1 of 28

PAN WEBINAR SERIES�29TH NOVEMBER 2023

2 of 28

11/28/2023

3 of 28

THE NEW NATIONAL ALGORITHM FOR INPATIENT MANAGEMENT OF COMMUNITY ACQUIRED CHILDHOOD PNEUMONIA � – WHAT CAN WE LEARN?

4 of 28

OUTLINE

11/28/2023

Burden of pneumonia

Who is affected?

CAP GUIDELINE

WPD

Why the need for an algorithm?

The algorithm explained

Conclusion

5 of 28

BURDEN

  • Pneumonia is the leading cause of death in children under five years accounting for 15% of all-cause mortality of children globally.
    • It kills more children under 5 years of age globally than HIV/AIDs, malaria, diarrhoea, and measles combined at rate of approximately 2500 per day.3
  • In sub-Sahara Africa different regions show a variable burden of childhood pneumonias.
  • Nigeria’s position has shifted from 5th to first position as the country with highest mortality due to pneumonia in the world
    • In 2018 about 3% of Nigerian children under the age of 5 years were reported with symptoms of acute respiratory infection.
      • with 162,000 child deaths annually.

​

11/28/2023

6 of 28

11/28/2023

7 of 28

Where do children die from pneumonia

11/28/2023

The children are most likely to die from pneumonia across Sub-Saharan Africa and South Asia.

The deaths in just 5 countries — India, Nigeria, Pakistan, the Democratic Republic of Congo, and Ethiopia – accounted for more than half of all deaths from childhood pneumonia in 2019.

8 of 28

11/28/2023

9 of 28

11/28/2023

10 of 28

2022 PAN UPDATED CAP GUIDELINES

11/28/2023

11 of 28

PNEUMONIA MANAGEMENT – excerpts from PAN guideline

  • History should explore LRTI information in the preceding 2-3 weeks prior to presentation.
  • Respiratory rates are best determined over a full 60-second period
  • Pulse oximetry
  • Serum procalcitonin, is a useful tool for decision-making
  • Appropriate interventions:health education on exclusive breastfeeding, increasing vaccination coverage, and early control of respiratory tract infection etc

​

​

​

  • The presence of one or more of: inability to drink/ feed, intractable vomiting, convulsions, lower chest in-drawing, central cyanosis, lethargy, nasal flaring, grunting, head nodding, and oxygen saturation <90% should be considered highly suggestive of severe pneumonia requiring hospitalization. [Evidence level III; Grade B-]
  • No single clinical finding is sufficient in determining the presence or absence of pneumonia; ETC

11/28/2023

12 of 28

-the ‘cumbersomeness 'of guidelines

  • Not everyone will have the access, time and ability to read assimilate and practice the details contained in the CAP guideline
    • This is more so a problem for the lower cadre of workers
  • Many have received combined IMCI training for many childhood diseases and outpatient management of pneumonia/ danger signs are covered using the Community case management of pneumonia approach
    • includes training community health workers (CHWs) taught to administer antibiotics to suspected child pneumonia cases in villages.

​

11/28/2023

13 of 28

-the in-patient algorithm

  • The adherence to the guidelines is poorer when the CHW are required to manage several illnesses or children with severe signs
  • Thus for children requiring in-patient management a separate simplified tool that brings out the main facts and what to do was needed
  • Thus in conjunction with the Federal ministry of health/UNICEF and the PAN Pneumonia team : led by Prof Ekure and Prof Osarogiagbon and a team of other experts went to task to accomplish this assignment & the algorithm in one page
  • - shows quick diagnostic steps
  • - quick supportive treatment steps
  • - antibiotics and what next to do

​

11/28/2023

14 of 28

NOVEMBER 12TH every year�The theme for 2023 centres on championing the fight to stop pneumonia.

11/28/2023

  • AND THUS THE NEED TO SHARE AGAIN THE NEW IN-PATIENT ALGORITHM

15 of 28

11/28/2023

16 of 28

The Algorithm components

11/28/2023

17 of 28

11/28/2023

18 of 28

11/28/2023

19 of 28

11/28/2023

Antibiotic Treatment Recommendations

Age range

Outpatients First line

​

Alternatives

<2 months

Admit and treat as neonatal

sepsis

​

≥2 months

High dose oral Amoxicillin (90mg/ kg/d in 2 divided

doses) for at least 5 days

Oral Amoxicillin- clavulanic Acid (Amoxicillin 90mg/kg/d in 2 divided doses)

OR

Oral Cefpodoxime (10mg/ kg/d in 2 divided

doses)

OR

Oral Cefuroxime (20- 30mg/kg/d in 2 divided doses) for at least 5 days

OUTPATIENTS

20 of 28

11/28/2023

21 of 28

11/28/2023

Age range

First line

Alternatives

≥2 months

​

IV Amoxicillin (150mg/kg/day

in 3 divided doses),

OR

IV Cefuroxime (150mg/kg/d in 3

divided doses)

AND

IV/IM Genticin (5-7.5mg/kg od) for at least 5 days

IV Ceftriaxone (50-100mg/kg/d every 12

-24hours)

OR

IV Cefotaxime (100- 200mg/kg/d in 4 divided doses)

OR

IV/IM Genticin (5-7.5mg/kg od for at

least 5 days), AND

IV Cloxacillin (100-200mg/kg in 4 divided doses)

​

Children

living with

HIV

​

​

IV Amoxicillin (150mg/kg/d in 3 divided doses),

OR

IV Cefuroxime (150mg/kg/d in 3

divided doses) PLUS

IV/IM Genticin (5-7.5mg/kg od)

