PEDIATRICS COMMUNITY

ACQUIRED PNEUMONIA CASE

 
STUDY
CPC CASE ENDORSEMENT
BY: MANDAL,AJAY KUMAR
CLERKSHIP STUDENT
GULLAS COLLEGE OF MEDICINE
 GENERAL DATA
● C.Z.M.V.
● 2 YEARS OLD
● MALE
● FILIPINO
● CATHOLIC
● MARIBOJOC, BOHOL
● DATE OF ADMISSION: 01/08/2022

Informant:Grandmother
Reliability: 80%
CHIEF COMPLAINT

FEVER
 HISTORY OF PRESENT ILLNESS
3 day prior to admission
Patient had onset of fever (38.0°C) that started abruptly. The patient condition was relieved
temporarily when he was given paracetamol (125 mg/5 ml), 5 ml every 4 hours(AD=10
mg/kg/dose) at primary health care. Fever was continuous with no associated symptoms (i.E.
Cough, difficulty of breathing) no consult done.

On day of admission
Persistence of fever and this time associated with decrease in apatite and activity. No other
symptoms noted, persistence of fever prompted the patient to seek consult in GCGMH and got
admitted.
 REVIEW OF SYSTEM
General Skin Thorax and lungs
(+) fever HEENT CVS
(-) jaundice (-) cold
(+) Decrease (-) rash (-) headache (-) Palpitations
activity (-) epistaxis (-) cough (-) chest pain
(-) pigmentation
(+) Irritability (-) pruritus (-) Ear and Nasal (+)tachypnea
(+) Loss of discharges
appetite
 

Endocrine Hema
Gastrointestinal Genitourinary
(-) cold and Musculoskeletal (-) pallor
(-) Abdominal pain (-) hematuria (-) limitation of motion (-) easy
heat intolerance
(-) vomiting (-) dysuria (-) stiffness bruisability
(-) hematochezia (-) limping
/melena Nervous/ Behavioral
(-) Tremors
(-) sleep problems
(-) convulsions
(-) Seizures
 BIRTH AND METERNAL HISTORY
(NATAL, PRENATAL AND PERINATAL)
PERINATAL HISTORY NATAL HISTORY NEONATAL HISTORY
● Born to a 28 year old G2P2 ● Delivered full term by ● Good cry, good activity
(2002) mother Normal spontaneous
delivery in Health ● Birth rank: 2nd
● Non-smoker, non-alcoholic center, MARIBOJOC,
beverage drinker BOHOL ● Birthweight: 2.5 kg
● Birth length: Unrecalled
● No history of bleeding, ● Cephalic
infections and radiation ● NO COMPLICATIONS ● Pediatric Aging: 37
exposure DURING DELIVERY weeks

● Duration of labor 5 Hrs. ● No resuscitation

● No complications during
birth
 GROWTH AND DEVELOPMENTAL HISTORY

 APPROPRIATE FOR AGE

 3 months – no head lag
 7 months – crawling
 1 yrs old – walking, saying mama papa
 18 months - run
 NUTRITIONAL/ FEEDING HISTORY

● Purely breastfed up to 6 month of age

● At 6th month of age, solid foods were introduced (i.e., Lugaw,

cereals), which patient tolerated

● Mixed feeding (breast milk + solid foods) until present

● He eats 3 times a day and diet includes mostly rice, fish and
vegetables
 IMMUNIZATION HISTORY
Fully vaccinated for the age, as reported by informant
 PAST MEDICAL HISTORY

• No any surgeries or hospitalization done.

 FAMILY HISTORY
• Mother - 29 yrs/ housewife/ college level/ well
• Father - 31 yrs/ construction worker/ college level/well
• Paternal side – no known diseases

• Maternal side – no known diseases

• Has older brother 4 yrs old suffer from unspecified allergies (skin rashes)
 PERSONAL AND SOCIAL HISTORY

• Patient likes to watch cartoons videos in day time.

• The patient plays with his brother and neighbor's child.

