Download Bacterial Pneumonia

Respiratory Diseases
in HIV-infected Children
- Part 1Upper Respiratory Infection
and Pneumonia
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
Learning Objectives
By the end of this session, participants
should be able to:
 Identify the most common causes of
respiratory disease in HIV patients
 Describe how to manage ear infections
 Explain how to clinically diagnose and
treat:
• Bacterial pneumonia
• Viral pneumonia
• Fungal pneumonia
2
What are Common Respiratory Syndromes
in HIV infected Children?
Infectious
causes
Upper respiratory infections:
•Ear infections
Upper respiratory infections:
•Sinusitis Lower respiratory infections:
 Ear infections Lower respiratory
 Pneumocystis
infections:jiroveci
 Sinusitis
(PCP)
•Pneumocystispneumonia
jiroveci pneumonia
 Bacterial pneumonia
(PCP)
 Pulmonary tuberculosis
•Bacterial pneumonia
Viral pneumonia
•Pulmonary tuberculosis
 Fungal pneumonia
•Viral pneumonia
•Fungal pneumonia
Non-infectious Lymphocytic interstitial pneumonitis
causes
(LIP)
Bệnh cảnh nhập viện
ở BV Nhi Đồng 1 – khảo sát năm 2006
n = 134
5
Thiếu máu
8
bệnh não
13
Tiêu…
17
sốt kéo dài
16
suy dinh …
71
hô hấp
0
10
20
30
40
50
60
70
80
50% trẻ nhập viện vì bệnh cảnh hô hấp
Bs. Trương Hữu Khanh NĐ1
Upper Respiratory
Infections
5
Ear Infections
Symptoms
Otitis
media
Treatment
• Usually begins at age • Acute pain, often
6-9 months
severe
• Fever, pain, irritability • Edema, erythema of
• Tends to be recurrent
the canal
• Complications:
• Thick, clumpy
perforated tympanic
otorrhea
membranes common,
chronic otitis media
Otitis
Amoxicillin:
externa 80-90mg/kg/day for
10-14 days
Cipro or ofloxacin otic
drops
Sinusitis (1)

Pathology:
Viral upper respiratory tract infection
Viral rhinosinusitis
Acute bacterial sinusitis
Sinusitis (2)


Symptoms:
• Fevers, poor feeding
• Nasal congestion, purulent nasal discharge
• Cough for >10-14 days, or high fever to 39oC
and purulent discharge for 3-4 days, indicate
bacterial sinusitis
Treatment:
Mild cases
Amoxicillin 45mg/kg/day
More severe cases Amoxicillin-clavulanate
(80-90mg/kg/day)
Alternatives
Azithromycin, cotrim, cefuroxime,
8
ceftriaxone, levofloxacin
Pharyngitis


Usually caused by virus or Bacteria:
Group A streptococcus
Symptoms:
•
•
•
•
Fever
With/without rash
Sore throat
Large tonsils and lymph node on the
neck
9
Pharyngitis

Acute pharyngitis caused by Strep.
10
Lower Respiratory
Infections
11
Lower Respiratory Infections

Pneumonia is the number one cause
of deaths in children worldwide:
• Responsible for nearly 1 in 5 deaths, for
an estimated 1.8 million deaths annually
• Most cases are in Africa and South East
Asia
• Incidence may be higher where there is
high prevalence of HIV
• Occurs more often and more severe,
with higher mortality rates, in HIVinfected children
12
Pneumonia
– Etiology by Age
Age
Etiologies
<2 months
•Gram-negative organisms
•Anaerobes
•and PCP
<1 year
•PCP
<2 years
•Viral (RSV), mixed with bacteria
<5 years
•Bacterial:
>5 years
•Mycoplasma pneumoniae
•or Chlamydophila pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
and Staphylococcus aureus
TB?
LIP?
Pneumonia – Diagnosis
Non-severe
pneumonia
(can be
managed as
outpatient)
Diagnosis based on clinical presentation
Indicate:
•Pulse oximetry
Moderate to
•Microbiology:
severe
Obtaining sputum when possible
pneumonia
Blood culture
(especially in
•Acute phase reactant (CRP, ESR)
inpatient
•Complete blood count
setting)
•Viral specific testing
•CXR
Bacterial Pneumonia
15
Bacterial Respiratory Infections

Bacterial pneumonias were more
common in HIV-infected children
than HIV-uninfected:
S. pneumoniae
H. Influenzae B
S. aureus
E. coli
M. tuberculosis
43x
21x
49x
98x
23x
* Madhi SA et al, Clin Infect Dis 2000;31:170.
16
Bacterial Pneumonia
in HIV-infected Patients
Compared to non-HIV infected:
 More frequent, more severe, more
likely to be fatal
 Caused by a wider variety of
organisms, including resistant ones
 More likely to be polymicrobial
 More often accompanied by
bacteremia
17
Bacterial Pneumonia –
Clinical Presentation







Onset usually acute
High fevers, rigors, chills
Cough productive of sputum
Tachypnea, dyspnea
Chest pain
May have poor feeding,
nausea/vomiting
Rales often present on lung exam
18
Bacterial Pneumonia – CXR (1)

