La gestione del bambino con
sospetta polmonite
Nicola Principi
DIAGNOSI DI CAP
• Sospetto diagnostico -> VALUTAZIONE CLINICA
(ipofonesi plessica, modificazioni del FVT,
alterazioni del MV, polipnea)
• Certezza diagnostica -> RADIOGRAFIA DEL
TORACE (presenza di infiltrati alveolari o
interstiziali con o senza versamento pleurico)
FREQUENZA RESPIRATORIA E
PRESENZA DI CAP NEL BAMBINO
Età
Frequenza respiratoria/min
< 2 mesi
> 60
2 – 12 mesi
> 50
> 12 mesi
> 40
I dati in Tabella risultano avere una sensibilità del 74%
e una specificità del 67% per la diagnosi di CAP
E’ sempre necessario eseguire la radiografia del
torace per porre diagnosi di CAP?

NO nei casi di lieve o media gravità con
sintomatologia clinica ben espressa

SI nei casi dubbi, per evitare inutili trattamenti
antibiotici

SI nei casi gravi, per definire la situazione di
partenza dell’episodio

SI nei casi inseriti in protocolli di ricerca per
definire i rapporti esistenti tra le variabili in
studio e i tipi di alterazione polmonare
Esposito S et al., Pediatr Infect Dis 2012
ETIOLOGY OF CAP IN FINNISH
HOSPITALIZED CHILDREN
AGE
(Years)
N°
VIRAL
ETIOLOGY
BACTERIAL
ETIOLOGY
MIXED
ALL
ETIOLOGY
*
<2
108
80
47
34
93
2-5
84
58
56
33
81
>5
62
37
58
19
76
TOTAL
254
62
53
30
85
*Total with detected etiology. Results expressed as percentages of
patients. Adapted from Juven et al. Pediatr Infect Dis J. 2000
Episodes of Rx-confirmed CAP with viruses in
children aged 13-36 months
(Esposito S et al., Influenza & Other Resp Viruses 2013)
2007-08
2008-09
2009-10
Total episodes
VIRUS
No.
(%) *
Coinf.
No.(%)^
No.
(%)*
Coinf.
No.(%)^
No.
(%)*
Coinf.
No.(%)^
No.
(%)*
Coinf.
No.(%)^
RSV
35
(41.1)
16
58 (38.6)
21
30
(30.3)
10
123
(36.8)
47
Rhinovirus
26
(30.5)
15
44 (29.3)
21
24
(24.2)
7
94
(28.1)
43
Bocavirus
12
(14.1)
9
15 (10.0)
11
12
(12.1)
6
39
(11.6)
26
Influenza
4 (4.7)
1
16 (10.6)
6
10
(10.1)
1
39
(11.6)
8
Metapneumo
.
12 (14.1)
5
13(8.6)
4
6 (6.1)
0
31 (9.2)
9
Coronavirus
3 (3.5)
2
7 (5.8)
3
5 (5.0)
4
15 (4.5)
9
Parainfluenz
a (1-4)
0 (0)
0
4 (2.6)
2
6 (6.1)
2
10 (3.0)
4
Adenovirus
1 (1.1)
0
4 (2.6)
3
2 (2.0)
1
7 (2.1)
4
Episodes
with viruses
68/85
(80.0)
20/68
(29.4)
122/150
(81.3)
36/122
(29.5)
78/99
(78.8)
14/78
(17.9)
268/334
(80.2)
70/268
(26.1)
•% among the total number of CAP investigated;
•^ % of the total number of infections in which the single virus was identified
Principal Bacteria Causing Childhood Pneumonia
(Community-Acquired Apart From the Age Group
Birth-1 Month), by Age
Esposito S, Cohen R, Domingo JD, Pecurariu OF, Greenberg D, Heininger U, Knuf M, Lutsar I, Principi N, Rodrigues F,
Sharland M, Spoulou V, Syrogiannopoulos GA, Usonis V, Vergison A, Schaad UB. Pediatr Infect Dis J. 2012 Jun;31(6):e78-85.
