Approach to recurrent pneumonia in paediatric

1. APPROACH TO A CHILD WITH
RECURRENT OR PERSISTENT
PNEUMONIA
MODERATOR:DR.SAROJ KUMAR
BY:DR. KESHAV CHANDRA

2. PNEUMONIA
• Pneumonia, defined as inflammation of the lung
parenchyma.
• is the leading infectious cause of death globally
among children younger than 5 yr, accounting for
an estimated 920,000 deaths each year( 1/3 of all
under 5 death due to infection).
• In India 35,000 to 37,000 death per annum is
reported in child under 5 yr of age due to
community acquired pneumonia accounting for
13-16% of total mortality.(2010 Indian data)

4. • WHO has defined pneumonia solely based on
clinical findings, looking for :
• - respiratory rate
• - presence of chest retraction

6. ADVANTAGES OF REVISED WHO
PNEUMONIA
I. simplify the management of pneumonia at
outpatient level.
II. Increased access to antibiotic treatment
closer to home .
III. Reduce substantially the no of referrals for
hospitalisation.
IV. One oral antibiotic for the treatment of both
fast breathing pneumonia and chest
indrawing pneumonia

7. Pneumonia child needs hospitalisation
• Age < 6months
• Sickle cell anemia with acute chest syndrome.
• Multiple lobe involvement.
• Immunocompromised state.
• Toxic appearance.
• Moderate to severe respiratory distress
• Requirement of supplemental oxygen
• Dehydration
• No response to appropriate oral antibiotic therapy.
• Complicated pneumonia(pleural effusion, empyema, abscess, bronchopleural
fistula,ARDS, sepsis, extrapulmonary inf. such as meningitis, arthritis, osteomyelitis,endocarditis)

8. Etiological Agents:

9.  S. pneumoniae, H. influenzae, and S. aureus are the major causes of
hospitalization and death from bacterial pneumonia among children in
developing countries.
 The incidence of pneumonia caused by H. influenzae or S.
pneumoniae has been significantly reduced in areas where routine
immunization has been implemented.
 Viral pathogens are the most common causes of lower respiratory
tract infections in infants and children older than 1 mo but younger
than 5 yr of age.

10. Pneumonia Etiologies Grouped by Age of the Patient
Age group Frequent pathogen In decreasing order
Neonates
(<3 wk)
Group B streptococcus, Escherichia coli, other Gram-negative
bacilli, Streptococcus pneumoniae, Haemophilus influenzae (type
b,* nontypeable)
3 wk-3
mo
Respiratory syncytial virus, other respiratory viruses (rhinoviruses,
parainfluenza viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable);
if patient is afebrile, consider Chlamydia trachomatis
4 mo-4
yr
RSV, other respiratory viruses (rhinoviruses, parainfluenza viruses,
influenza viruses, human metapneumovirus, adenovirus), S.
pneumoniae, H. influenzae (type b,* nontypeable),
Mycoplasma pneumoniae, group A streptococcus
≥5 yr M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H.
influenzae (type b,* nontypeable), influenza viruses, adenovirus,
other respiratory viruses, Legionella pneumophila

11. Etiological agent of pneumonia (Indian children)
Age group Common cause Less common cause
0 -2 months •Klebsiella pneumoniae
•E.coli
•Other gram negative bacteria
•Staphylococcus
•S. pneumoniae
•H.influenzae
•Anaerobes
•Viruses- CMV,Herpes
2 months-5 yrs •S.pneumoniae
•H.influenzae
•S.aureus
•K.pneumoniae
•Chlamydia,mycoplasma
•Viruses—
•RSV, Parainfluenzae,influenza.
Adenovirus,
Pertusis, M.tuberculosis
> 5 Yrs •S.Pneumoniae
•Mycoplasma
•chlamydia
•H.Influenzae
•S.aureus
•M.tuberculosis
•Viruses---
•Adenovirus, EBV,Influenza
virus,Parainfluenza viruse

12. CLASSIFICATION
• 1. Based on Anatomical location;--
• Lobar pneumonia—consolidation of a large portion of a lobe
or of an entire lobe
• Bronchopneumonia—patchy, suppurative infammation of the
bronchi and surrounding alveoli.
• The patchy consolidation may affect one or several lobes and
is usually bilateral.
• Interstitial pneumonia-- inflammation that is within the
alveolar wall rather than the alveolar air space. The infiltrate
tends to be lymphocytes and macrophages, and hyaline
membranes may line the alveolar spaces

13. 2. Based on the origin of infection :--
• Community acquire pneumonia-
• Nosocomial pneumonia-

14. 3. Based on etiology classified into bacterial, viral ,
fungal, parasitic, atypical, parasitic, aspiration
pneumonia.
Bacterial pneumonia most often occurs when
respiratory tract organisms colonize the trachea
and subsequently gain access to the lungs.
When bacterial infection is established in the
lung parenchyma, the pathologic process varies
according to the invading organism.

