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La gestione del bambino con sospetta polmonite Nicola Principi.

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Presentazione sul tema: "La gestione del bambino con sospetta polmonite Nicola Principi."— Transcript della presentazione:

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2 La gestione del bambino con sospetta polmonite Nicola Principi

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4 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)

5 FREQUENZA RESPIRATORIA E PRESENZA DI CAP NEL BAMBINO EtàFrequenza 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

6 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

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8 Esposito S et al., Pediatr Infect Dis 2012

9 ETIOLOGY OF CAP IN FINNISH HOSPITALIZED CHILDREN AGE (Years) N°VIRAL ETIOLOGY BACTERIAL ETIOLOGY MIXED ETIOLOGY ALL * < > TOTAL *Total with detected etiology. Results expressed as percentages of patients. Adapted from Juven et al. Pediatr Infect Dis J. 2000

10 Episodes of Rx-confirmed CAP with viruses in children aged months (Esposito S et al., Influenza & Other Resp Viruses 2013) VIRUSNo. (%) * Coinf. No.(%)^ No. (%)* Coinf. No.(%)^ No. (%)* Coinf. No.(%)^ No. (%)* Coinf. No.(%)^ RSV35 (41.1) 1658 (38.6)2130 (30.3) (36.8) 47 Rhinovirus26 (30.5) 1544 (29.3)2124 (24.2) 794 (28.1) 43 Bocavirus12 (14.1) 915 (10.0)1112 (12.1) 639 (11.6) 26 Influenza4 (4.7)116 (10.6)610 (10.1) 139 (11.6) 8 Metapneumo. 12 (14.1)513(8.6)46 (6.1)031 (9.2)9 Coronavirus3 (3.5)27 (5.8)35 (5.0)415 (4.5)9 Parainfluenz a (1-4) 0 (0)04 (2.6)26 (6.1)210 (3.0)4 Adenovirus1 (1.1)04 (2.6)32 (2.0)17 (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) Total episodes % among the total number of CAP investigated; ^ % of the total number of infections in which the single virus was identified

11 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 Jun;31(6):e doi:

12 PNEUMOCOCCAL SEROTYPES IN CHILDREN WITH CAP AGED <5 YRS BEFORE THE USE OF PCV-13 (Esposito S et al., Pediatr Infect Dis 2012 ) COVERAGE PCV-7 : 28% PCV-10: 36% PCV-13: 74%

13 PNEUMOCOCCAL SEROTYPES IN PEDIATRIC CAP (Resti M et al. Clin Infect Dis 2010)

14 CAP AND ATYPICAL BACTERIA IN 418 CHILDREN Principi et al. Clin Infect Dis 2001 %

15 BACTERIAL vs VIRAL PNEUMONIA Virkki et al. Thorax 2002 N=215 Bacterial Viral % % Alveolar infiltrates Interstitial infiltrates 4852 WBC >15 x 10 9 /l 6337 ESR > 30 mm/h 6436 CRP > 40 mg/l 7030 CRP > 80 mg/l 7525

16 ADVANTAGES AND LIMITS OF PROCALCITONIN IN CLINICAL PRACTICE From Gendrel D et al. Pediatr Infect Dis J 1999

17 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 Bacterial Versus Viral Pneumonia Virkki R et al Thorax, 2002

18 EFFICIENCY OF RAPID DIAGNOSTIC TESTS FOR INFLUENZA VIRUSES IN OFFICE PRACTICE TESTDIRECTIGEN FLU A+B Z STAT FLU QUICKVUE INFLUENZA TEST FLU OIA COMPANYBECTON DICKINSON ZYME TX, INC. QUIDELBIOSTAR SENSITIVITY (%) 67 (T) 62 (T) 73 (N) 62 (T) SPECIFICITY (%) 92 (T) 99 (T) (N) 79.5 (T) T= Throat Swab; N= Nasal Swab Benjamin J. Contemp Pediatr 2000