 ENVIROMENTAL HISTORY

• They have 3 rooms in the house, where 6 people of family live and have a good
water supply and living conditions.
• They maintain cleanliness, coconut trees surround the family’s house.
• And no standing water present
 PHYSICAL EXAMINATION
VITAL SIGNS
TEMP: 38.9 °C
BP: 90/60 MMHG
HR: 149 BPM
RR: 48 BREATHS/M
SPO2: 99% AT ROOM AIR
ANTHROPOMETRIC MEASUREMENT:
• WEIGHT:11.7 KG
• HEIGHT: 90 CM
• HEAD CIRCUMFERENCE: 49CM
 PHYSICAL EXAMINATION

ANTHROPOMETRIC
MEASUREMENT:
A. WEIGHT FOR AGE:11.7 KG
(Z score of weight for age fall
between 0 to below -1)

Normal for age

 PHYSICAL EXAMINATION
ANTHROPOMETRIC
MEASUREMENT:
B. Length(height) for age: 90 cm
(Z score of height for age fall between 0
to 2 )
Height is normal for age
 PHYSICAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT:
C. WEIGHT-FOR-LENGTH/HEIGHT
(Z score of weight for length fall between 0
to below -1)
Its normal for age.
 PHYSICAL EXAMINATION
ANTHROPOMETRIC
MEASUREMENT:
D. HEAD CIRCUMFERENCE FOR AGE: 49 CM
 (Z score for head circumference fall
between≥ -2 to ≤ +2)

Normal for age.

 PHYSICAL EXAMINATION
General survey:
• Patient is awake, (+) irritability, not in respiratory distress

Skin
• Warm to touch, moist. No rash, petechiae, cyanosis or clubbing.

HEENT
• Normocephalic/atraumatic head, hair with normal texture
• Pinkish palpebral conjunctivae, anicteric sclerae
• Mobile pinna without masses or tenderness, no discharge
• (-) Lymphadenopathy, (-) thyroid mass
 PHYSICAL EXAMINATION
Chest/lungs
• Inspection: thorax is symmetrical with equal chest expansion, no scar, no mass,
intercostals and subcostal retractions, tachypneic
• Palpation: no tenderness, masses or lesions
• Percussion: resonant both lung fields
• Auscultation: (+) rales, both lungs
Cardiovascular
• Inspection: AP, no lesions
• Palpation: apex beat at the 4th ICS LMCL; (-) thrills/heaves
• Auscultation: tachycardic, DHS, no murmurs, no bruits on carotid arteries
 PHYSICAL EXAMINATION
Abdomen
• Inspection: flat, no scars or lesions
• Auscultation: normoactive bowel sounds
• Percussion: tympanitic all over
• Palpation: soft, non-tender, no scar and mass, no organomegaly, liver edge not palpable

Extremities
• No deformities, no clubbing, no cyanosis or edema, strong pulses
• CRT <2 sec

Genitourinary:

• Grossly male, no skin lesions

 PHYSICAL EXAMINATION
Neurological
Mental status: conscious and well oriented to person and place able to recall
father’s name.
Cranial nerves
• CN I: smell intact
• CN II: PERRLA
• CN III, IV, VI: intact extraocular movements
• CN V: intact corneal reflexes, intact facial sensation of both side, normal jaw
movements
• CN VII: symmetrical facial expression, closes eyes voluntarily
• CN VIII: startles to clap and loud noises
 PHYSICAL EXAMINATION
• CN IX, X: positive gag reflex, able to swallow milk with good suck, soft palate
movement is noticeable.
• Cn xi: not done
• CN XII; tongue midline
Motor system
(-) Asymmetry, weakness, clumsiness. Normal muscle bulk and tone throughout.
Reflexes
 REFLEXES Biceps Triceps knee Ankle

R +2 +2 +2 +2

L +2 +2 +2 +2

Meningeal signs (negative brudzinki’s and kernig’s sign) noted.

 SALIENT FEATURES
2 yrs. old, male
(+) Irritability
Loss of appetite
(+) Fever for 3 days
On PE (+) rales , tachycardic
Intercostals and subcostal retractions
Tachypneic
 DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS RULE IN RULE OUT
A. Covid-19 History of fever (-) Cough
Tachypnea (-) Sore throat
Rapid progression of symptoms No known close contact
Cannot be completely rule out

B. Bronchiolitis (+) Fever (-) Vomiting

(+) Loss of appetite (-) Nasal flaring and congestion
(+) Rales (-) Wheezing
(+) Tachycardia Common in younger than 2 years of age
(+)Retraction
(+)tachypneic
C. Pneumonia, viral (+) 2yrs old patient (-) Cough
(+) Irritability (-) Rhinorrhea
(+) Rales (-)Fever >38.5°C
(+) most common in pCAP (4month- 4 yrs) Cannot totally rule out
(+)Retraction
(+)Tachypneic
D. Pneumonia, bacterial (+) Irritability (-) Vomiting
(+) Rales (-) Diarrhea
(+) Fever>38.5°C (-) wheezing
(+)Retraction Most common in 3weeks to 3months of age
Cannot totally rule out
 PRIMARY IMPRESSION
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA, CATEGORY C

