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Posted : admin On 29.12.2019The Spanish Association of Pediatrics has as one of its main objectives the dissemination of rigorous and updated scientific information on the different areas of pediatrics. Annals of Pediatrics is the Body of Scientific Expression of the Association and is the vehicle through which members communicate.
Publishes original papers on clinical research in pediatrics from Spain and Latin American countries, as well as review articles prepared by the best professionals in each specialty communications and annual meeting minute books of the Association, and practice guidelines developed by the various Societies / Sections Specialized integrated into the Spanish Association of Pediatrics. The magazine, referring to the Spanish-speaking pediatric, indexed in major international databases: Index Medicus / Medline, EMBASE / Excerpta Medica and Spanish Medical Index.
Derrame Pleural Portugues
The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotising pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.
While there is broader consensus on first-line antibiotic treatment, its choice should be determined on a case-by-case basis in a certain group of at-risk patients. There is greater controversy surrounding the best approach to the management of complicated cases with pleural effusion, both from a medical and a technical–surgical standpoint, which we will therefore analyse here. Supportive careIn addition to antibiotic treatment, children admitted with CAP require supportive care, a subject that was partly addressed in the previous consensus document and that we proceed to complete in this one. MonitoringPulse oximetry, which can be continuous. If the condition is serious, pCO 2 should be measured, as hypercapnia is a sign of impending respiratory failure. Respiratory support.
(A)Oxygen therapy: with nasal cannulae, masks or face tents if the basal oxygen saturation (SaO 2) is equal or lower than 92%, to achieve a FiO 2 of up to 40% with the prongs or up to 50% with Venturi masks. If this were not sufficient, high-flow cannulae or non-rebreather masks with 100% oxygen should be used, assessing the need for intensive care unit admission in the following hours except in cases with limitation of therapeutic effort. (B)Respiratory support: in exceptional cases, patients with CAP require mechanical ventilation. There is growing evidence of the advantages of non-invasive ventilation.Fluid and electrolyte managementBaseline requirements must be met by either the oral or, when necessary, the intravenous route. Patients with clinically significant heart disease may require fluid restriction (2/3) and diuretics.A third of the patients may have hyponatraemia (. This recommendation is mostly based on the expert recommendations documented in clinical guidelines. There have been no clinical trials that compared the efficacy of these antibiotics with that of broader-spectrum antibiotics, although there are retrospective studies that suggest the results are comparable.Hospitalised patients usually improve and can be switched to oral amoxicillin when they have remained afebrile for 24–48 h.
We recommend a course of treatment lasting 7–10 days.There is a high and unwarranted use of third-generation cephalosporins in hospitalised children with CAP. Thus, a multicentric study conducted in Spain showed that up to 34% of them received initial empirical treatment with these agents. Typical community-acquired pneumonia associated with other pathogenspresents various situations in which treatment with other antibiotics is recommended.
Amoxicillin/clavulanic acid is recommended in children that have not been vaccinated against Haemophilus influenzae ( H. Influenzae) type b and children less than 6 months of age, except for children younger than 3 months, in whom the recommended treatment is ampicillin–cefotaxime.In certain situations, and especially in severe cases, other bacteria should be considered, such as S. Aureus and S. Pyogenes, requiring different antibiotic treatment. The recommended empirical treatment for necrotising forms, which amount to 0.8% of CAP cases (and 6% of hospitalised patients with CAP) and in Spain are usually associated with S. Aureus (usually methicillin-susceptible but PVL-producing) followed by S. Pneumoniae, consists of a cefotaxime and clindamycin regimen for a minimum of 14–21 days.In children with CAP associated with influenza, usually caused by S.
Pneumoniae or less frequently by S. Pyogenes or H. Influenzae, empirical treatment with amoxicillin–clavulanic acid as opposed to amoxicillin or ampicillin is recommended.In children with varicella that have CAP of a suspected bacterial aetiology, the recommended treatment is antibiotics covering S. Pyogenes and S.
