Pitfalls terapi pneumonia

Pneumonia

Schidlow DV, 1996

Child with Pneumonia

Introduction

Ostapchuck M et al, 2004;Greenberg D et al, 2005; McIntosh K, 2002

Introduction

Alberta Medical Association, 2001; Jadavji T et al,1997

IntroductionDeveloping country ± 60% pneumonia cases caused by bacterial antibiotic.

In developed country mostly viral


Introduction


Introduction


Introduction


Introduction• Recent research showed

that antibiotic regimen in WHO guidelines has reduced 50% mortality in developed country, but there’s also excessive use of antibiotics (75%)

Shann F et al, 1999

Need a guidelines for a Rational use of antibiotics.

Introduction


Introduction


Antibiotics for Non Severe Pneumonia

Ostapchuck M et al, 2004;Greenberg D et al, 2005


Ostapchuck M et al, 2004; McIntosh K, 2002


Alberta Medical Association, 2001


WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007


WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007


WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007, CATCHUP study group 2002


Kabra SK et al. 2009


Kabra SK et al. 2009

Antibiotics for Non Severe Pneumonia Guidelines from The British Thoracic Society

(2002):• For children < 5 years old: first line drugs is

amoxicillin (well tolerated, not expensive)

The British Thoracic Society, 2002

Alternative antibiotics:co-amoxiclav, cephachlor,

eritromycin, Chlaritromycin, and azitromycin


Guidelines , The British Thoracic Society, 2002:• In children > 5 years old most common

organism is M. Pneumoniae• First line drugs is macrolide


If S. pneumoniae suspected amoxicillinIf S. aureus suspected macrolide or

combination of flucloxacillin and amoxicillin


Monotherapy is recommended.

National Guideline Clearinghouse, 2006



Follow Up• Evaluation performed after

24-72 hours of treatment, if no improvement change antibiotics


Signs of improvement:Decrease respiratory rateLower feverAppetite improvement

Indication for Admission

Alberta Medical Association, 2001; WHO , 2008

Indication for Admission

Alberta Medical Association, 2001; WHO , 2008

Antibiotic for Admitted Pneumonia

Fonseca W, 2003; Pakistan MASCOT, 2002

WHO, 2005

Antibiotic for Admitted Pneumonia

Antibiotic for Admitted PneumoniaGuideline for the Management of Community

Acquired Pneumonia in childhood:


As therapy begin, the organismcausing pneumonia is unknown.

Treatment based on age and specific symptoms for specific pathogen.

0-8 Weeks

Enarson PM, 2005

2-59 Months

Enarson PM, 2005

Other Study

Macrolide

Cephalosporins and Non Cephalosporins

Cephalosporins• A randomized controlled trial compared

3rd generation of cephalosporins and Cephachlor no differences

(Paupe J, et all, 1992 )

Table 1. Therapeutic management of pneumoniaPatient age Outpatient Inpatient Critically ill

Birth to20 days

Admit Ampicillin IV or IM:Age <7 days:Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in divided doses every 12 hoursWeight ≥2 kg: 75 to 150 mg per kgper day in divided doses every 8 hours

Ampicillin IV or IM, in same dosages as for inpatientsplusGentamicin IV or IM, with or without cefotaxime IV, in same dosages as for inpatients

Ostapachuk, M,.2004

Patient age Outpatient Inpatient Critically ill

Birth to20 days

Admit Ampicillin IV or IM:Age ≥7 days:Weight <1.2 kg (2.6 lb): 50 to 100mg per kg per day divided every12 hoursWeight 1.2 to 2 kg: 75 to 150 mg perkg per day in divided doses every8 hoursWeight >2 kg: 100 to 200 mg perkg per day in divided doses every6 hours

Table 1. Therapeutic management of pneumonia

Ostapachuk, M,.2004

Patient age

Outpatient Inpatient Critically ill

Birth to20 days

Admit plusGentamicin IV or IM:≥37 weeks of gestationAnd Age zero to 7 days: 2.5 mg per kg every 12 hoursAge >7 days: 2.5 mg per kg every8 hourswith or withoutCefotaxime (Claforan) IV:Age ≤7 days: 100 mg per kg per day in divided doses every 12 hoursAge >7 days:150 mg per kg per day in divided dosesevery 8 hours

Ostapachuk, M,.2004


Patient age


3 weeks to3 months

If patient is afebrile:Azithromycin (Zithromax),10 mg per kg orally on day 1, then 5 mg per kg per day on days 2 through 5orErythromycin, 30 to 40 mg per kg per day orally in divided doses every 6 hours for 10 daysAdmit if patient is febrile orhypoxic.