BASIS:
(+) IRRITABILITY
LOSS OF APPETITE
(+) FEVER FOR 3 DAYS
ON PE (+) RALES , TACHYCARDIC
INTERCOSTALS AND SUBCOSTAL RETRACTIONS
TACHYPNEIC
COURSE IN THE WARDS
 COURSE IN THE WARDS
AT THE ER (JANUARY 8, 2022)
Subjective Objective Assessment Plan

● (+) Fever General survey: Awake, irritable, not in ● PCAP-C ● Admit patient to ISO 5
● (+) Coryza respiratory distress ● T/C Dengue ● Secure consent to care
● (-) vomiting Vital Signs: fever ● Diet for age
● (-) abdominal T: 38.5 oC without ● Start IVF: D5LR 1L at 45 cc/hr
pain HR: 120 bpm warning ● Diagnostics:
● (-) cough RR: 48 cpm signs ○ CBC
● (+) decreased O2 Sat: 99% RA ○ Dengue Duo
appetite Weight: 11.7 kg ○ Chest X-ray
○ Procalcitonin
SKIN: warm, dry, good skin turgor ○ CRP
HEENT: anicteric sclerae, pink palpebral ○ Blood C/S
conjunctivae, no alar flaring, pink moist lips ○ RAT, NPS/OPS
C/L: equal chest expansion, (+) subcostal & ● Therapeutics:
intercostal retractions, resonant, (+) rales on ○ Penicillin G 600,000 units every 6 hours (AD:
bilateral lung fields, no wheeze 205,000 mkD)
CVS: adynamic precordium, distinct heart ○ Paracetamol 140 mg IVTT now, then every 4
sounds, no murmur hours for temp >38 C (AD: 12 mkD)
ABDOMEN: Flat, normoactive bowel sounds, ● Monitoring:
tympanitic, soft, non-tender ○ Vital signs every 4 hours
EXTREMITIES: strong peripheral pulses, ○ I & O every shift
CRT <2 secs ○ Refer accordingly
 SERUM CHEMISTRY & SEROLOGY
JANUARY 8, 2022

Procalcitonin 5.11 ng/ml (0-0.50)

CRP 92.90 mg/L

SARS-CoV-2 antigen test Negative

(immunochromatography)

Dengue NS1 Antigen Positive

Dengue IgM Negative

Dengue IgG Negative

 LABORATORY RESULTS
JANUARY 8, 2022
COMPLETE BLOOD COUNT
WBC 38.5 x10^9/L

RBC 4.32 x10^12/L

Hgb 10.60 g/dL

Hct 33.1 %

Plt Count 304 x10^9/L

Neutrophils 87 %

Lymphocytes 7%

Monocytes 6%

Eosinophils 0%

Basophils 0%
JANUARY 8, 2022: CHEST X-RAY PA VIEW

● Trachea in midline
● No bony deformities
● Distinct cardiac borders
● Sharp costophrenic angles
● Well-defined hemidiaphragms
● No effusion
● Densities on both inner lung zones
● Gastric bubble not well defined

Impression: pneumonia both lungs

 COURSE IN THE WARDS
HOSPITAL DAY 1 (JANUARY 9, 2022)
Subjective Objective Assessment Plan

● (+) cough General survey: awake, not in PCAP-C ● Trans out to Pedia Ward under Pulmo Service
● (+) fever respiratory distress ● IVF shift to heplock
● Poor appetite Vital Signs:
● (-) vomiting T: 40.3oC ● Therapeutics:
HR: 120 bpm ○ Continue Penicillin G
RR: 30 cpm ○ Zinc Sulfate syrup 55 mg/5 ml OD PO
O2 Sat: 96% RA ○ Give Paracetamol 140 mg IVTT PRN every 6 hours
for temp >/= 38 C (AD: 12 mkD)
SKIN: warm, fair, good skin turgor ○ Salbutamol nebulizer now x 3 doses every 15
HEENT: anicteric sclerae, pink minutes
palpebral conjunctivae, no alar ○ Hook to O2 via nasal cannula at 2 LPM
flaring, pink moist lips
C/L: equal chest expansion, no ● Monitoring:
retractions, resonant, (+) rales ○ Vital signs every 4 hours
bilateral lung fields, (+) wheeze ○ I & O every shift
CVS: adynamic precordium, ○ Refer accordingly
distinct heart sounds, no murmur
ABDOMEN: Flat, NABS,
tympanitic, soft, non-tender
EXTREMITIES: strong peripheral
pulses, CRT <2 secs
 COURSE IN THE WARDS
HOSPITAL DAY 2 (JANUARY 10, 2022)
Subjective Objective Assessment Plan