15. M. pneumoniae attaches to the respiratory
epithelium, inhibits ciliary action, and leads to
cellular destruction and an inflammatory
response in the submucosa. As the infection
progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway
obstruction, with spread of infection occurring
along the bronchial tree, as is seen in viral
pneumonia.
S. pneumoniae produces local edema that aids in
the proliferation of organisms and their spread
into adjacent portions of lung, often resulting in
the characteristic focal lobar involvement.

16. Group A streptococcus lower respiratory
tract infection typically results in more diffuse lung
involvement with interstitial pneumonia with frequent pleural
involvement.
S. aureus pneumonia manifests as confluent
bronchopneumonia, which is often unilateral and
characterized by the presence of extensive areas of
hemorrhagic necrosis and irregular areas of cavitation of the
lung parenchyma, resulting in pneumatocele and empyema.

17. Viral pneumonia usually results from spread of infection
along the airways, accompanied by direct injury of the
respiratory epithelium, which results in airway obstruction
from swelling, abnormal secretions, and cellular debris. The
small caliber of airways in young infants makes such patients
particularly susceptible to severe infection.
Viral infection of the respiratory tract can also predispose to
secondary bacterial infection by disturbing normal host
defense mechanisms.
Up to 30% of patients with known viral infection, particularly
influenza viruses, may have coexisting bacterial pathogens.

18. Bacterial pneumonia
• Bacterial pneumonia is
often associated with an
elevated WBC count, in the
range of 15,000-
40,000/mm3 ,
• predominance of
polymorphonuclear
leukocytes
• Confluent lobar
consolidation
seen(pneumococcal)
• Fever is of high grade.
• Crackles +
Viral pneumonia
• In viral pneumonia, the
WBC count can be normal
or elevated but is usually
not higher than
20,000/mm3 , with a
• lymphocyte predominance.
• characterized by
hyperinflation with bilateral
interstitial infiltrates and
peribronchial cuffing.
• Low grade fever.and
associated with prodromes.
• Wheezing +

19. Recurrent pneumonia is defined as:-
 2 or more episodes in a single year
or
 3 or more episodes ever, with radiographic clearing
between occurrences.
Persistent pneumonia is defined as clinical symptoms
along with radiological abnormality to continue
beyond 1 month or more despite treatment.

20. • The incidence of ARIs in developing countries
varies from 4-8 episode per child per year.
• Almost 10% of these episodes are of
pneumonia and of these 10% are severe
pneumonia and require hospitalisation.
• The cause of recurrent pneumonia or
persistent pneumonia overlap each other;
therefore approach to such patient is similar.

21. Underlying disease for Recurrent or Persistent
Pneumonia
1.Congenital malformation:
Airways:
 Cleft palate, laryngeal cleft
o Pierre robin syndrome
o Tracheoesophageal fistulae(H-Type)
o Tracheomalacia, bronchomalacia,laryngomalacia
Lungs:-
o Pulmonary hypoplasia
o Pulmonary sequestration, congenital cystic adenomatoid
malformation, congenital lobar emphysema
o Bronchogenic cyst and tumour
Cardiovascular:
o Congenital heart defect especially with left to right shunt

22. 2.Aspirations:
Gastroesophageal reflex
Esophageal motilty disorder, stricture, diverticulum
Foreign body aspiration
Pharyngeal incoordination causing swallowing abnormality
Neuromuscular disorder
3.Defect in clearance of airway secretions:
Cystic fibrosis
Abnormality of ciliary structure or function( kartagener syndrome
Airway compression (mediastenal tubercular lymhadenopathy,
bronchogenic cyst or neoplasm)
4.Disorder of local/ systemic immunity:
Primary immunodeficiency
Acquired immunodeficiencies-
 HIV
Immunosuppresive therapy
Malnutrition

23.  Lodha et al. in a study from tertiary care hospital in north
India reported cause of recurrent pneumonia (excluding cystic
fibrosis and TB) as :-
• Aspiration-24%
• Immunodeficiency-16%
• Structural abnormality-9%
• Others-29%
• No cause could be identified in 15%

24. Etiological organisms
• Etiological agents responsible for recurrent or persistent
pneumonia may depend on cause of underlying illness and
treatment received.
• Immunocompetent children may get infected with usual
organisms in beginning.
• With recurrent administration of antibiotic and hospitalisation
, they may get infection with unusaul organisms including Gm
Negative Bacilli.
• Immunocompromised host may get infected with unusual
organism including Gm negative bacilli, fungi, pneumocystis
jirovecii, etc.