doi:
PNEUMOCOCCAL SEROTYPES IN CHILDREN WITH CAP
AGED <5 YRS BEFORE THE USE OF PCV-13
(Esposito S et al., Pediatr Infect Dis 2012 )
4; 2.0%
Not Typeable;
26.0 %
6B; 2.0%
9V; 2.0%
14; 18.0%
18C; 0%
COVERAGE
PCV-7 : 28%
PCV-10: 36%
PCV-13: 74%
19F; 2.0%
23F; 2.0%
1; 2.0%
5; 0%
19A; 32.0%
7F; 6.0%
3; 4.0%
6A; 2.0%
PNEUMOCOCCAL SEROTYPES IN PEDIATRIC CAP
(Resti M et al. Clin Infect Dis 2010)
CAP AND ATYPICAL BACTERIA
IN 418 CHILDREN
%
Principi et al. Clin Infect Dis 2001
BACTERIAL vs VIRAL PNEUMONIA
Virkki et al. Thorax 2002
N=215
Alveolar infiltrates
Interstitial infiltrates
WBC >15 x 109/l
ESR > 30 mm/h
CRP > 40 mg/l
CRP > 80 mg/l
Bacterial
%
71
48
63
64
70
75
Viral
%
29
52
37
36
30
25
ADVANTAGES AND LIMITS OF
PROCALCITONIN IN CLINICAL PRACTICE
From Gendrel D et al. Pediatr Infect Dis J 1999
Bacterial
Versus
Viral
Pneumonia
6,5 y, S.pneumoniae,
widespread interstitial
1,9 y, S.pneumoniae,
alveolar changes
2.8 y, Rhinovirus,
alveolar changes
0.3 y, parainfluenzae and
HHV6, alveolar changes
Virkki R et
al
Thorax,
2002
EFFICIENCY OF RAPID DIAGNOSTIC
TESTS FOR INFLUENZA VIRUSES IN
OFFICE PRACTICE
TEST
DIRECTIGEN
FLU A+B
Z STAT
FLU
QUICKVUE
INFLUENZA
TEST
FLU OIA
COMPANY
BECTON
DICKINSON
ZYME
TX, INC.
QUIDEL
BIOSTAR
SENSITIVITY
(%)
67
(T)
62
(T)
73
(N)
62
(T)
SPECIFICITY
(%)
92
(T)
99
(T)
95-99
(N)
79.5
(T)
T= Throat Swab; N= Nasal Swab
Benjamin J. Contemp Pediatr 2000
TEST MICROBIOLOGICI PER LA
DIAGNOSI EZIOLOGICA DI CAP
TEST
VANTAGGI
LIMITI
Tampone
nasofaringeo
Facile esecuzione
Non correla con i dati
polmonari se non per virus e
batteri atipici
Coltura
dell´espettorato
Buona sensibilitá
Non attendibile nel bambino
piccolo
Emocoltura
Facile esecuzione
Bassa sensibilitá
Puntura
polmonare
Facile esecuzione,
buona sensibilitá
Media invasivitá
Puntura cricoidea
Buona sensibilitá
Alta invasivitá
BAL
Buona sensibilitá
Alta invasivitá
NASOPHARYNGEAL COLONIZATION (%)
IN PNEUMONIA VS HEALTHY CHILDREN
30
25
20
15
10
5
0
S.pneumoniae H.influenzae M.catarrhalis
Healthy
Pneumonia
From Nohynek et al. Pediatr Infect Dis J 1995
RISULTATI DEL TEST RAPIDO
BINAX NOW
Popolazione
Casi con IPD
Tot. con Binax
NOW positivo
(%)
Binax NOW pos Binax NOW pos e
e colonizzaz.