● (+) febrile episodes General survey: Awake, irritable, not PCAP-C ● Diet as tolerated
● (-) vomiting in respiratory distress ● Trial room air and note if tolerated
● (-) cough
● (-) coryza Vital Signs: ● Diagnostic:
T: 36.5 C ○ Repeat CBC
HR: 109 bpm
RR: 28 cpm ● Therapeutics:
O2 Sat: 99% on 2 LPM NC ○ Continue Penicillin G D2
○ Continue Zinc Sulfate syrup
SKIN: warm, good skin turgor ● Monitoring:
HEENT: anicteric sclerae, pink ○ Vital signs every 4 hours
palpebral conjunctiva, (-) alar flaring, ○ I & O every shift
pink moist lips ○ Refer accordingly
C/L: equal chest expansion, no
retractions, resonant, (-) rales, (-)
wheeze
CVS: adynamic precordium, distinct
heart sounds, no murmur
ABDOMEN: Flat, NABS, tympanitic,
soft, non-tender
EXTREMITIES: strong peripheral
pulses, CRT <2 secs
 LABORATORY RESULTS
JANUARY 10, 2022

COMPLETE BLOOD COUNT

1/8/22 1/10/22 1/8/22 1/10/22

WBC 38.5 x10^9/L 22.6 x10^9/L Plt Count 304 x10^9/L 315 x10^9/L

RBC 4.32 x10^12/L 4.63 x10^12/L

Neutrophils 87 % 74%
Hgb 10.60 g/dL 11.10 g/dL

Hct 33.1 % 34.3% Lymphocytes 7% 18%

Monocytes 6% 7%

Eosinophils 0% 1%

Basophils 0% 0%
 COURSE IN THE WARDS
HOSPITAL DAY 3 (JANUARY 11, 2022)
Subjective Objective Assessment Plan

● (+) febrile General survey: irritable, NIRD ● Diet as tolerated

episodes Vital Signs: PCAP-C ● On room air
● Decreased T: 36.4 C
appetite HR: 92 bpm ● Diagnostics:
● (-) cough RR: 24 cpm ○ Repeat Chest X-ray
● (-) vomiting O2 Sat: 97% room air ○ Repeat CBC, procalcitonin, CRP
● (-) abdominal pain ○ Urinalysis
SKIN: warm, good skin turgor ○ Blood C/S
HEENT: anicteric sclerae, pink ○ Serum Na, K, iCa, i Mg, Cl
palpebral conjunctiva, (-) alar flaring,
pink moist lips ● Therapeutics:
C/L: equal chest expansion, no ○ Continue Penicillin G D3
retractions, resonant, (-) rales, (-) ○ Continue Zinc Sulfate syrup
wheeze
CVS: adynamic precordium, distinct ● Monitoring:
heart sounds, no murmur ○ Vital signs every 4 hours
ABDOMEN: Flat, NABS, tympanitic, ○ I & O every shift
soft, non-tender ○ Refer accordingly
EXTREMITIES: strong peripheral
pulses, CRT <2 secs
JANUARY 11, 2022LABORATORY RESULTS

COMPLETE BLOOD COUNT

1/8/22 1/10/22 1/11/22
1/8/22 1/10/22 1/11/10
Plt Count 304 x10^9/L 315 x10^9/L 320 x10^9/L
WBC 38.5 x10^9/L 22.6 x10^9/L 12.6 x10^9/L

RBC 4.32 x10^12/L 4.63 x10^12/L 4.83 x10^12/L Neutrophils 87 % 74% 53%

Hgb 10.60 g/dL 11.10 g/dL 11.60 g/dL Lymphocytes 7% 18% 32%

Hct 33.1 % 34.3% 35.8%

Monocytes 6% 7% 10%

Eosinophils 0% 1% 5%

Basophils 0% 0% 0%
 SERUM CHEMISTRY
JANUARY 11, 2022

Chloride 107 mmol/L

Ionized Magnesium 0.45 mg/L
Sodium 137.4 mmol/L
Potassium 4.10 mmol/L
Ionized Calcium 1.16 mmol/L
Ionized Magnesium 0.45 mmol/L
JANUARY 11, 2022: CHEST X-RAY COMPARATIVE

Findings are similar from previous image

taken on January 8, 2022 except for
resolution of inner lung zone densities.

