Community Acquired Pneumonia

Speaker: Lilliam Ambroggio, United States & Giulia Brigadoi, Italy

Case 1: Stuart – Suspected Bacterial Pneumonia (Moderate Severity)

• Age/Gender: 11-month-old male
• Symptoms: 5-day fever (peaking at 39.8°C), cough, runny nose, appetite loss
• Previous Treatment: Poor adherence to outpatient amoxicillin
• ED Findings: Mild tachypnea, right lower lobe crackles, no rash
• Vitals: HR 150, RR 48, O2 sat 95%, Temp 38.4°C
• Imaging: Chest X-ray showed right lower lobe consolidation
• Lab Results:
  • CRP: 111 mg/L
  • Procalcitonin: 1.4 ng/mL

Diagnosis and Management:

1. Decision made to admit due to pneumonia signs and moderate severity.
2. Antibiotic Recommendation:
   1. First-line: High-dose oral amoxicillin (90 mg/kg/day TID) if tolerated
   2. Alternative (IV route): Ampicillin or Penicillin G for patients unable to take oral drugs
   3. Early switch to oral therapy is encouraged to reduce hospital stay.

Case 2: Kevin – Likely Mycoplasma Pneumonia (Mild Case)

• Age: 8 years
• Symptoms: 8-day fever >38°C, maculopapular rash, urticaria, cough, muscle aches
• Previous Treatment: 3-day course of amoxicillin
• Vitals: HR 90, RR 24, O₂ sat 98%, Temp 37.4°C
• Physical Exam: Well-appearing, mild rales
• Lab Results:
  • CRP: 31 mg/L
  • Procalcitonin: 0.06 ng/mL
• Imaging: Interstitial pattern on chest X-ray

Diagnosis and Management:

1. Etiology: Suggestive of atypical pneumonia (likely Mycoplasma)
2. Antibiotic Options:
   1. May withhold antibiotics (self-limiting nature)
   2. If needed (due to rash or prolonged symptoms): Azithromycin, Clarithromycin, or Doxycycline

Case 3: Sofia – Viral Pneumonia (Very Mild Case)

• Age: 5 years
• Symptoms: 1-day fever, cough, runny nose; sibling has similar symptoms
• Vitals: HR 120, RR 38, O₂ sat normal, Temp 37.9°C
• Exam: Well-appearing with mild wheezing
• Management: No labs or imaging ordered

Treatment Decision:

1. No antibiotics prescribed (Watchful waiting approach). Criteria for withholding antibiotics:
   1. Mild symptoms
   2. Well-appearing child
   3. Close follow-up feasible
2. If antibiotics needed:
   1. First-line: Oral amoxicillin (40–90 mg/kg/day based on local resistance)
   2. For unvaccinated children: Amoxicillin-clavulanic acid
   3. Penicillin allergy: Macrolides or tetracyclines based on reaction type

Case 4: Charlotte – Complicated Pneumonia with Pleural Effusion

• Age: 6 years
• Symptoms: 4-day fever (to 39.8°C), cough, loss of appetite, abdominal pain, increased work of breathing
• Vitals: HR 165, RR 38, O2 sat 90%, ill-appearing
• Exam: Intercostal retractions, nasal flaring, decreased breath sounds
• Labs:
  • CRP: 328 mg/L
  • Procalcitonin: 8 ng/mL
• Imaging: Chest X-ray showed pleural effusion and left-sided consolidation
• Further deterioration: Persistent fever and worsening inflammation despite therapy
• Follow-up CT: Large, loculated pleural effusion

Antibiotic Management:

1. Empiric therapy: Ceftriaxone or cefotaxime plus clindamycin or vancomycin for anti-staphylococcal coverage (based on resistance)
2. Pleural Effusion Management:
   1. Initial approach:
      1. Chest tube drainage with or without fibrinolytics (e.g., urokinase, streptokinase)
      2. In loculated effusion (as in Charlotte): Drainage + fibrinolytics preferred
   2. Advanced options (if no improvement):
      1. Video-assisted thoracoscopy (VATS) as rescue or primary strategy
      2. DNase & open thoracotomy is not recommended in children