assenza di
NF (%)
colonizzaz. NF (%)
5/5 (100,0)*
2/2 (100,0)*
3/3 (100,0)*
Casi senza
IPD
29/150 (19,3)
16/28 (57,1)°
13/122 (10,7)
Controlli
35/200 (17,5)
26/53 (49,1)°
9/147 (6,1)
*p<0,05 vs casi senza IPD e controlli
°p<0,0001 vs casi senza IPD e controlli senza colonizzaz. NF
Esposito S et al. Pediatr Infect Dis J 2004
DIAGNOSTIC TESTS FOR M. PNEUMONIAE
AND
C. PNEUMONIAE
TEST
SPECIMEN
COMMENTS
CULTURE
Throat or NP swab,
sputum, bronchial
washing, tissue
Requires tissue culture; not
routinely available; requires
several days of incubation
PCR
Throat or NP swab,
sputum, bronchial
washing, tissue
No FDA-approved kits; available
from research laboratories;
potential for rapid diagnosis
SEROLOGY Serum
Paired acute-convalescent
sera preferred; IgM may take
up to 4-6 weeks to appear
(therefore retrospective)
HOW TO TREAT PEDIATRIC CAP
The choice of empirical antibiotic treatment for
paediatric CAP should be based on diagnostic
algorithms that begin with age of the patient, and then
consider epidemiological and clinical factors (with
particular attention on severity of the disease),
vaccination status, PK/PD characteristics and finally the
results of laboratory tests and chest radiography
Esposito S et al., Pediatr Infect Dis J 2012
CHILDREN IN THE FIRST MONTH OF AGE
 The traditionally used combination of ampicillin and one
of the aminoglycosides (mainly gentamicin) remains the
treatment of choice
 As an alternative, a broad spectrum parenteral
cephalosporin can be used
 In
cases
when
Listeria
monocytogenes
or
Enterococcus sp. or anaerobes are considered,
ampicillin should be included in the regimen
 In critically ill patients, staphylococcal pneumonia
should be considered and, in these circumstances, antistaphylococcal penicillin or, in areas where methicillinresistant strains of S. aureus have appeared, an active
non beta-lactam agent (such as clindamycin or
vancomycin) should then be added to the regimen
CHILDREN AGED 1 MONTH UP TO 3 MONTHS
S. pneumoniae is the most important aetiological agents
of CAP in this age group throughout the world
A -lactam antibiotic is recommended
As in the case of neonates, in critically ill patients anti-
staphylococcal antibiotic can be used
Chlamydia trachomatis and Bordetella pertussis should
be considered especially in presence of little or no fever
and severe cough. In such cases, macrolides are the
drugs of choice
TERAPIA DELLA CAP NEL LATTANTE DI
1-3 MESI
(LIVELLO DI PROVA: 6; FORZA DELLA RACCOMANDAZIONE: B)
ASSENZA DI FEBBRE, TOSSE
IMPORTANTE, INFILTRATO
INTERSTIZIALE
VEROSIMILMENTE
CHLAMYDIA TRACHOMATIS E
BORDETELLA PERTUSSIS
ERITROMICINA O
CLARITROMICINA PER 14
GIORNI O AZITROMICINA
PER 3 GIORNI
PRESENZA DI FEBBRE,
CONSOLIDAMENTO LOBARE
VEROSIMILMENTE
STREPTOCOCCUS PNEUMONIAE;
RARAM. Hib E STAPHYLOCOCCUS
AUREUS
AMOXICILLINA ORALE O, NEI
CASI PIU’ GRAVI, CEFOTAXIMA
O CEFUROXIMA O
CEFTRIAXONE EV PER 10
GIORNI
ANTIBIOTIC THERAPY OF CAP OF INFANTS
AND CHILDREN > 4 MONTHS
OF AGE
 STREPTOCOCCUS PNEUMONIAE AND
ATYPICAL BACTERIA ARE THE MOST
FREQUENT CAUSE OF CAP IN CHILDREN > 4
MONTHS OF AGE
 DIFFERENTIATION OF PNEUMOCOCCAL
FROM ATYPICAL BACTERIA CASES IS VERY
DIFFICULT
 ANTIBIOTIC THERAPY MUST COVER ALL
THE MOST FREQUENT ETIOLOGIES
TERAPIA SUGGERITA NEL BAMBINO CON CAP
(4 mesi – 5 anni)
AMOXICILLINA ORALE (80-90 mg/kg/die in 3 dosi)
Se la terapia sembra fallire dopo 48-72 ore, aggiungere:
ERITROMICINA ORALE (30-40 mg/kg/die in 3-4 dosi) O
CLARITROMICINA (15 mg/kg/die in 2 dosi) O
AZITROMICINA (10 mg/kg/die in 1 dose)
NEI CASI GRAVI USARE DA SUBITO UN BETALATTAMICO BETA-LATTAMASI RESISTENTE (ES.
