NURSING PROFILE Name: A.A. Hospital Number: 01-69-42 Age: 27 days old Weight: 4.

71 kgs Address: Inapoy, Mabinay, Negros Oriental Chief Complaint: Cough assoc. w/ cyanosis Date of Admission: Nov. 7, 2013 @ 7:05 PM History of Present Illness: 3 days PTA: Cough & Coryza. Consultation w/ Amoxicillin & NaCl nasal spray Afternoon PTA: Cough Exacerbations increased in severity and with circumoral cyanosis Physical Examination: V/S: T = 36.6 C, CR= 162 bpm, RR=52 cpm Cough Restlessness Cyanosis (mouth) (+) Rales both lungs Rhonchi Pediatric COMMUNITY-ACQUIRED PNEUMONIA - severe risk Pneumonia is a substantial cause of morbidity and mortality in childhood throughout the world, rivaling diarrhea as a cause of death in developing countries. Pneumoniaacute infection of the pulmonary parenchyma accompanied by symptoms of acute illness and abnormal chest findings (atleast 1: Diminished breath sounds, rhonchi, crackles & wheezes) acquired in the community w/in 24 hrs to < 2wks or occuring </= 48 hrs of hospital admission in pts. Who do not meet the criteria for health care associated pneumnia. ETIOLOGIC AGENTS ACCORDING TO AGE GROUP:

The cause of pneumonia in an individual patient is often difficult to determine because direct culture of lung tissue is invasive and rarely performed. Cultures performed on specimens obtained from the upper respiratory tract or sputum often do not accurately reflect the cause of lower respiratory tract infection. With the use of state-of-the-art diagnostic testing, a bacterial or viral cause of pneumonia can be identified in 40-80% of children with community-acquired pneumonia. Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen in children 3 wk to 4 yr of age, whereas Mycoplasma pneumoniae and Chlamydophila pneumoniae are the most frequent pathogens in children 5 yr and older. In addition to pneumococcus, other bacterial causes of pneumonia in previously healthy children in the USA include group A streptococcus (Streptococcus pyogenes) and Staphylococcus aureus. (Table ABOVE). The incidence of H. influenzae has been significantly reduced in areas where routine Hib immunization has been implemented. Unlike bronchiolitis, for which the peak incidence is in the 1st yr of life, the highest frequency of viral pneumonia occurs between the ages of 2 and 3 yr, decreasing slowly thereafter. (Ref.: Nelson Pediatric..) PATHOPHYSIOLOGY: From Medscape: The main function of the respiratory system is to supply sufficient oxygen to meet metabolic demands and remove carbon dioxide. A variety of processes including ventilation, perfusion, and diffusion are involved in tissue oxygenation and carbon dioxide removal. (Bret, Medscape) The lower respiratory tract is normally kept sterile by physiologic defense mechanisms, including mucociliary clearance, the properties of normal secretions such as secretory immunoglobulin A (IgA), and clearing of the airway by coughing.(Nelson, 2011) Viral pneumonia usually results from spread of infection along the airways, accompanied by direct injury of the respiratory epithelium, which results in airway obstruction from swelling, abnormal secretions, and cellular debris. Bacterial pneumonia most often occurs when respiratory tract organisms colonize the trachea and subsequently gain access to the lungs. When bacterial infection is established in the lung parenchyma, the pathologic process varies according to the invading organism. M. pneumoniae attaches to the respiratory epithelium, inhibits ciliary action, and leads to cellular destruction and an inflammatory response in the submucosa. As the infection progresses, sloughed cellular debris, inflammatory cells, and mucus cause airway obstruction, with spread of infection occurring along the bronchial tree, as it does in viralpneumonia. S. pneumoniae produces local edema that aids in the proliferation of organisms and their spread into adjacent portions of lung, often resulting in the characteristic focal lobar involvement. Group A streptococcus infection of the lower respiratory tract results in more diffuse infection with interstitial pneumonia. The pathology includes necrosis of tracheobronchial mucosa; formation of large amounts of exudate, edema, and local hemorrhage, with extension into the interalveolar septa; and involvement of lymphatic vessels and the increased likelihood of pleural involvement. S. aureus pneumonia manifests in confluent bronchopneumonia, which is often unilateral and characterized by the presence of extensive areas of hemorrhagic necrosis and irregular areas of cavitation of the lung parenchyma, resulting in pneumatoceles, empyema, or, at times, bronchopulmonary fistulas. Afebrile pneumonia of infancy is a syndrome generally seen between two weeks and three to four months of life. It is classically caused by Chlamydia trachomatis. Infants born vaginally to infected