Key Clinical Guidelines Recap:

• Outpatient, mild CAP: No routine imaging or testing; use amoxicillin if needed
• Moderate to severe CAP: CRP, procalcitonin may guide initiation/discontinuation of antibiotics
• Mycoplasma pneumonia: Macrolides only when clinically indicated; self-limiting in most cases
• Complicated pneumonia: Requires targeted antibiotics and possible pleural intervention
• Avoid unnecessary antibiotic use in children with viral pneumonia or mild symptoms

Complicated Urinary Tract Infection

Speaker: Michael Buettcher, Switzerland

Introduction:

Complicated UTI: A UTI in a child at higher risk of treatment failure due to anatomical, functional, or immunological factors.

Key subgroups:

• Known anatomical/functional abnormalities (e.g., VUR, post-surgical)
• Multiple recurrent UTIs
• Severe clinical presentations (e.g., sepsis, nephronia)
• Non-urological comorbidities (e.g., immunocompromised)
• Neonates (<3 months)

Diagnostic Workup:

• Initial workup: Clinical history, urine analysis, urine culture, blood tests (FBC, CRP, creatinine), renal ultrasound.
• Further imaging: DMSA, MCUG, or MRI based on age, severity, and underlying abnormalities.
• Avoid over-diagnosis: Use clean catch or catheter/suprapubic aspiration urine samples to minimize contamination.

Treatment Strategies:

• Antibiotic prophylaxis recommended for high-grade VUR, spina bifida, bowel-bladder dysfunction, and uncircumcised boys with recurrent UTI.

Case Summaries:

Case 1: 6-Week-Old Male Infant

• Presentation: Fever (39.2°C), rhinorrhea, good hydration, reduced feeding, single vomiting episode.
• Urine: Clean catch positive for E. coli (>10⁵ CFU/mL), fully sensitive.
• Treatment: Started on co-amoxiclav, de-escalated to amoxicillin.
• Imaging: Ultrasound showed renal pelvis and ureteric dilatation.
• Follow-up: MCUG confirmed grade 4 VUR → Started on prophylaxis.

Case 2: 2-Month-Old Male

• History: Known bilateral hydronephrosis.
• Presentation: Afebrile, poor feeding, vomiting, failure to thrive.
• Labs: Hyponatremia, hyperkalemia, metabolic acidosis (pseudo-hypoaldosteronism).
• Urine: E. coli resistant to co-amoxiclav, sensitive to cefuroxime.
• Treatment: IV cefuroxime, then oral antibiotics + prophylaxis.
• Imaging: Bilateral high-grade (VUR 5 & 4).

Case 3: 7-Year-Old Girl

• History: Past E. coli UTI, grade 4 bilateral VUR, off prophylaxis at age 5.
• Presentation: Fever (40°C), vomiting, right flank pain, dehydration.
• Labs: High CRP (316), pyuria, mild thrombocytopenia.
• Imaging: Enlarged echogenic kidneys, MRI showed focal bacterial nephritis (lobar nephronia).
• Treatment: IV ceftriaxone → escalated to meropenem + gentamicin → resolution after 72 hrs.
• Outcome: Repeat MCUG showed grade 3 bilateral VUR → Underwent endoscopic VUR correction; doing well on follow-up.

Key Takeaways:

1. Complicated UTIs should be classified into clear subgroups for targeted treatment and follow-up.
2. Always use proper urine collection methods to avoid overdiagnosis.
3. Tailor therapy duration and escalation based on clinical severity and pathogen resistance.
4. Consider MCUG and prophylaxis in high-grade VUR or recurrent infection cases.
5. Watch for pseudo-hypoaldosteronism in young infants with electrolyte disturbances and UTI.

ESPID 2025, 26-30 May, Bucharest