25. Approach to a child with recurrent or
persistent pneumonia
• Detailed clinical history and examination with
preliminary investigations including X ray film
of chest gives clues about underlying illness in
majority of cases.

26. Detailed clinical history
Age of onset:-
Symptoms from neonatal period or early infancy indicate possibility of
malformation or severe immune deficiency disoders.
Details of the episodes:-
 Detail history of the first episodes, course of illness, aggravating
factors, details of the treatment etc., may give important clues for
underlying cause.
 Respiratory distress at birth followed by recurrent pneumonia and
persistence wet cough since infancy point toward possibility of
primary ciliary dyskinesia or cystic fibrosis.

27. Past history/ associated complaints:-
 Recurrent infection involving respiratory and gastrointestinal
infection suggest a possibility of humoral immune deficiency.
Recurrent fungal infections indicate a possibility of T cell or phagocytic
defect.
 History of foreign body aspiration followed by recurrent
respiratory infection is a common cause of pneumonia in preschool age
group.
 If the recurrent pneumonia is due to immune defciency, and the
patient does not have signifcant infections outside the respiratory tract,
then the immunodefciency is likely to be a B-cell problem. The infectious
agent is often a common respiratory tract pathogen.

28. Immunoglobulin (Ig) G deficiency, IgG subclass deficiency, and
IgA deficiency are all associated with recurrent sinopulmonary
infections.
If the child has poor growth and serious infections in other organ
systems, the immunode ciency is more likely to be in the cell–
mediated system or in the phagocytic portion of the immune
system. These infections can be due to common respiratory
pathogens or opportunistic pathogens.

29. • Perinatal history:-
H/O delayed passage of meconiumat birth suggest cystic fibrosis.
Maternal infection during pregnancy may give clue to intrauterine infection.
Family history:-
H/O similar illness in other siblings suggests inherited disorders like cystic fibrosis,
primary ciliary dyskinesia, or immune deficiency disorders.
A family history of tuberculosis in adult patient suggests tuberculosis as cause of
persistent pneumonia.
Environmental history:-
Increase level of pollutant including PM2.5 & PM10 predisposes to recurrent
chest infection and increased morbidity.
Exposure to birds may suggests hypersensitivity pneumonitis.
Feeding history:-
Choking during feeding may suggest repeated aspiration.
Excessive crying during feeding or abdominal distension after feed suggest H-type
TE fistula.
Vomiting after feed or coughing at the end of feeding may suggest
gastroesophageal reflux.

30. Physical examination
• A general and systemic examination is important in all clinical illness.
• Oral thrush and fungal infection give clue for phagocytic defect.
• Generalised lyphadenopathy suggests tuberculosis or HIV infection.
• Absence or atrophic tonsil indicate possibility of B cell disorder
agammaglobulinemia.
• Presence of cleft plate give clue for aspiration pneumonia.
• Nasal regurgitation during feeding may be due to cleft palate or
pharyngeal incoordination.
• Situs inversus suggests diagnosis of immotile cilia syndrome.
• Chronicity and severity of illness is indicated by growth retardation,
persistent respiratory difficulty, hypoxia, clubbing, hyperinflammation or
reduced volume of hemithorax.

31. Investigations
Common investigation for diagnosis of underlying disease for recurrent
and persistent pneumonia include imaging, documentation of
swallowing defect, bronchoscopy, investigation for gastroesophageal
reflux, cystic fibrosis, and immune deficiency disoders.

32. Imaging:- diagnosis of recurrent/persistent pneumonia is based on
abnormality in xray film of chest..
Scolisis—prediposes to recurrent chest infection
Persistent lesion in lt lower lobe may indicate possibility of sequestration.
Presistent lesion in rt upper lobe suggest recurrent aspiraion .
Ct chest is important tool to confirm the structural abnomality suspected in
chest xray.
Fibreoptic bronchoscopy is one of the most important tool in diagnostic work
up . It helps in identification of various airway anomaly and intraluminal
pathology. Additionaly it helps in identification of etilogical agents by
obtaining bronchoalveolar lavage.
For documentation of GERD, Investigation include barium esophagogram,
24-hr esophageal PH monitoring.
Recurrent aspiration due to any cause can be assessed by presence of lipid
laden macrophages in brochoalveolar lavage

33. • Videofluoroscopic swallow study has been suggested for documentation
of aspiration.
• In suspected cystic fibrosis, documentation of elevated sweat chloride of
more than 60 meq/L or demonstration of two abnormal mutation is
required.
• Screening of primary ciliary dyskinesia is done by using nasal nitric oxide.
In children with clinical phenotype of primary ciliary dyskinesia and nasal
nitric oxide is less than 77nl/minute-- one may classify as probable
primary ciliary dyskinesia.
• Immune deficiency workup is indicated in children with recurrent infection
in multiple organ system. Immunoglobulin profile with screening for T-
cell, B- cell and phagocytic function can be performed.