mothers with genital disease are at risk for acquiring C. trachomatis, which usually presents as conjunctivitis and/or pneumonia. C. trachomatis is primarily transmitted to newborns via exposure to an infected mother's genital flora during vaginal birth. Pneumonia due to C. trachomatis is recognized in most affected infants between 4 and 12 weeks of age, although essentially all are symptomatic before 8 weeks [18]. Some infants may have upper respiratory tract symptoms as early as two weeks of age. Cough and nasal congestion without significant discharge are common, although occasional infants may have thick nasal secretions [24]. Otitis media may be present Patients usually are afebrile or have minimal fever. Characteristic features are a staccato cough that may occur in paroxysms and tachypnea, although these are not universally present [6]. Rales are often present on auscultation of the lungs; however, wheezing is uncommon. The liver and spleen may be easily palpable because of the hyperinflated lungs. Laboratory features The white blood cell count is typically normal. However, an elevated eosinophil count (300 to 400/microL) is frequently seen [25]. Arterial blood gas analysis often shows mild to moderate hypoxemia. This may persist for weeks after the acute infection has resolved [18]. The chest radiograph typically shows hyperinflation with bilateral, symmetrical, interstitial infiltrates [25]. In infants with pneumonia, testing for C. trachomatis should be performed on specimens obtained from the nasopharynx. (William J Barson, MD, http://www.uptodate.com/contents/pneumonia-in-children-epidemiologypathogenesis-and-etiology) Pathophysiology: Chlamydiae initiate infection by attaching to the outer membrane of susceptible host cells. The organism subsequently produces cytoplasmic inclusions in the infected cells, which then release the matured inclusions to infect adjacent cells. C pneumoniae pneumonia The incubation period of C pneumoniae pneumonia is approximately 3-4 weeks, with a usually gradual onset that may be biphasic. Although most infected persons are asymptomatic, and most have relatively mild respiratory illnesses, symptoms of bronchitis or pneumonia may follow upper respiratory tract symptoms (eg, rhinitis, laryngitis, pharyngitis, sinusitis) in 1-4 weeks. Sputum is usually scant, but cough is prominent, with possible prolonged symptoms such as persistent cough and malaise for weeks to months despite appropriate use of antibiotics. In addition, a history of hoarseness is more common in C pneumoniae infection than in mycoplasmal infection or other pneumonias. Headache occurs in as many as 58% of cases and may be important as a nonclassic pneumonia finding. Fever is more often present in the first few days than in 1 week or later, but it is less likely to be reported, as the fever is often absent by the time of clinical examination. Pharyngeal erythema without exudate occurs in various atypical pneumonias; however, sinus percussion tenderness is more common with C pneumoniaepneumonia than with other pneumonias. Rhonchi and rales are present even in mild disease. Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between occurrences. An underlying disorder should be considered if a child experiences recurrent pneumonia (Table 392-4)