Impression: resolution of pneumonia

 COURSE IN THE WARDS
HOSPITAL DAY 4 (JANUARY 12, 2022)
Subjective Objective Assessment Plan

● (-) febrile General survey: Awake, comfortable, not ● Diet as tolerated

episodes in respiratory distress PCAP-C resolving ● Remove heplock
● (-) vomiting ● On room air
● (-) dyspnea Vital Signs: ● Increase fluid intake
● (-) abdominal T: 37.2 C
pain HR: 120 bpm ● Diagnostics:
RR: 24 cpm ○ Urinalysis
O2 sat: 98%
● Therapeutics:
SKIN: warm, good skin turgor ○ Shift Penicillin G to Amoxicillin suspension
HEENT: anicteric sclerae, pink palpebral 250 mg/5ml, 4 ml TID (AD: 50 mg/kg/day)
conjunctiva, (-) alar flaring, pink moist
lips ● Monitoring:
C/L: equal chest expansion, no ○ CBS monitoring every 24 hours
retractions, resonant, (-) rales, (-) wheeze ○ Vital signs every 4 hours
CVS: adynamic precordium, distinct heart ○ I & O every shift
sounds, no murmur ○ Watch out for hypoglycemia, decreased
ABDOMEN: Flat, NABS, tympanitic, sensorium, dyspnea
soft, non-tender ○ Refer accordingly
EXTREMITIES: strong peripheral
pulses, CRT <2 secs
 URINALYSIS
JANUARY 12, 2022
Color Yellow pH 6.5

Transparency Clear Specific Gravity 1.030

Red cell 1 /uL Blood Negative

Pus cell 1 /uL Leukocyte Negative

Epithelial cell 0 /uL Glucose Negative

Bacteria 25 /uL Nitrite Negative

Protein Negative

Urobilinogen Normal

Ketones ++

Bilirubin Negative
 COURSE IN THE WARDS
HOSPITAL DAY 5 (JANUARY 13, 2022)
Subjective Objective Assessment Plan

● (-) febrile episodes General survey: Awake, comfortable, not in ● Diet As tolerated
● (-) vomiting respiratory distress PCAP-C resolving ● On room air
● (-) dyspnea ● Increase fluid intake
● (-) abdominal pain Vital Signs:
● (-) decreased T: 36.8 C ● Diagnostics:
sensorium HR: 104 bpm ○ HbA1c
RR: 20 cpm
O2 Sat: 99% room air ● Therapeutics:
CBS: 91 mg/dl ○ Continue amoxicillin suspension
SKIN: warm, fair, good skin turgor ● Monitoring:
HEENT: anicteric sclerae, pink palpebral ○ Vital signs every 4 hours
conjunctiva, no alar flaring, moist oral mucosa ○ I & O every shift
C/L: equal chest expansion, no retractions, ○ Continue CBS monitoring every 24
resonant, no rales, no wheeze hours
CVS: adynamic precordium, distinct heart ○ Watch out for hypoglycemia,
sounds, no murmur decreased sensorium, dyspnea
ABDOMEN: Flat, NABS, tympanitic, soft, non- ○ Refer accordingly
tender
EXTREMITIES: strong peripheral pulses, CRT
<2 secs
 COURSE IN THE WARDS
HOSPITAL DAY 5 (JANUARY 14, 2022)
Subjective Objective Assessment Plan