35. Treatment
• Treatment of recurrent or persistent pneumonia includes
- treatment of underlying illness
-control of current infection with appropriate antibiotics.
To start with broad spectrum antibiotics after obtaining appropriate
antibiotics samples.
After result of microbiological test, antibiotic can be
modified to narrow spectrum to avoid development of drug resistance.

36. Selection of Antimicrobial Therapy
for Specific Pathogens

37. PATHOGEN PARENTERAL THERAPY ORAL THERAPY (STEP-DOWN
THERAPY OR MILD
INFECTION
Streptococcus
pneumoniae
with MICs for
penicillin ≤ 2.0
μg/mL
Preferred: Ampicillin (150-200 mg/kg/day
every 6 hr) or penicillin
Alternatives: ceftriaxone (50-100
mg/kg/day
every 12-24 hr)
Preferred: amoxicillin (90
mg/kg/day in
2 doses or 45 mg/kg/day in 3
doses);
Alternatives: second- or third
generation cephalosporin
(cefpodoxime, cefixime)
S. pneumoniae
resistant to
penicillin, with
MICs ≥ 4.0
μg/mL
Preferred: ceftriaxone (100 mg/kg/day
every 12-24 hr);
Alternatives: ampicillin (300-400
mg/kg/day every 6 hr), levofloxacin
Preferred: oral levofloxacin
(16-20 mg/kg/day in 2 doses
for children 6 mo to 5 yr and
8-10 mg/kg/day once daily
for children 5-16 yr,
Staphylococcus
aureus ,
(methicillin
Susceptible)
Preferred: cefazolin (150 mg/kg/day
every 8hr)
Alternatives: clindamycin (40 mg/kg/day
every 6-8 hr) or vancomycin (40-60
mg/kg/day every 6-8 hr
Preferred: oral cephalexin
(75-100
mg/kg/day in 3 or 4 doses);
Alternative: oral clindamycin
(30-40
mg/kg/day in 3 or 4 doses

38. S. aureus ,
(methicillin
Resistant)
Preferred: vancomycin (40-60
mg/kg/day every 6-8 hr
Alternatives: linezolid (30
mg/kg/day every 8hr for children
<12 yr old and 20 mg/kg/day
every 12 hr for children ≥12 yr
old)
Preferred: oral clindamycin (30-40
mg/kg/day in 3 or 4 doses);
Alternatives: oral linezolid (30
mg/kg/day in 3 doses for children <12
yr and 20 mg/kg/day in 2 doses for
children ≥12 yr)
Haemophilus
influenza,
typeable (A-F)
or nontypeable
Preferred: intravenous ampicillin
(150-200 mg/kg/day every 6 hr)
Alternatives: intravenous
ciprofloxacin (30
mg/kg/day every 12 hr) or
intravenous
levofloxacin
Preferred: amoxicillin (75-100
mg/kg/day in 3 doses OR amoxicillin
clavulanate
Mycoplasma
Pneumoniae/
Chlamydophila
pneumoniae
Preferred: intravenous
azithromycin (10mg/kg on days 1
and 2 of therapy; transition to
oral therapy if possible);
Alternatives: levofloxacin
Preferred: azithromycin (10 mg/kg on
day 1, followed by 5 mg/kg/day once
daily on days 2-5);
Alternatives: clarithromycin (15
mg/kg/day in 2 doses

39. DURATION OF TREATMENT
• The optimal duration of antibiotic treatment for
pneumonia has not been well established
• However, antibiotics should generally be continued until
the patient has been afebrile for 72 hr, and the total
duration should not be less than 10 days (or 5 days if
azithromycin is used). Shorter courses (5-7 days) may
also be effective, particularly for children managed on an
outpatient basis
• In pneumonia due to staphylococcus, a total duration of
2 wks in uncomplicated, and 4-6 wks in complicated
case.