CLINICAL MANIFESTATIONS: Viral and bacterial pneumonias are often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough. In viral pneumonia, fever is usually present; temperatures are generally lower than in bacterial pneumonia. Tachypnea is the most consistent clinical manifestation of pneumonia. Increased work of breathing accompanied by intercostal, subcostal, and suprasternal retractions, nasal flaring, and use of accessory muscles is common. - Tachypnoea is a key clinical sign Tachypnoea by age (World Health Organisation): - < 2 months age - > 60 breaths per minute - 2- 12 months age - > 50 breaths per minute - 12 months to 5 years age - > 40 breaths per minute Physical findings depend on the stage of pneumonia. Early in the course of illness, diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the affected lung field. Severe infection may be accompanied by cyanosis and respiratory fatigue, especially in infants. Auscultation of the chest may reveal crackles and wheezing, but it is often difficult to localize the source of these adventitious sounds in very young children with hyperresonant chests. It is often not possible to distinguish viral pneumonia clinically from disease caused by Mycoplasma and other bacterial pathogens. Other symptoms that may be seen include: drowsiness with intermittent periods of restlessness; - rapid respirations; - anxiety; - occasionally, delirium. - Circumoral cyanosis may be observed. - In many children, splinting on the affected side to minimize pleuritic pain and improve ventilation is noted; such children may lie on one side with the knees drawn up to the chest.

With the development of increasing consolidation or complications of pneumonia such as effusion, empyema, and pyopneumothorax, dullness on percussion is noted and breath sounds may be diminished. A lag in respiratory excursion often occurs on the affected side. Abdominal distention may be prominent because of gastric dilation from swallowed air or ileus. Abdominal pain is common in lower lobe pneumonia. The liver may seem enlarged because of downward displacement of the diaphragm secondary to hyperinflation of the lungs or superimposed congestive heart failure. In infants, there may be a prodrome of upper respiratory tract infection and diminished appetite, leading to the abrupt onset of fever, restlessness, apprehension, and respiratory distress. These infants appear ill, with respiratory distress manifested as grunting; nasal flaring; retractions of the supraclavicular, intercostal, and subcostal areas; tachypnea; tachycardia; air hunger; and often cyanosis.

Results of physical examination may be misleading, particularly in young infants, with meager findings disproportionate to the degree of tachypnea. Some infants with bacterial pneumonia may have associated gastrointestinal disturbances characterized by vomiting, anorexia, diarrhea, and abdominal distention secondary to a paralytic ileus. Rapid progression of symptoms is characteristic in the most severe cases of bacterial pneumonia. (Nelson, 2009) http://www.adhb.govt.nz/starshipclinicalguidelines/Pneumonia.htm MANAGEMENT: Non Pharmacologic Pharmacologic Surgical Treatment of CAP involves pharmacological and non-pharmacological treatment. Management of CAP involves antibiotic therapy, oxygen, analgesia, antipyretics and supportive nursing care and monitoring. Factors suggesting need for hospitalization:

Ill or toxic appearance. Age < 3 months. Hypoxaemia: oxygen saturation less than 93% on air Respiratory distress interfering significantly with feeding. Significant dehydration. Complicated pneumonia. Deterioration despite appropriate oral antibiotics. Significant co-morbidity Social concerns: no car, no phone, language or communication barrier NON PHARMACOLOGIC MGT: Regular observation of vitals status (RR, HR, BP, SpO2, Temperature) Bed rest adequate hydration and nutrition continuous oxygen therapy improving airway (i.e.posture, humidification, suctioning, deep breathing & coughing exercises) Assistance with activities of daily living. Patient is asked to drink plenty of fluids including juices, water, tea, lemonade, etc.

Oxygen is usually used in hospitalised patient with breathing problems Use of humidified air helps in loosening the mucus Patient may take aspirin, NSAIDs, for controlling fever. However, Aspirin should not be given to children. Patient is advised to take plenty of rest. Chest therapy is used for loosening the mucus so that it can be expelled out by deep coughing.