19 TEST MICROBIOLOGICI PER LA DIAGNOSI EZIOLOGICA DI CAP TESTVANTAGGILIMITI Tampone nasofaringeo Facile esecuzioneNon correla con i dati polmonari se non per virus e batteri atipici Coltura dell´espettorato Buona sensibilitáNon attendibile nel bambino piccolo EmocolturaFacile esecuzioneBassa sensibilitá Puntura polmonare Facile esecuzione, buona sensibilitá Media invasivitá Puntura cricoideaBuona sensibilitáAlta invasivitá BALBuona sensibilitáAlta invasivitá

20 NASOPHARYNGEAL COLONIZATION (%) IN PNEUMONIA VS HEALTHY CHILDREN From Nohynek et al. Pediatr Infect Dis J 1995

21 RISULTATI DEL TEST RAPIDO BINAX NOW PopolazioneTot. con Binax NOW positivo (%) Binax NOW pos e colonizzaz. NF (%) Binax NOW pos e assenza di colonizzaz. NF (%) Casi con IPD5/5 (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) Controlli35/200 (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

22 DIAGNOSTIC TESTS FOR M. PNEUMONIAE AND C. PNEUMONIAE TEST SPECIMEN COMMENTS CULTUREThroat or NP swab,Requires tissue culture; not sputum, bronchialroutinely available; requires washing, tissue several days of incubation PCRThroat or NP swab, No FDA-approved kits; available sputum, bronchialfrom research laboratories; washing, tissuepotential for rapid diagnosis SEROLOGYSerumPaired acute-convalescent sera preferred; IgM may take up to 4-6 weeks to appear (therefore retrospective)

23 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

24 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, anti- staphylococcal penicillin or, in areas where methicillin- resistant strains of S. aureus have appeared, an active non beta-lactam agent (such as clindamycin or vancomycin) should then be added to the regimen

25 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

26 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

27 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

28 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 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 BETA- LATTAMICO BETA-LATTAMASI RESISTENTE (ES. CEFALOSPORINA EV) IN ASSOCIAZIONE A UN MACROLIDE PER OS O EV Durata usuale della terapia: giorni LIVELLO DI PROVA: 6; FORZA DELLA RACCOMANDAZIONE: B

29 ROLE OF PNEUMOCOCCAL PENICILLIN RESISTANCE ON CAP OUTCOME (From Cardoso MRA et al., Arch Dis Child 2008)

30 From ECDC, 2013

31 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 ore, aggiungere: AMOXICILLINA ORALE (80-90 mg/kg/die in 3 dosi) NEI CASI GRAVI USARE DA SUBITO UN BETA- LATTAMICO BETA-LATTAMASI RESISTENTE (ES. CEFALOSPORINA EV) IN ASSOCIAZIONE A UN MACROLIDE PER OS O EV Durata usuale della terapia: giorni LIVELLO DI PROVA: 6; FORZA DELLA RACCOMANDAZIONE: B

32 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

33 THROUGH SERUM LEVELS OF GLYCOPEPTIDES ACCORDING TO INITIAL DOSAGE (25, 40 OR 50 MG/KG/DIE) (F rom Ito H et al., J Infect Chemother 2013)

34 Drug Main finding Linezolid It seemed to be effective in % of children with pneumococcal bacteremia or pneumonia; few data concerning its effect on pneumococcal penicillin- resistant strains Ceftobiprole 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) Ceftaroline It had greater in vitro activity (MIC=0.5 µg/mL) than penicillin, cefotaxime or ceftriaxone (MIC=8 for all the comparators) NEW DRUGS FOR THE TREATMENT OF PNEUMOCOCCAL INFECTIONS WITH INTERESTING PRELIMINARY RESULTS (From Esposito S & Principi N. Expert Opinion Pharmacotherapy 2013)

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37 Antibiotic (Ab) exposure by treatment group and CAP severity (From Esposito S et al., Respir Med 2011)

38 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)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)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 hours (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 hours (strong recommendation; low-quality evidence)) Chest Radiography IDSA guidelines; CID Kindly proded by Prof. Greenberg


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