levofloxacin
16-20 mg/kg/zi la 12 h (6l -5 ani) si 8-10 mg/kg/zi o data pe zi (516 ani)
po: amoxicilina 75-100 mg/kg/zi (nu prod lact) sau amoxiclavulanat (amoxicilina 45 mg/kg/zi in 3 doze sau 90 mg/kg/zi
in 2 doze) (prod lact)
alternativa po: cefdinir, cefpdoxima sau ceftibuten
iv:

TRATAMENTUL PC DE ETIOL BACT

M. pneumoniae, C. trachomatis/pneumoniae

azitromicina 10 mg/kg/zi in z1, z2, ulterior po


alternativa iv: lactobionat de eritromicina 20 mg/kg/zi
la 6 h sau levofloxacin 16-20 mg/kg/zi la 12 h (6l -5
ani) si 8-10 mg/kg/zi o data pe zi (5-16 ani)
po: azitromicina 10 mg/kg/zi in z1, apoi 5 mg/kg/zi
din z2z5
alternativa po: claritromicina 15 mg/kg/zi in 2 doze
sau eritromicina 40 mg/kg/zi in 4 doze, > 7 ani
doxiciclina 2-4 mg/kg/zi in 2 doze, adolescenti
levofloxacin 500 mg/zi doza unica sau moxifloxacin
400 mg/ zi doza unica
iv:

TERAPIA ANTIVIRALA

Oseltamivir
trat:

60 mg/zi (<15 kg), 90 mg/zi (15-23 kg), 120 mg/zi (23-40 kg), 150 mg/zi (>40
kg) 2 doze/zi
profilaxie : 30 mg/zi (<15 kg), 45 mg/zi (15-23 kg), 60 mg/zi (23-40 kg), 75 mg/zi
(>40 kg)

Zanamivir

tratament:

2 inhalatii x 2/zi, 5 zile (10 mg/doza, > 7 ani)


profilaxie : 2 inhalatii o data/zi, 10 zile (10 mg/doza, > 7 ani)

Amantadina
tratament:

5-8 mg/kg/zi 1-2 doze, max 150 mg/zi (1-9 ani), 200 mg/zi in 2 doze (9-

12 ani)
profilaxie :5-8 mg/kg/zi 1-2 doze, max 150 mg/zi (1-9 ani), 200 mg/zi in 2 doze (9-12
ani)

Rimantadina
trat:

6.6 mg/kg/zi (max 150 mg/zi) in 2 doze (1-9 ani), 200 mg/kg/zi 1 2 doze (>10

ani)
profilaxie: 5 mg/kg/zi doza unica (1-9 ani), max 150 mg/zi, 200 mg/kg/zi 1-2 doze
(>10 ani)

Terapie empirica pt pneumonia comunitara la copii


(ambulator)
suspiciune
pneumonie
bacteriana
< 5 ani:
amoxicilina po 90
mg/kg/zi in 2 doze
alt: amoxiclavulanat po

>5 ani: amoxicilina po 90


mg/kg/zi in 2 doze, max 4 g/zi
macrolid (?pneum atipica)
alt: amoxi-clavulanat po

suspiciune
pneumonie atipica
<5 ani: azitromicina po 10
mg/kg in z1, ulterior 5 mg/kg/zi
in DU z2z5
alt: claritromicina po 15
mg/kg/zi in 2 doze 7-14 zile sau
eritromicina po 40 mg/kg/zi in 4
doze

>5 ani: azitromicina po 10


mg/kg in z1, ulterior 5
mg/kg/zi in DU z2z5
( max 500 mg in z1 si max
250 mg in z2z5)
alt: claritromicina po 15
mg/kg/zi in 2 doze (max 1
g/zi), eritromicina sau
doxiciclina (>7 ani)

suspiciune
pneumonie cu
virus gripal

< 5 ani :
Oseltamivir

> 5 ani:
Oseltamivir sau
Zanamivir (> 7
ani)
alt: peramivir,
oseltamivir,
zanamivir in
studiu clinic pt
copii

TERAPIE EMPIRICA PT PNEUMONIA


COMUNITARA LA COPII SPITALIZATI

suspiciune pneumonie bacteriana (pacient cu


imunizare completa, + Hib si pneumococ)
ampicilina

sau penicilina G
alt: ceftriaxona sau cefotaxim +
vancomicina/clindamicina pt suspiciune MRSA

suspiciune pneumonie bacteriana (pacient cu


imunizare incompleta, - Hib si pneumococ)
ceftriaxona

sau cefotaxim +
vancomicina/clindamicina pt susp MRSA
alt: levofloxacina + vancomicina/clindamicina

TERAPIE EMPIRICA PT PNEUMONIA


COMUNITARA LA COPII SPITALIZATI

suspiciune pneumonie bacteriana atipica (pacient cu


imunizare completa, + Hib si pneumococ)
azitromicina

+ -lactamice (pana la confirmarea dg)


alt: claritromicina sau eritromicina, doxiciclina (>7 ani) sau
levofloxacina (adolescenti, intoleranta la macrolide)

suspiciune pneumonie bacteriana atipica (pacient cu


imunizare incompleta, - Hib si pneumococ)
azitromicina

+ -lactamice (pana la confirmarea dg)


alt: claritromicina sau eritromicina, doxiciclina (>7 ani) sau
levofloxacina (adolescenti, intoleranta la macrolide)

VA MULTUMESC!