Erythromycin, 40 mg per kg per day IV individed doses every 6 hours*If patient is febrile, add one of these agents:Cefotaxime, 200 mg per kg per day IV in divided doses every 8 hours*orCefuroxime (Ceftin), 150 mg per kg per day IV in divided doses every8 hours*

Cefotaxime, 200 mg per kg per dayIV in divided doses every 8 hoursplus cloxacillin (Tegopen), 150to 200 mg per kg per day IV individed doses every 6 hours*orCefuroxime alone, 150 mg per kgper day IV in divided doses every8 hours*

Ostapachuk, M,.2004


Patient age


4 mo to5 years

Amoxicillin, 90 mg per kg per day orally in divided doses every 8 hours for 7 to 10 daysConsider initial dose ofceftriaxone (Rocephin),50 mg per kg per day IM, up to 1 g per day. Follow with oral therapy for full course.Alternatives: amoxicillin clavulanic acid (Augmentin), azithromycin, cefaclor(Ceclor), clarithromycin(Biaxin), erythromycin

Cefotaxime, 150 mg per kg per day IV in divided doses every 6 hours*orCefuroxime, 150 mg per kg per day IV in divided doses every 8 hours*If the patient has pneumococcal infection:Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours*

Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours,plus erythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for 10 to 14 days*orCefotaxime, 200 mg per kg per day IV in divided doses every 8 hours,plus cloxacillin, 150 to 200 mg per kg per day IV in divided doses every 6 hours for 10 to 14 days

Ostapachuk, M,.2004


Table 1. Therapeutic management of pneumoniaPatient age


5 yearsand older

Azithromycin, 10 mg perkg (maximum of 500 mg)orally on day 1, followedby 5 mg per kg per day ondays 2 through 5Or Clarithromycin, 15 mg per kg per day orally in divided doses every 12 hours for 7 to 10 daysOr Erythromycin, 40 mg per kg per day orally in divideddoses every 6 hours for 7 to10 days If the patient haspneumococcal infection:Amoxicillin alone, 90 mgper kg per day orally individed doses every 8 hours

Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hoursplusErythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for10 to 14 daysIf pneumococcal infection is confirmed:Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours

Cefuroxime, 150 mg per kg per dayIV in divided doses every 8 hoursplusErythromycin, 40 mg per kg per dayIV or orally in divided doses every6 hours for 10 to 14 days

Ostapachuk, M,.2004

Follow Up• Every 6 hours or at

least once a day• Observations consist

of respiratory rate, temperature, level of consciousness and feeding

National guidelines Clearinghouse, 2006

Amelioration signs :•Decreasing of respiratory rate•No chest indrawing•Lowering of fever•Better appetite

Follow Up cont’• Rules of hospital discharge :

– Adequately consumes oral antibiotics – Antibiotic therapy can be done at home– Family agree and understand the

management at home– Support from environment for the therapy– Family should take their child to the

clinician for next examination

Ostapachuk, M,.2004

Pitfalls Management of Pneumonia in Children

• Chest x-ray should not routinelly done in children with mild pneumonia. (A)

• Evaluation of chest x-ray only performed if no improvement or there is worsening. (C)

Enarson M, 2006The British Thoracic Society,2002


• Antibiotics administration empirically often inappropriate with the etiology overused antibiotics . Amoxycillin is the first line antibiotic for pneumonia. Alternatives co-amoxyclav, cephachlor, erytromycin clarytromycin and azytromycin . (B)

Enarson M, 2006The British Thoracic Society,2002


• Nasogastric tube should not be applied in severe pneumonia (D)