Prevention of Chlamydia Pneumoniae Infection: The Chlamydia Pneumoniae Infection in children can be prevented by maintaining cleanliness and infection free environment. Practicing good hygiene Frequent hand washing Avoiding contact with infected people PHARMACOLOGIC MGT: Infants younger than three weeks with respiratory distress always should be admitted to a hospital, and a diagnosis of bacterial pneumonia should be assumed until proved otherwise. Cultures of blood, urine, and cerebrospinal fluid should be obtained, and treatment with ampicillin and gentamicin, with or without cefotaxime (Claforan), should be started as soon as possible. (based on evidence-based guidelines from the University of Cincinnati Childrens Hospital, the Alberta Medical Association, and the British Thoracic Society.)
PATIENT AGE Birth to 20 days OUTPATIENT Admit INPATIENT Ampicillin IV or IM:Age>7 days:Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in divided doses every 12 hoursWeight 2 kg: 75 to 150 mg per kg per day in divided doses every 8 hoursAge 7 days:Weight <1.2 kg (2.6 lb): 50 to 100 mg per kg per day divided every 12 hoursWeight 1.2 to 2 kg: 75 to 150 mg per kg per day in divided doses every 8 hoursWeight >2 kg: 100 to 200 mg per kg per day in divided doses every 6 hoursplusGentamicin IV or IM:37 weeks of gestationandAge zero to 7 days: 2.5 mg per kg every 12 hoursAge >7 days: 2.5 mg per kg every 8 hourswith or withoutCefotaxime (Claforan) IV:Age 7 days:100 mg per kg per day in divided doses every 12 hoursAge >7 days:150 mg per kg per day in divided doses every 8 hours CRITICALLY ILL Ampicillin IV or IM, in same dosages as for inpatientsplusGentamicin IV or IM, with or without cefotaxime IV, in same dosages as for inpatients

REFERENCE: Alberta Clinical Practice Guidelines Steering Committee. Guideline for the diagnosis and management of community acquired pneumonia: pediatric. 2002. Accessed online June 1, 2004, at:http://www.albertadoctors.org/bcm/ama/amawebsite.nsf/AllDocSearch/87256DB000705C3F87256E0500553605/$File/PNEUMONIA_PEDIATRICS.PDF

Analgesia and Antipyretic - paracetamol 500mg-1g 6 hourly (max. 4g/day) PO/PR Oxygen Therapy - oxygen 6-10 L/min via nasal prongs or Venturi Mask to maintain oxygen saturation > 97% SURGICAL MGT: When a child with pneumonia develops a pleural effusion, thoracentesis should be performed for diagnostic and therapeutic purposes (see Thoracentesis). The pleural fluid should be obtained to assess pH and glucose levels and a Gram stain and culture, CBC count with differential, and protein assessment should be performed. Amylase and lactase dehydrogenase (LDH) levels can also be measured but are less useful in a parapneumonic effusion than effusions of other etiologies. The results are helpful in determining if the effusion is a transudate or exudate and help to determine the best course of management for the effusion. Drainage of parapneumonic effusions with or without intrapleural instillation of a fibrinolytic agent (eg, tissue plasminogen activator [TPA]) may be indicated. Chest tube placement for drainage of an effusion or empyema may be performed. Video-assisted thoracic surgery (VATS) procedure may be performed for decortication of organized empyema or loculated effusions. Although most patients with pneumonia do not need invasive therapy, it may be necessary in patients with abscesses, empyema, or certain other complications. THORACOTOMY Thoracotomy is the standard surgery for pneumonia. It requires general anesthesia and an incision to open the chest and view the lungs. This procedure allows the surgeon to remove dead or damaged lung tissue. In severe cases, the entire lobe of the lung is removed. This is called a lobectomy. Remaining healthy lung tissue re-expands after surgery to make up for tissue that has been removed. CHEST TUBES Chest tubes are used to drain infected pleural fluid. Tubes are not typically required for pneumonia or abscesses. The tubes are inserted after the patient is given a local anesthetic. They remain in place for 2 - 4 days, and are removed in one quick movement. This can be very distressing, although some patients experience no discomfort. Complications of chest tubes include: Accidental injury of the lung Fluid build-up within the lung if the pleural fluid is removed too rapidly Infection Perforation of the diaphragm Removing the chest tubes may cause the lung to collapse, requiring the reintroduction of a chest tube to inflate the lung. http://www.nytimes.com/health/guides/disease/pneumonia/print.html Complications of Pneumonia NOV01 Posted by Sushant in About Pneumonia Lets briefly discuss the common complications of pneumonia. Abscesses: The abscesses are pus filled cavities that are formed due to damaged lung tissues. In severe untreated cases, they can lead to haemorrhage (bleeding) in the lungs. Abscesses are treated by using antibiotics.

