Archive for the ‘Respiratory’ Category

NEW HOPE FOR PNEUMONIA DR.D.K.JHA M.D

Saturday, November 11th, 2017

Pneumonia is responsible for highest number of death in children below 5 years of age worldwide.

The highest number of pneumonia cases in children are found in India.

There are numerous causes of pneumonia including viruses,bacteria,fungi among infectious causes.

Streptococcus peumoniae and Haemophilus influenzae type b(HIB) account for 60% of cases of community acquired pneumonia in Indian children below 5 years of age .

These community acquired bacterial pneumonia are treated by antibacterial agents(ANTIBIOTICS) as a mainstay of treatment.

There is an increasing incidence of resistance of these organisms to existing antibiotics.

Moreover,there are very few antibiotics in the pipeline research to fight these resistant bacteria.

There is urgent need of a new antibiotic to fight resistant community acquired bacterial pneumonia.

World health organisation(WHO) has oversimplified the definition of pneumonia so that no case of pneumonia should be misssed even by ground level health workers.

According to WHO

NO tachypnea=No peumonia

Tachypnea=Pneumonia

Tachypnea with chest retraction=Severe pneumonia

Tachypnea with chest retraction with cyanosis/lethargy/poor feeding=very severe pneumonia

According to the definition and categorization by WHO, pneumonia is overdiagnosed as these findings may be present in children suffering from respiratory diseases other than pneumonia like bronchiolitis and asthma.

Pneumonia in children is diagnosed by a combination of clinical features and investigations.

CLINICAL FEATURES: Fever

Tachypnea:(Respiratory rate>60/minutes below 2 months of age,>50/minute between 2-12 months of age,>40/minute between 1-5 years of age and more than 30/minute between 6-8 years of age)

Tachycardia:(Pulse rate>160/minute between 2-12 months of age,>120/minute between 1-2 years of age and >110 between 2-8 years of age

Chest retraction In the form of subcostal,intercostal and suprasternal retraction

Auscultatory finding: Diminished intensity of breath sound over affected area and deep inspiratory crackles are indication of consolidation in lung parenchyma which is pathognomonic of pneumonia.Bronchial breath sound and wheezes may be heard.

In severe pneomonia, clinical cyanosis may be visible or hypoxia may be detected by pulse oximetry.

INVESTIGATION:Complete blood count may show leucocytosis with predominance of polymorphoneuclear cells.

CRP is significant only if it more than 20mg/dl and blood culture is positive in only 15-20% cases

CHEST X-RAY : it may show nonhomogenous opacity in the lung field indicative of consolidation.Air bronchogram if visible is pathognomonic of consolidation.If opacity is involving a lobe ,it is lobar pneumonia and if the opacity is in bronchial distribution bilaterally, it is bronchopneumonia. Pneomatocele may be visible in Staph Pneumonia.

TREATMENT;The mainstay of treatment of bacterial pneumonia is antibiotics with or without supportive care in the form of intravenous fliud and oxygen if needed.

Oral amoxycillin is the drug of choice in OPD cases.If resistance to it is suspected the doses may be  doubled or a combination of amoxycillin and clavulanic acid may be given.Alternative agents are cefuroxime or cefprozil. Azithromycin should be given only when Mycoplasma or Chlamydia pneumonia are suspected.

In admitted patient the drug of choice is intravenous third generation  cephalosporin.If Staph Pneumonia is suspected Vancomycin or Clindamycin should be given.It should be for 3 days after the child becomes afebrile or for 10 days whichever is later.

There is a new hope for the growing resistance of bacteria to commonly used antibiotics.

Lefamulin belongs to a new class of antibiotics called Pleuromutilins.

Is has the same clinical profile as moxifloxacin which is also used to treat resistant tuberculosis apart from community acquired bacterial Pneumonia.Similar rates of adverse affects has been seen in both the drugs.The efficacy to kill bacteria is also the same.Lefamulin acts by binding to a specific site of bacterial ribosome responsible for protein synthesis.Retapumilin was the first drug of Pleuromutilin group ,approved for human use.This drug Retapumilin is approved for topical use.

Lefamulin has been tried successfully and it is in the final stage of trial . Probably it will hit the the market in the later half of 2018 if approved by FDA.If so,it will be the first drug approved for oral or intravenous use from Pleuromutilin group.Once it will come in the market it may help in treating resistant community acquired bacterial pneumonia and it may spare the drug moxifloxacillin for its use in resistant Tuberculosis as well.

REFERENCES:1.WHO Library Cataloguing-in-Publication Data
Revised WHO classification and treatment of pneumonia in children at
health facilities: evidence summaries.
1.Pneumonia – drug therapy. 2.Child. 3.Health Facilities. 4.Guideline.
I.World Health Organization.
ISBN 978 92 4 150781 3 (NLM classification: WA 320)

2.Expert panel report 3,guidelines for the diagnosis and management of asthma,NIH publicationNo.07-4051,Bethesda ,MD, 2007.U.S Dpartment of health and human services;National institute of health,National heart,,lung and blood institute,National Ashma Education and Prevention Program.

3.Nabriva’s Pneumonia Drug Succeeds in Late-stage Trial – Medscape – Sep 18, 2017.

4. Nelson Text book of Pediatrics ,edition-20