CEFALOSPORINA EV) IN ASSOCIAZIONE A UN
MACROLIDE PER OS O EV
Durata usuale della terapia: 10-14 giorni
LIVELLO DI PROVA: 6; FORZA DELLA RACCOMANDAZIONE: B
ROLE OF PNEUMOCOCCAL
PENICILLIN RESISTANCE ON CAP
OUTCOME
(From Cardoso MRA et al., Arch Dis Child 2008)
From ECDC, 2013
TERAPIA SUGGERITA NEL BAMBINO CON CAP
(6-18 anni)
ERITROMICINA ORALE (30-40 mg/kg/die in 3-4 dosi)
O CLARITROMICINA (15 mg/kg/die in 2 dosi) O
AZITROMICINA (10 mg/kg/die in 1 dose)
Se la terapia sembra fallire dopo 48-72 ore, aggiungere:
AMOXICILLINA ORALE (80-90 mg/kg/die in 3 dosi)
NEI CASI GRAVI USARE DA SUBITO UN BETALATTAMICO BETA-LATTAMASI RESISTENTE (ES.
CEFALOSPORINA EV) IN ASSOCIAZIONE A UN
MACROLIDE PER OS O EV
Durata usuale della terapia: 10-14 giorni
LIVELLO DI PROVA: 6; FORZA DELLA RACCOMANDAZIONE: B
TERAPIA CON VANCOMICINA DELLE
POLMONITI DA IN PEDIATRIA
 Nei soggetti pluritrattati e nelle aree geografiche ove la
resistenza di Streptococcus pneumoniae e Staphylococcus
aureus è >20%, la vancomicina è considerata il farmaco di
scelta
 Il dosaggio consigliato da molti anni è 40 mg/kg/die in 3-4
dosi
 Recenti ricerche indicano un aumento del rischio di fallimento
per aumento delle MIC
 Un riferimento considerato ottimale per la previsione
dell’efficacia della terapia è il trough level, vale a dire la
concentrazione immediatamente precedente la dose successiva
 Il trough level deve rimanere quante più volte possibile sopra
10 mg/L per avere efficacia ed evitare l’insorgere di eventi
avversi
THROUGH SERUM LEVELS OF GLYCOPEPTIDES
ACCORDING TO INITIAL DOSAGE (25, 40 OR 50
MG/KG/DIE)
(From Ito H et al., J Infect Chemother 2013)
NEW DRUGS FOR THE TREATMENT OF
PNEUMOCOCCAL INFECTIONS WITH
INTERESTING PRELIMINARY RESULTS
(From Esposito S & Principi N. Expert Opinion Pharmacotherapy 2013)
Drug
Linezolid
Ceftobiprole
Ceftaroline
Main finding
It seemed to be effective in 77.5-90.0% of children
with pneumococcal bacteremia or pneumonia; few data
concerning its effect on pneumococcal penicillinresistant strains
It inhibited 95% of S. pneumoniae strains, including
penicillin non-susceptible strains (those with a MIC ≥4
µg/mL) and highly resistant ceftriaxone strains (those
with a MIC ≥8 µg/mL)
It had greater in vitro activity (MIC=0.5 µg/mL) than
penicillin, cefotaxime or ceftriaxone (MIC=8 for all
the comparators)
Antibiotic (Ab) exposure by treatment group and
CAP severity
(From Esposito S et al., Respir Med 2011)
Chest Radiography
• Repeated chest radiographs should be obtained in children who fail
to demonstrate clinical improvement and in those who have
progressive symptoms or clinical deterioration within 48–72 hours
after initiation of antibiotic therapy (strong recommendation;
moderate-quality evidence)
• Routine daily chest radiography is not recommended in children
with pneumonia complicated by parapneumonic effusion after
chest tube placement or after videoassisted thoracoscopic surgery
(VATS), if they remain clinically stable (strong recommendation;
low-quality evidence)
• Follow-up chest radiographs should be obtained in patients with
complicated pneumonia with worsening respiratory distress or
clinical instability, or in those with persistent fever that is not
responding to therapy over 48-72 hours (strong recommendation;
IDSA guidelines; CID 2011. Kindly proded by Prof. Greenberg
low-quality evidence))