It occurs due to aspiration pneumonia caused by various micro organisms that infect the lungs such as Staphylococcus Aureus or Klebsiella pneumonia. The abscesses caused by Streptococcus pneumonia are uncommon. Respiratory Failure: It refers to the failure of the respiratory system in individuals infected with pneumococcal pneumonia. It is a fatal condition that poses great risk to patients life. It includes the following conditions ARDS (Acute respiratory distress syndrome) involves severe reduction in Oxygen levels due to compromised lung functions. It is a major cause of death in many patients. Ventilatory failure involves mechanical changes in the lungs due to pneumonia Hypoxemic respiratory failure involves loss of oxygen in the arteries. Bacteraemia: This condition is characterised by the presence of bacteria in blood. It occurs due to infection caused by pneumococcus and other gram-negative organisms like Haemophilus influenza. Pleural Effusion: In this condition the space present between the lung and chest walls witness the build up of fluid. Generally, the lungs are covered by visceral pleura and chest walls are covered by parietal pleura. This build-up of the fluid between the pleural membranes results in breathlessness and sharp chest pain while inhaling. Empyema: In this condition, the pus gets accumulated in region between the lung and chest wall. Collapsed Lung: It is characterised by the accumulation of air in the space between the pleural membranes. It is a fatal condition that can arrest the functioning of the lungs. It occurs due to the infection from Streptococcus pneumonia or as a complication of invasive procedures used for the treatment of pleural effusion. Abscesses in the brain/other organs: In some cases, the infection present in the lungs get spread to the heart and eventually reached to various organs of the body via bloodstream. In severe cases, it results in abscesses in the brain and other organs. Severe Haemoptysis (Coughing up blood): It is a potentially fatal complication of pneumonia that is more commonly found in patients with associated lung problems like cystic fibrosis. Other Complications of Pneumonia The other complications of Pneumonia result from the spread of infection to the various parts of the body. Secondary bacterial lung infection Infections of the digestive system Septicemia characterised by presence of bacteria in various body organs Meningitis (swelling of the spinal cord covering) Septic Arthritis (infection of a joint due to spread of bacteria via the bloodstream) Endocarditis (infection of the heart muscle) Pericarditis (infection of the sac surrounding the heart) http://www.symptoms.in/complications-of-pneumonia.html Pneumonia Complications Health professionals caring for children with pneumonia should be aware of the range of potential complications, how to recognise them and their management. The following serves to highlight these complications but is not intended as a full list nor a comprehensive guide to their management.