● (-) febrile General survey: Awake, comfortable, not in PCAP-C resolved ● May go home
episodes respiratory distress ● Take home medications:
● (-) vomiting ○ Amoxicillin 250 mg/5 ml, give 4
● (-) dyspnea Vital Signs: ml 3x a day for 5 more days
● (-) abdominal T: 36.7 C ○ Zinc Sulfate 55 mg/5 ml, give 5
pain HR: 110 bpm ml once a day for 3 months
● (-) decreased RR: 30 cpm ● Increase fluid intake
sensorium O2 Sat: 99% room air ● Observe good physical and oral
CBS: 91 mg/dl hygiene
● Keep away from crowded places
SKIN: warm, fair, good skin turgor ● Follow-up immunization at LHC
HEENT: anicteric sclerae, pink palpebral ● Follow-up check-up on January 21,
conjunctiva, no alar flaring, moist oral mucosa 2022 at LHC
C/L: equal chest expansion, no retractions, ● Advised
resonant, no rales, no wheeze
CVS: adynamic precordium, distinct heart
sounds, no murmur
ABDOMEN: Flat, NABS, tympanitic, soft, non-
tender
EXTREMITIES: strong peripheral pulses, CRT
<2 secs
HbA1c: 5.3%
 CASE DISCUSSION
PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA
 EPIDEMIOLOGY

 PNEUMONIA
 Inflammation of the lung parenchyma

 Leading infectious cause of death globally among children <5

years old
45

 Closely linked to poverty, with more than 99% of pneumonia

deaths in low-middle income countries
 EPIDEMIOLOGY
•In Philippines Setting:
 Age standard death rate of 126.05/100,000 population
(2017)

 3rd leading cause of death across all ages.

46

 In Filipino children below 5 years old, it is the most

common cause of death - 14% of all causes of mortality
 ETIOLOGY
 Most cases are caused by microorganisms, but there are also non-infectious causes
– Aspiration of food and gastric acid, hypersensitivity reaction, drug-induced

 Streptococcus pneumoniae-Most common bacterial pathogen in children 3 weeks-

4 years of age
 Mycoplasma pneumoniae, Chlamydophila pneumoniae - most frequent bacterial
pathogen in children 5 years and older

47
 Viral pathogens- Most common cause of lower respiratory tract infection in
children >1 month-<5 years old
 Respiratory Syncitial Virus and Rhinoviruses - most common pathogen in less
than 2 year old
 ETIOLOGY

48
 ETIOLOGY
•IN PHILIPPINE SETTING:
 In a study on viral etiology among pediatric pneumonia patients in
CAR, respiratory syncytial virus (RSV) was the most prevalent (93
out of 106 positive swab results)

 Other important etiologies:

 Measles
49
 Covid-19
 ETIOLOGY
•RISK FACTORS:
 Not exclusively breastfed - mixed feeding at 1 month old
 Undernutrition
 Zinc deficiency
 Exposure to indoor air pollution - father who is a smoker
 Low birthweight-2100 grams
 Socioeconomic factors
50

 Comorbidities
 PATHOGENESIS
 Lower respiratory tract defense mechanisms
 Mucociliary clearance
 Macrophages
 Secretory IgA
 Coughing reflex
 Pneumonia results from disruption of a complex lower respiratory ecosystem that is
the site of dynamic interactions between potential pneumonia pathogens, resident
microbial communities, host51 immune defenses.

 Viral pneumonia-Results from spread of infection in airways accompanied by direct

injury of respiratory epithelium resulting in airway obstruction, Which further
 PATHOGENESIS
 Bacterial pneumonia-Occurs when respiratory tract organisms colonize the
trachea and gain access to the lungs.

 M.Pneumoniae: attaches to respiratory epithelium, inhibits ciliary action leading

to cellular destruction and inflammatory response to submucosa.

 S. pneumoniae: Produces local edema that aids in the proliferation of organisms

and their spread to adjacent portion of lung resulting in focal lobar involvement

53
 PATHOGENESIS
 Group A streptococcus: Results in more diffuse lung involvement with interstitial
pneumonia causing necrosis of tracheobronchial mucosa, formation of large amount
of exudate, edema, and local hemorrhage.

 S.Aureus: Manifest as confluent bronchopneumonia, often unilateral with extensive

areas of hemorrhagic necrosis and irregular areas of cavitation of lung parenchyma
resulting in pneumatoceles, bronchopulmonary fistula.

54
 Recurrent pneumonia: 2 or more episodes in single year or 3 or more episodes
ever with radiographic clearing between occurrences.
 CLINICAL MANIFESTATIONS
 Pneumonia is frequently preceded by several days of symptoms of an
URTI( Rhinitis and cough).