40. Take home message
• Recurrent pneumonia is defined as:-
 2 or more episodes in a single year
• or
 3 or more episodes ever, with radiographic clearing between occurrences.
• Persistent pneumonia is defined as clinical symptoms along with
radiological abnormality to continue beyond 1 month or more despite
treatment.
• .
• The common condition predisposing are aspiration syndromes, structural
abnormalities, cystic fibrosis and immunodeficiency disorders.
• Detailed history and examination are essential.
• Common performed investigation are chest xray, tuberculin test ,sweat
chloride test, bronchoscopy & Bronchoalveolar lavage, CT chest and
immunological studies.
• Management consists treating underline causes.

42. Non typable H. influezae
H. influenzae type b conjugate vaccines have no effect on
infections caused by nontypeable strains because nontypeable
strains are nonencapsulated.
And the conjugated vaccine WORKS on encapsulated strains.

43. Atypical Bacteria
• Atypical bacteria are bacteria that do not color with gram-staining but
rather remain colorless: they are neither Gram-positive nor Gram-negative.
These include the Chlamydia, Legionella and
the Mycoplasma ,the Rickettsiaceae are also often considered atypical.
• Gram-positive bacteria have a thick peptidoglycan layer in their cell wall,
which retains the crystal violet during Gram staining, resulting in a purple
color. Gram-negative bacteria have a thin peptidoglycan layer which does
not retain the crystal violet, so when safranin is added during the process,
they stain red.
• The Chlamydia and Mycoplasma lack a peptidoglycan layer so do not retain
crystal violet or safranin, resulting in no color. Ricketsiaceae are technically
Gram-negative, but are too small to stain well, so are often considered
atypical.
• Peptidoglycans are the site of action of beta-lactam antibiotics such
as penicillins and cephalosporins, so chlamydia and mycoplasma are
naturally resistant to these drugs, which in this sense also makes them
“atypical” in the treatment of their infections. Macrolides such
as erythromycin however, are usually effective at such staining.

44. In 2011, the Pediatric Infectious Diseases Society (PIDS) and the Infectious
Diseases Society of America (IDSA) published clinical practice guidelines for
community-acquired pneumonia in children older than 3 mo of age.
An infiltrate on chest radiograph (posteroanterior and lateral views) supports
the diagnosis of pneumonia; images may also identify a complication such as a
pleural effusion or empyema. Viral pneumonia is usually characterized by
hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing (Fig.
428.2 ). Confluent lobar consolidation is typically seen with pneumococcal
pneumonia (Fig. 428.3 ).
The radiographic appearance alone does not accurately
identify pneumonia etiology, and other clinical features of the illness must be
considered. Repeat chest radiographs are not required for proof of cure for
patients with uncomplicated pneumonia. Moreover, current PIDS–IDSA
guidelines do not recommend that a chest radiograph be performed for children
with suspected pneumonia (cough, fever, localized crackles, or decreased breath
sounds) who are well enough to be managed as outpatients because imaging in
this context only rarely changes management

45. Role of zn in pneumonia
• Zinc is thought to help decrease susceptibility to acute lower
respiratory tract infections by regulating various immune
functions, including protecting the health and integrity of the
respiratory cells during lung inflammation or injury.
• Zinc is an important micronutrient supporting growth and
normal function of the immune system.8 Zinc deficiency
results in growth impairment, anorexia, behavioural changes,
and impaired immune function, leading to susceptibility to
infections.

47. • Surgical closure of a cleft lip is usually
performed by 3 mo of age, when the infant
has shown satisfactory weight gain and is free
of any oral, respiratory, or systemic infection.
• In an otherwise healthy child, closure of the
palate is usually done before 1 yr of age to
enhance normal speech development.

48. • Pierre Robin syndrome consists of micrognathia and is usually
accompanied by a high arched or cleft palate (Fig. 337.1 ). The
tongue is usually of normal size, but the floor of the mouth is
foreshortened.
• The infant should be maintained in a prone or partially prone
position so that the tongue falls forward to relieve respiratory
obstruction. Some patients require tracheostomy. Mandibular
distraction procedures in the neonate can improve mandibular size,
enhance respiration, and facilitate oral feedings.
• Sufficient spontaneous mandibular growth can take place within a
few months to relieve the potential airway obstruction. Often the
growth of the mandible achieves a normal profile in 4-6 yr. Of
children with Pierre Robin syndrome, 30–50% have Stickler
syndrome

49. • Esophageal atresia (EA) is the most common congenital anomaly of the
esophagus, with a prevalence of 1.7 per 10,000 live births. Of these, >90%
have an associated tracheoesophageal fistula (TEF). In the most common
form of EA, the upper esophagus ends in a blind pouch and the TEF is
connected to the distal esophagus (type C).