• Every pneumonia patient has to be monitored for oxygen saturation. (A)

• Children with oxygen saturation below 92% must given oxygen therapy with nasal canule, head box, or facial mask, to keep the saturation above 92%. (A)

The British Thoracic Society,2002


• Intravenous fluid administered for 80% from daily requirement and electrolyte examination must be done in severe pneumonia. (C)

• Chest physiotherapy is not always useful (B)

The British Thoracic Society,2002

Study design Evidence

level

Recomendation

Advance systematic study Ia A+

One or more good study Ib A-

One or more prospective study II B+

One or more retrospective

study

III B-

Experts’ assumption formally Iva C

Experts’ assumption informally

or other information

IVb D

Table 2 . Evidence Level and Recommendation


CONCLUSION• Antibiotic administration is a challenge for clinician in the

management of pneumonia• Some pneumonia caused by viral infection • As we decide to give antibiotic, we must consider which

antibiotic should be used (broad spectrum or narrow spectrum)

• First give antibiotic empirically based on children age• Second observe within 24-72 hours• All of the steps above are useful to prevet pittfalls in the

management of pneumonia

Cochrane Database of Systematic Review 2008

To determine the equivalence in effectiveness and safety of oral antibiotics compared to parenteral antibiotics

Oral Antibiotics vs Parenteral Antibiotics for Severe Pneumonia

Rojas-Reyes MX, Rugeles CG, 2006


Published or unpublished randomized controlled trials (RCTs) comparing any oral and parenteral antibiotic children 3 months to 5 years

Oral therapy effective and safe alternative to parenteral antibiotics in hospitalized children

Rojas-Reyes MX, Rugeles CG, 2006


Short –course vs Long-course antibiotic therapy for non-severe community-acquired pneumonia

Results:Analysis of three days of treatment with the same antibiotic non significant differences in clinical cure, treatment failure, and relapse rate after seven days of clinical cure

Haider BA, Saeed MA, Bhutta ZA, 2007


Conclusion

A short course (3 days) of antibiotic therapy is as effective as a longer treatment (5 days) for non severe pneumonia in children under five years of age.

Haider BA, Saeed MA, Bhutta ZA, 2007

Cochrane Database of Intervention Review

To identify effective antibiotic drug therapy for community acquired pneumonia in children by comparing various antibiotics.

Antibiotics for CAP in Children

Kabra SK, Lodha R, Pandey RM, 2009

Cochrane Database of Intervention Review • Cotrimoxazole is inferior to amoxycillin and

prokain penicillin• Penicillin in conjunction with gentamycin

better than chloramphenicol alone.• Co-amoxyclavulanic acid was better than

amoxycillin alone• No difference between injectable penicillin and

oral amoxycillinKabra SK, Lodha R, Pandey RM, 2009

Cochrane Database of Intervention Review No differences between• Injectable penicillin and oral amoxycillin• Azithromycin and erythromycin • Cefpodoxime and amoxycillin• Azithromycin and co-amoxyclavulanic

acid.


ConclusionAmbulatory patients• Amoxycillin was better than co-trimoxazole• No difference between azithromycin and

erythromycin• No difference between cefpodoxime and co-

amoxyclavulanic



Cochrane Database of Intervention Review • Hospitalized patients• Procain penicillin was better than

cotrimoxazole• Penicillin + gentamycin better than

chloramphenicol alone• Injectable penicillin and oral amoxycillin

similar failure rates



Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults

To evaluate the efficacy of OTC cough medications as an adjunct to antibiotics in

children and adults with pneumonia

Chang CC, Cheng AC, Chang AB, 2009

Cochrane Database of Intervention Review• Insufficient evidence to decide whether

OTC medications for cough associated with acute pneumonia are beneficial.

• Mucolytics may be beneficialinsufficient evidence

• Codeine and antihistamines should not be used in young children

Chang CC, Cheng AC, Chang AB, 2009

Buku saku pelayanan kesehatan anak di rumah sakit rujukan tingkat pertama di kabupaten/kota

Technical updates of the guidelines on the Integrated Management of Childhood Illness (IMCI)

Education

Pitfalls terapi pneumonia