 Tachypnea (most consistent manifestation)

 Other common: retractions, nasal flaring, use of accessory muscles, 

 In infants, it may be accompanied

55
by: poor feeding, abrupt onset of fever,
restlessness, apprehension and respiratory distress(Grunting, nasal
flaring, Retractions, Tachypnea, tachycardia and Cyanosis)
 CLINICAL MANIFESTATIONS
BACTERIAL
VIRAL PNEUMONIA
PNEUMONIA

CLINICAL Low grade fever of High grade fever

MANIFESTATION >37.5c-<38c >38c

Hyperinflation with
CHEST bilateral interstitial Confluent lobar
RADIOGRAPH infiltrates peribronchial consolidation
cuffing
WBC increased but not
higher than WBC in the range of
CBC 15,000-40,000/mm3,
20,000/mm3, lymphocyte Neutrophil predominance
predominance
56
DIAGNOSIS
Recommendations for PCAP C AND D:
Routine exams-
A. X-RAYS( PA or Lateral)
B. WBC Count
C. Culture and Sensitivity of:
1. Blood, Pleural fluid and Tracheal
aspirate for PCAP D
2. Sputum for older children

The following should not be Requested:

 ESR
 C-Reactive Protein
 DIAGNOSIS
POSSIBLE RADIOGRAPHY FINDING

BACTERIAL PNEUMONIA
VIRAL PNEUMONIA  Confluent lobar consolidation is
 Hyperinflation with Bilateral typically seen with pneumococcal
interstitial infiltrates pneumonia
 Peribronchial cuffing
TREATMENT
CLASSIFICATION BASED ON PAPP
 WHO WILL REQUIRE ADMISSION?
A patient initially classified as PCAP A or B but is not
responding to current treatment after 48 hours may be
admitted

A patient classified as PCAP C may be

 Admitted to the regular ward.

 Managed initially on an outpatient basis if all of the following are

not present at initial site-of-care

1. Age less than 2 years old.

2. Convulsion.

3. Chest x-ray with effusion, lung abscess, air leak or

multilobar consolidation.

4. Oxygen saturation < 95% at room air.

 WHEN IS ANTIBIOTIC RECOMMENDED?
For PCAP A or PCAP B, an antibiotic For PCAP C, empiric antibiotic may be
started if any of the following is present.
may be administered if a patient is
Elevated
Beyond 2 years of age or 1. Serum c-reactive protein [CRP]
With high grade fever without
2. Serum procalcitonin level [PCT]
wheeze
3. white blood cell [WBC] count greater
than 15,000
4. lipocalin 2 [lpc-2]
For PCAP D, a specialist may be
Alveolar consolidation on chest x-ray
consulted

Persistent high-grade fever without wheeze

EMPIRIC ANTIBIOTIC IF BACTERIAL ETIOLOGY CONSIDERED

•PCAP A or PCAP B without previous antibiotic, regardless of

immunization status against hib and S.Pneumoniae:
 Amoxicillin
- 40-50 mg/kg/day in 3 DD minimum 3 days
- May be given in 2 DD for min 5 days
 Azithromycin or clarithromycin
- 10 mg/kg/day OD 63for 3 days
- Hypersensitive to amoxicillin
- Suspicion of atypical organisms (M.Pneumoniae)
 EMPIRIC ANTIBIOTIC IF BACTERIAL ETIOLOGY
CONSIDERED
PCAP C without previous antibiotic and requires hospitalization

 Penicillin G
Completed primary immunization against hib
100,000 units/kg/day in 4DD

 Ampicillin
Not completed primary immunization against hib or immunization status unknown.
100 mg/kg/day in 4 DD

 Amoxicillin
Oral feeding tolerated
No O2 support required
40-50 mg/kg/day in 3 divided doses for 7 days
EMPIRIC ANTIBIOTIC IF BACTERIAL ETIOLOGY CONSIDERED

 PCAP D: A Specialist may be consulted

 For a patient suspected to have community-acquired

methicillin-resistant Staphylococcus aureus
 Vancomycin may be started
 A specialist may be consulted
65

 Ancillary treatment
 WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL
ETIOLOGY IS STRONGLY CONSIDERED?
 PCAP A, B, C, D
 In which non-influenza virus is the suspected, antiviral therapy may not be
beneficial