​

IV ceftriaxone (50-100mg/kg/d every 12

-24hrs),

OR

IV Cefotaxime (100- 200mg/kg/d in 4

divided doses)

INPATIENTS

22 of 28

11/28/2023

Children

living with

HIV

​

PLUS

high dose CotrimTMP/ SMX

(20mg/kg/d of trimethoprim) for

at least 10 days

​

PLUS

high dose Cotrimoxazole (20mg/ kg/d trimethoprim in 4 divided doses) for

at least 10 days

PLUS

IV/IM Gentamycin (5 – 7.5mg/kg od)

​

​

Children

with

Sickle cell

disease

​

IV Amoxicillin (150mg/kg/d in 3 divided doses),

OR

IV Cefuroxime (150mg/ kg/d in 3 divided doses),

PLUS

IV/IM Genticin (5-7.5mg/kg od)

PLUS

oral Erythromycin (60-100mg/ kg/d in 4 divided doses) for at least 5 days.

​

IV Ceftriaxone (50- 100mg/kg/d 12-

24hrly),

OR

IV Cefotaxime (100- 200mg/kg/d in 4

divided doses),

OR

oral azithromycin (10 mg /kg) od dose

for 3 days,

AND

IM/IV Gentamycin (5-7.5mg/kg/od) for at least 5 days,

PLUS

oral Azithromycin (10mg/kg/d for 3

days).

23 of 28

11/28/2023

When to consider transfer to ICU

  • If clinical state does not improve after 48 hours or worsens within this period
  • If the child requires mechanical ventilation at presentation
  • Progressive/persistent de-saturation (<92%), or deepening cyanosis
  • If BP remains low OR capillary refill time is prolonged (shock)
  • Altered/deteriorating mental status
  • Presence of any complications

24 of 28

11/28/2023

Consider for home discharge

  • When clinical features fast breathing, respiratory distress, oxygen requirement and fever have resolved for at least 24 hours

​

  • Able to feed by mouth

​

  • Tolerates oral medications

​

  • Review immunisation records and make plans to update

​

  • Make plans for update in 48 hours

25 of 28

  • THANK YOU
  • - BACK TO DR AYUK

11/28/2023

26 of 28

11/28/2023

Concluding remarks

  • The PAN in-patient pneumonia algorithm has long been launched, adopted and various stepdown done across the country to ensure appropriate utility

​

  • In the spirit of the WPD we have also presented this to the PAN community

​

  • Lets all join hands to stop pneumonia deaths and reduce the statistics from Nigeria as we help get this in-patient pneumonia algorithm everywhere possible!
  • THANK YOU ONCE AGAIN

​

11/28/2023

27 of 28

REFERENCES

11/28/2023

​

1. McAllister DA, Liu L, Shi T,Chu Y, Reed C, Burrows J et al. Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015 : a systematic analysis. Lancet Glob Health. 2019;7(1):e47e57. doi:10.1016/S2214-109X (18)30408-X.

2. Child survival and the SDG.Available at https:// data.unicef.org/topic/childsurvival/child-survival-sdgs/. Last accessed September 2021.

3. Olowu A, Elusiyan JBE,Esangbedo D, Ekure EN, Esezobor C, Falade AG et al. Management of community acquired pneumonia (CAP) in children: Clinical practice guidelines by the Paediatrics Association of Nigeria (PAN). Niger J Paed 2015;42(4):283– 292. http://dx.doi.org/10.4314/ njp.v42i4.1

4. The ADAPTE Collaboration(2009). The ADAPTE Process: Resource Toolkit for Guideline Adaptation. Version 2.0 Available from: http://www.g-i-

n.net. Last accessed September 2021.

5. Lim WS, Baudouin SV,

George RC, Hill AT, Jamieson

C, Le Jeune I, et al. British

Thoracic Society Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Update 2009. Thorax 2009; 64 (Suppl III):iii1–iii55. doi:10.1136/ thx.2009.121434

6. Reubenson G, Avenant T, Moore DP, Itzikowitz G, Andronikou S, Cohen C, et al. Management of communityacquired pneumonia in children: South African Thoracic Society guidelines (part 3). S

Afr Med J 2020;110(8):734740. https://doi.org/10.7196/ SAMJ.2020.v110i8.15020.

7. Bradley JS, Byington CL,Shah SS, Alverson B, Carter

ER, Harrison C, et al. Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of communityacquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011 Oct;53(7):e25e76. doi: 10.1093/cid/cir531.

8. Mackenzie G. The definitionand classification of pneumonia. Pneumonia 2016;8:14. doi

10.1186/s41479-016-0012-z 9. World Health Organization. Revised WHO Classification and Treatment of Pneumonia in Children at Health Facilities: Evidence Summaries. Geneva: WHO, 2014. Available at https://www.who.int/ publications/i/ item/9789241507813. Last accessed October 2021.

10. Modi AR, Kovacs CS. Hospital-acquired and ventilatorassociated pneumonia: Diagnosis, management, and prevention. Cleveland Clinic J Med 2020; 87:633-639.

11. Beletew B, Bimerew M,Mengesha A, Wudu M, Azmeraw M. Prevalence of pneumonia and its associated factors among under-five children in East Africa: a systematic review and meta-analysis. BMC Pediatr 2020; 20: 254. doi: 10.1186/s12887-02002083-z.

28 of 28

Questions/interactions

11/28/2023