pcap guidelines
TRANSCRIPT
PCAP GUIDELINESPCAP GUIDELINES
Etiology
• Outpatient and in-patients: bacterial > viral
• For bacterial: Streptoccocus pneumoniae> H.
influenzae> Mycoplasma sp.> Chlamydia sp.
VariablesPCAP A
Minimal
PCAP B
Low
PCAP C
Moderate
PCAP D
High
Co-morbids None + + +
Compliant
Caregiver
+ + None None
Ability to + + None None
Risk Classification
Ability to
Follow up
+ + None None
Dehydration None Mild Moderate Severe
Feeding Yes Yes No No
Age > 11 months > 11 months < 11 months < 11 months
RR 2-12 mos > Or = 50 > 50 > 60 > 70
1-5 yrs > Or = 40 > 40 > 50 > 50
> 5 yrs > Or = 30 > 30 > 35 > 35
VariablesPCAP A
Minimal
PCAP B
Low
PCAP C
Moderate
PCAP D
High
Retractions Intercostal/
subcostal
Supra-
clavicular
Head bobbing + +
Cyanosis + +
Grunting +
Apnea +
Sensorium Awake Awake Irritable Lethargic/ Sensorium Awake Awake Irritable Lethargic/
stuporous/
comatose
Complications + +
Action OPD OPD Admit to
wards
Admit to ICU
Follow up at
end of
treatment
Follow up
after 3 days
Refer to
specialist
Diagnostics
• No diagnostic aids initially requested for PCAP
A or B managed on an outpatient basis
• Routine exams for PCAP C or D:
– CXR PAL– CXR PAL
– WBC count
– CS: blood (for PCAP D), pleural fluid, ETA upon
intubation
– Blood gas/O2 sat
Diagnostics
• Sputum CS for older children
• ESR and CRP are not routinely requested
Predictors of bacterial pathogen
• Clinical prediction using a bacterial
pneumonia score
– BPS ≥ 4 ~ (+) bacterial pathogen in hospitalized
patients 1 month – 5 yearspatients 1 month – 5 years
• Probable organisms acc. to age
– Increase age, higher chance of bacterial pathogen,
increasing frequency of atypical organism
• Decreased breath sounds
Treatment
• Antibiotics are recommended in:
1. Patients classified as either PCAP A or B and is:
(a) beyond 2 years of age; or (b) having high
grade fever without wheezegrade fever without wheeze
2. Patients classified as PCAP C and is: (a) beyond 2
years of age; (b)having high grade fever without
wheeze; (c) having alveolar consolidation in chest
x-ray; (d) or having WBC count > 15,000
3. Patients classified as PCAP D
Treatment
• Empiric treatment (bacterial etiology):
– PCAP A or B w/o previous antibiotic: Amoxicillin
45 mg/kg/day in 3 divided doses x 3 days (min)
• Macrolide if w/ hypersensitivity of amoxicillin• Macrolide if w/ hypersensitivity of amoxicillin
• Other regimens: Co-trimoxazole, azithromycin,
erythromycin, co-amoxiclav, clarithromycin
– PCAP C w/o previous antibiotic and has complete
immunization against Hib: Penicillin G 100,000
‘u’/kg/day
• Oral amoxicillin in patients who can tolerate feeding
(comparable to parenteral penicillin)
Treatment
• Empiric treatment (bacterial etiology):
– PCAP C w/o Hib immunization: IV ampicillin 100
mg/kg/day in 4 divided doses
• Monotherapy (parenteral ampicillin) or combination • Monotherapy (parenteral ampicillin) or combination
therapy (IV penicillin + chloramphenicol) in patients
who cannot tolerate feeding
• Other regimens: Amoxicillin/sulbactam, cefuroxime,
chloramphenicol
– PCAP D: consult a specialist
Treatment
• If CA-MRSA suspected, refer immediately to
the appropriate specalist.
• Strategies in clinical management of MRSA:
– Follow antibiotic susceptibility based on culture – Follow antibiotic susceptibility based on culture
studies
– Vancomycin remains to be the 1st line therapy for
severe infections possibly caused by MRSA
– CA-MRSA were more likely to be synergistically
inhibited by vancomycin + gentamicin vs.
vancomycin alone
Treatment
• Initial treatment (viral etiology):
– Ancillary treatment
– Oseltamivir 2 mg/kg/dose BID x 5 days may be
given for laboratory confirmed influenzagiven for laboratory confirmed influenza
Response to antibiotics
• Decrease in respiratory signs (i.e. tachypnea)
and defervescense within 72 hours after
initiation of antibiotic – FAVORABLE
– Nonsevere: RR>5 bpm slower than baseline– Nonsevere: RR>5 bpm slower than baseline
– Severe: defervescense, decrease in tacypnea &
chest indrawing, increase in O2 sat & ability to
feed within 48 hours
• Persistence of symptoms beyond 72 hours
after initiation of antibiotics – RE-EVALUATE
Response to antibiotics
• Improved: RR < age-specific range without
chest indrawing or any danger signs (central
cyanosis, inability to drink, abnormally sleepy
or convulsions)or convulsions)
• Treatment failure
– Same: RR > age-specific range WITHOUT chest
indrawing or any danger signs
– Worse: Developed chest indrawing or any of the
danger signs
Response to antibiotics
• If a patient w/ PCAP A or B is not responding
to antibiotics w/in 72 hours, consider:
– Change the initial antibiotic; or
– Start an oral macrolide; or– Start an oral macrolide; or
– Re-evaluate diagnosis
• Causes of treatment failure: co-infection w/
RSV, non-adherence to treatment
Response to antibiotics
• If a patient w/ PCAP C is not responding to
antibiotics w/in 72 hours, consider:
– Penicillin resistant Strep pneumoniae; or
– Presence of pulmonary or extrapulmonary– Presence of pulmonary or extrapulmonary
complications; or
– Other diagnosis
• Causes of treatment failure: antibiotic
resistance, clinical sepsis, progressive
pneumonia, mixed infection
Response to antibiotics
• If a patient w/ PCAP D is not responding to
antibiotics w/in 72 hours, consider:
– Immediate re-consultation w/ a specialist
Response to antibiotics
• Switch from IV to oral 2-3 days after initiation
of antibiotics recommended if:
– Responding to the initial antibiotic therapy
– Able to feed w/ intact GI absorption– Able to feed w/ intact GI absorption
– Without pulmonary or extrapulmonary
complications
• Switch from 3 days of IV ampicillin to 4 days of
amoxicillin (preferred) or cotrimoxazole
Ancillary treatment
• Oxygen and hydration if needed among
inpatients
• Cough preparations, chest physiotherapy,
pNSS nebulization, steam inhalation, topical pNSS nebulization, steam inhalation, topical
solution, bronchodilators are not routinely
used
• A bronchodilator may be used if with
wheezing
Prevention
• Pneumococcal and Hib vaccination
• Zinc supplementation may be administered to
prevent pneumonia
• Handwashing using antibacterial soaps• Handwashing using antibacterial soaps
• Breastfeeding