Aureus, such as cefuroxime, or in more severe cases, penicillin G or cefotaxime combined with clindamycin, especially in cases of necrotising pneumonia of with signs of toxic shock syndrome. Community-acquired pneumonia complicated by parapneumonic pleural effusionThe same antibiotics used in CAP without pleural effusion (ampicillin or penicillin) are recommended , save for exceptional cases detailed in, although they should be administered at higher doses to achieve adequate pleural fluid concentrations.It is recommended that administration is switched to the oral route once the patient has remained afebrile for 48 h, for a total course lasting 2–4 weeks depending on the causative agent, although treatment could be extended for a few more days in prolonged or severe cases. Atypical community-acquired pneumoniaThese cases are most frequently caused by viral infections, especially in children younger than 4 or 5 years, and they do not usually require admission to the hospital or antibiotic treatment. In children older than 4 or 5 years, in whom disease is more frequently caused by Mycoplasma pneumoniae and to a much lesser degree by Chlamydophila pneumoniae, treatment with macrolides is recommended, by the oral route whenever possible and otherwise intravenously.Clarithromycin and azithromycin are the two most commonly used antibiotics, at the same doses for both the oral and the intravenous preparations, with azithromycin being better tolerated. The use of erythromycin has waned due to its adverse effects, including phlebotoxicity when administered intravenously, and its complicated dosage (every 6 h for 10–14 days). Influenza can be treated with antivirals, and there are no oseltamivir-resistant strains in Spain. There are reasonable doubts concerning the effectiveness of oseltamivir in hospitalised patients with no risk factors, so its use should be restricted to hypoxaemic or seriously ill patients, especially those with significant underlying disease.
Severe community-acquired pneumonia that requires admission to the Paediatric Intensive Care UnitThe aetiological spectrum is broader: S. Pneumoniae, S. Pyogenes, and others. This consensus recommends cefotaxime, possibly in combination with an antibiotic with antistaphylococcal activity such as cloxacillin.
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Considering the association of S. Aureus, including MRSA, and influenza, it would be appropriate to use clindamycin (or vancomycin, depending on local data on susceptibility) combined with a cephalosporin (cefuroxime or cefotaxime). Typical CAP– Cefotaxime (200–300 mg/kg/day, every 6 h)+one of the following:– Cloxacillin IV (150–200 mg/kg/day, every 6 h)or– Clindamycin IV (30–40 mg/kg/day, every 6–8 h),or– Vancomycin IV (60 mg/kg/day, every 6 h)±Macrolide IV (erythromycin 40 mg/kg/day every 6 h, or clarithromycin 15 mg/kg/day, every 12 h; or azithromycin 10 mg/kg/day, every 24 h)Community-acquired interstitial pneumonia– Cefotaxime (200 mg/kg/day) + macrolide IV (erythromycin, clarithromycin or azithromycin)±– Cotrimoxazol IV (20 mg of trimetoprim/kg/day every 6 h). In adults, combination treatment with a macrolide results in reduced mortality, but there are no data on this subject for children. A study of children more than 5 years of age hospitalized with CAP of varying severity found that they had shorter lengths of stay. Antibiotic treatment in patients with underlying diseaseAlthough cases of pneumonia in these patients are usually community-acquired, they may have special characteristics: a great variety of potentially involved microorganisms, frequent coinfections, a broad range of clinical findings and a potentially greater severity. These circumstances lead to a greater number of diagnostic tests and more aggressive treatments.The probable aetiological agents depend on the underlying disease and the characteristics of radiographic findings.
Usual pathogens such as respiratory viruses and S. Pneumoniae should be generally considered, as well as non-typeable H. Underlying diseaseMain aetiological agentsMost commonly used treatmentsHumoral immunodeficiencyS. Pneumoniae, H. InfluenzaeLess common: Salmonella, Pseudomonas, S. AureusEnterovirusAmoxicillin–clavulanic acid, cefotaximeCombined immunodeficiency– Encapsulated bacteria, Listeria, P. Aeruginosa, Stenotrophomonas, Burkholderia cepacia, Legionella, Nocardia– VZV, rubella, VHS, CMV, adenovirus, RSV, influenza, parainfluenza, hMPV– MAC, M.
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Fortuitum, BCG, other opportunistic mycobacteria. Reactivation TB – Pneumocystis jirovecii, Aspergillus, C.
Albicans, CryptococcusCefotaxime, cefepime, cotrimoxazol, acyclovir, antifungals (fluconazole, voriconazole, liposomal amphotericin B)Phagocytic cell disorders/neutropeniaS. Aeruginosa, Stenotrophomonas, B.
Marcescens, enterobacteria such as Salmonella, E. Coli, Nocardia. BCG, non-tuberculous mycobacteria Aspergillus, CandidaAmoxicillin–clavulanic acid, cefotaxime. Cloxacillin, clindamycin, vancomycin.
Piperacillin–tazobactam, cefepime or meropenem. Antifungals (voriconazole, liposomal amphotericin B)HIV infectionS.
ResultsSixty-three patients were included in the study. An increase of 29% was observed in the number of patients admitted with parapneumonia effusion from 2005 to 2006. The most common aetiology was Streptococcus pneumoniae. In 65% of patients pleural effusion was an empyema and in 33% it was an exudate. In all patients with C-reac-tive protein below 100 mg/L the effusion was an exudate, whereas 81% of patients with C-reactive protein above 170 mg/L had an empyema, p.