 FOR PCAP C, D
 Antiviral drug therapy for clinically suspected or laboratory-confirmed influenza
virus to reduce
 Risk of pneumonia may not be beneficial
 Time to symptom resolution may be beneficial
 Oseltamivir
1. 3-8 months old: 3mg/kg/dose BID x 5 days
2. 9-11 months old: 3.5 mg/kg/dose BID x 5 days
3. 12 months old: 30mg-75 mg BID x 5 days
 Zanamavir
1. >7 years old: 10 mg BID x 5 days
 PATIENT RESPONDING TO TREATMENT?
PCAP A or B: For PCAP D:
 Assess within 24 to 48 hours  Assess within 48-72 hrs if all
 Cough improved
parameters have significantly
 Body temperature returns to normal
improved:
 Respiratory rate
PCAP C:  Tachypnea
 Assess within 24 to 48 hours if any of  O2sat
the following improves or returns to  Body temperature
normal:  Cardiac rate
1. Respiratory rate
2. O2sat at room air
3. Body temperature
4. Cardiac rate
5. Work of breathing
 PATIENT NOT RESPONDING TO TREATMENT
PCAP A OR B
 Treatment failure: Not improving or clinically worsening within 72 hrs.
after initiating treatment
 Diagnostic evaluation to determine:
 Coexisting or other etiologic agents
 Etiologic agent resistant to current antibiotic
 Other diagnosis
 Necrotizing pneumonia
68

 Pleural effusion
 Asthma
 PATIENT NOT RESPONDING TO TREATMENT
PCAP C
 Treatment failure: not improving or clinically worsening within 48 hrs.
after initiating treatment
 Diagnostic evaluation to determine:
 Coexisting or other etiologic agents
 Etiologic agent resistant to current antibiotic
 Other diagnosis
 Acute respiratory failure 69

 Pleural effusion
 Pneumothorax, Necrotizing pneumonia
 Lung abscess, Asthma
 Pulmonary tuberculosis and Sepsis
 SWITCH THERAPY
 For PCAP C, switch from IV to oral may be beneficial to reduce length
of hospital stay provided all the following should be present:

 Current parenteral antibiotic has been given at least 24 hrs

 Afebrile within the last 8 hrs without antipyretic
 Responsive to current antibiotic
 Able to feed; without vomiting or diarrhea
70

 Without pulmonary complications

 O2sat > or = to 95% at room air
 ANCILLARY TREATMENT
PCAP A & B:
 Oral steroid with coexisting asthma
 Bronchodilator if with wheezing

PCAP C:
 Nasal prong or catheter for oxygen
 Zinc supplement
71

 Bubble CPAP
 Steroid or spirulina
 Oxygen (if < 95% at room air)
 PREVENTION
 Conjugated vaccine (PCV 10 or 13) against streptococcus
pneumoniae
 Vaccine against haemophilus influenzae type b , influenzae sp,
and diphtheria, pertussis, rubeola, and varicella.
 Breastfeeding
 Avoidance of cigarette smoke
72
 COMPLICATIONS
● Usually the result of direct spread of bacterial infection within the
thoracic cavity or bacteremia and hematologic spread

● Parapneumonic effusions and empyema

● Meningitis, endocarditis, suppurative arthritis, and osteomyelitis

73
 PROGNOSIS
● Patients with uncomplicated community-acquired bacterial pneumonia
show response to therapy, with improvement in clinical symptoms
within 48-72 hrs. of initiation of antibiotics

● Radiographic evidence of improvement lags substantially behind clinical

improvement.
● Mortality from community-acquired pneumonia in developed countries
74
is rare, and most children with pneumonia do not experience long-term
pulmonary sequelae
● Some data suggest that up to 45% of children have symptoms of asthma
 PROGNOSIS
Possibilities considered when a patient does not improve with appropriate
antibiotic therapy
1. Complications, such as pleural effusion or empyema
2. Bacterial resistance
3. Nonbacterial etiologies such as viruses or fungi and aspiration of
foreign bodies or food
4. Bronchial obstruction from endobronchial lesions, foreign body, or
mucous plugs 75

5. Pre-existing diseases
6. Other noninfectious causes
 REFERENCES
 Nelson’s textbook of pediatrics 21st edition.

 Pediatric Infectious Disease Society of the Philippines Journal Vol 22 No. 2,

pp.6-11 July-December 2021. Santos JA,A Review of Pneumonia in the
Philippines.

 3rd Philippines academy of pediatric pulmonologist in the evaluation and

management of pediatric community-acquired pneumonia(2016).
THANK YOU !!!