Often seen:
•
•
•
•
Lobar infiltrate
Bronchoalveolar infiltrate
Parapneumonic effusions
Pleural effusions
19
Bacterial Pneumonia – CXR (2)
Bacterial Pneumonia – CXR (3)
Bacterial Pneumonia – CXR (4)
Bacterial Pneumonia – CXR (5)
Bacterial Pneumonia –
Treatment
Inpatient
(moderate to severe
pneumonia)
Ampicillin +
gentamycin (WHO)
or Ceftriaxone
or cefotaxime
Outpatient
(mild to moderate pneumonia)
 Azithromycin (also for atypical
pneumonia)
 Amoxicillin/clavulanate
 Use Cotrimoxazole for PCP for all
infants ≤ 1 year
 Vancomycin, clindamycin if suspect
MRSA
 Levofloxacin or ciprofloxacin if
suspect resistant S. pneumoniae and
TB has been ruled out
Viral Respiratory
Infections
25
Viral Respiratory Infections (1)

Most viral infections manifest no differently
in HIV-negative children than in HIVpositive children until HIV disease is
advanced
• RSV, influenza, parainfluenza, coronaviruses,
rhinovirus, are similar except:


Virus is excreted for longer
For RSV, influenza and parainfluenza, wheezing is
less frequent
• Bacterial co-infections are more frequent
• Hospitalization and mortality rates are higher
26
Viral Respiratory Infections (2)

Outcomes are worse with certain
infections:
• Measles, varicella, CMV, adenovirus
• CMV pneumonia is present in advanced
HIV infection, usually as a co-pathogen,
especially in infants and young children
27
Viral Respiratory Infections (3)

Diagnosis:
• RSV: bronchiolitis
• Influenza: seasonal, with local circulation
• CMV: severe pneumonia. CXR with bilateral
infiltrates, CMV IgM+, PCR+ with high titer

Treatment: mostly supportive
• Influenza: oseltamivir (Tamiflu), zanamivir
(Relenza), peramivir (IV), amantadine,
rimantadine
• CMV: gancyclovir IV
28
Fungal Pneumonia
29
Fungal Pneumonia


Difficult to diagnose clinically
Diagnosis requires microbiology, specific testing
• Sputum or bronchoalveolar stain and culture,
biopsy

Fungal pneumonia in the immunocompromosed
patients is often part of a systemic, multi-organ
infection
• Cryptococcosis with meningitis
• Penicillium marneffei with skin lesions,
splenomegaly


CXR reveals no typical findings
Treatment according to etiology
30
Pneumonia – IMCI
Severity of
Pneumonia
Definitions
Mild
Cough or difficulty breathing with age-adjusted
tachypnea:
 Age 0-2 months: ≥60/min
 Age 2-11 months: ≥50/min
 Age 1-5 years: ≥40/min
 Age > 5 years: ≥20/min
Severe
Cough or difficulty breathing plus one of the following:
 Lower chest indrawing
 Nasal flaring
 Or grunting
Very
severe
Cough or difficulty breathing plus one of the following:
 Cyanosis
 Severe respiratory distress
 Inability to drink or vomiting everything
 Lethargy
 Loss of consciousness/convulsions
Pneumonia
– Criteria for Admission

Moderate to severe pneumonia, with respiratory
distress and hypoxemia (SpO2 <90%)

8 signs of respiratory distress
1.
Tachypnea, respiratory rate, breaths/min


2.
3.
4.
5.
6.
7.
8.
Age 0–2 months: .60
Age 2–12 months: .50
 Age 1–5 Years: .40
 Age .5 Years: .20
Dyspnea
Retractions (suprasternal, intercostals, or subcostal)
Grunting
Nasal flaring
Apnea
Altered mental status
Pulse oximetry measurement ,90% on room air
32
Case Study
33
Linh, Girl (1)


A 17 month old girl with fever and dyspnea
is transferred to your clinic
PM: 10 days prior to the admission, patient
presented fever (38), productive cough,
dyspnea. The fever and dyspnea went
worse with time. The child had no vomiting
or convulsion. The patient had been treated
at provincial hospital for 4 days without
improvement.
34
Linh, Girl (2)



Both parent are HIV positive, not yet on ART
The child was not on PMCTC; TB vaccination at
1 months
PE:
• alert, no fever, non-productive cough
• Blue lips while crying, subcostal withdrawing, BR:
70 per min, Sp02 : 82% no oxygen
• Lung: moist rales, sound breath decreased on the
left lung
• Heart: HR: 155 per min, regular
• Oral thrush
• Abdomen: soft, hepatomegaly, 4cm subcostal

HIV ELISA: Positive
35
Linh, Girl (3)

What do you see on
CRX?
At admission
• Opaque entire left
lung, mediasternal
shift

What is your clinical
diagnosis:
•
•
•
•
Bacterial pneumonia
Pleural effusion
Tuberculosis
PCP
36
Linh, Girl (4)

What possible diagnostic tests are necessary?
• WBC: 15 G/l
• Thoracentesis: pus fluid
• Pleural fluid culture: Staphyloccocus aureus, TB
PCR neagative
• PCR for TB from gastric lavage: negative

What is the diagnosis?
• Pneumonia and empyema

What is the best treatment plan?
• Pleural drainage
• Antibiotics: Vancomycin, Ceftriaxone, Amikacin
37
Linh, Girl (5)


The patient got better after 7 days treatment (no
fever, no dyspnea) and after two weeks patient
was discharged
HIV + confirmed, initiated ARV
After 7 days treatment
At the timing of discharge
Key Points


Otitis media is common in children with
HIV and should be treated with a long
course of antibiotics to prevent
complications
Recurrent bacterial pneumonia is common
in HIV infected children
39
Thank you!
Questions?
40