(a) Syndrome of inappropriate anti-diuretic hormone (SIADH): Inappropriate secretion of anti-diuretic hormone leads to retention of water and hyponatraemia. This is recognised frequently in paediatric respiratory illness. Most children should be managed with maintenance (see Intravenous Fluids guideline). Consider symptomatic hyponatraemia if there is irritability, an altered level of consciousness. Initial test is serum electrolytes. Seek expert advice on management. (b) Lung necrosis: Necrosis and liquefaction of lung tissue. Suspicion may be raised by poor response to treatment, including persisting fever. Definitive diagnosis requires contrast chest CT (see expert advice before requesting this). Additional therapy or surgical intervention is not necessarily required and outcome with conservative management in childhood is usually good. Careful follow up is required as long term sequelae may follow. (c) Pneumatocoele: These are thin-walled air-filled cysts that develop within the parenchyma. They are particularly associated with Staphylococcus aureus and will usually resolve over time without specific intervention. Careful follow up is recommended to ensure full recovery and resolution. Family should be notified that it may be unsafe for the child to fly while the pneumatocoele(s) are present. (d) Atelectasis / Lobar collapse: This is not uncommon. Chest physiotherapy (airway clearance techniques) may be indicated. Follow up should be arranged to ensure resolution as may be associated with long term sequelae. Children with persistent lobar collapse should be referred to a respiratory paediatrician for review and potentially a flexible bronchoscopy. (e) Parapneumonic effusion / empyema: See also Empyema guideline. All children with pneumonia whose fever doesnt settle on appropriate antibiotic therapy within 48hrs should be screened for a pleural collection (examination and chest x-ray). Children with parapneumonic effusions / empyema should be admitted on intravenous antibiotics (see complicated pneumonia above) to cover the likely organisms (Streptococcal species and Staphylococcus aureus but tuberculosis should be considered). Baseline full blood count, inflammatory markers and blood cultures are recommended. If the child is significantly compromised (high work of breathing, hypoxia, and/or persistent signs of sepsis), aren't making expected progress, or the effusion is very large, then additional intervention should be considered. This will usually be video-assisted thorascopic surgery (VATS) with a chest drain or a chest drain with fibrinolytic therapy. Both of these interventions result in more rapid recovery than a chest drain or antibiotics alone. A chest ultrasound is useful pre-intervention to confirm, quantify and characterise the effusion. Routine thoracocentesis or chest CT are not recommended. If you aren't familiar with empyema management, seek expert advise. (f) Lung abscess: The symptoms and signs of lung abscess are the same as for pneumonia and they may be difficult to distinguish on clinical grounds alone. Diagnosis is usually made by chest x-ray supported by contrast CT chest. The presence of underlying lung disease or malformation, foreign body, aspiration, or immunodeficiency should be carefully considered. Blood cultures, full blood count and inflammatory markers should be obtained at diagnosis. Therapy is a prolonged course of antibiotics, usually a minimum of 4 weeks. Management of lung abscess should be guided by a respiratory paediatrician.

(g) Chronic bronchitis / bronchiectasis (sequelae): Children with persistent symptoms and/or signs including chronic productive cough, persistent crackles, clubbing and/or x-ray findings should be evaluated further for possible underlying bronchitis/bronchiectasis. See Guideline on Cough - investigation of chronic cough &/or confirmed bronchiectasis http://www.adhb.govt.nz/starshipclinicalguidelines/Pneumonia.htm uthor:Dr Best, Brabyn, Grant, Shepherd & Twiss Service:CED, Infectious Diseases, General Paediatrics, Respiratory.Editor:Dr Raewyn GavinDate Reviewed:August 2010 How Can Pneumonia Be Prevented? Pneumonia can be very serious and even life threatening. When possible, take steps to prevent the infection, especially if youre in a high-risk group. Vaccines Vaccines are available to prevent pneumococcal pneumonia and the flu. Vaccines cant prevent all cases of infection. However, compared to people who dont get vaccinated, those who do and still get pneumonia tend to have: Milder cases of the infection Pneumonia that doesnt last as long Fewer serious complications Pneumococcal Pneumonia Vaccine A vaccine is available to prevent pneumococcal pneumonia. In most people, one shot is good for at least 5 years of protection. This vaccine is often recommended for: People who are 65 years or older. People who have chronic diseases, serious long-term health problems, or weak immune systems. Examples include people who have cancer, HIV/AIDS, or damaged or removed spleens. Alaska Natives and certain American Indian populations. Children who are 2 years or younger, and children between the ages of 2 and 5 who have a chronic disease (like cancer or HIV/AIDS) or are Alaska Natives, American Indians, or African Americans. The vaccine also is recommended for children between the ages of 2 and 5 who attend group daycare programs. Influenza Vaccine The vaccine that helps prevent the flu is good for 1 year. Its usually given in October or November, before peak flu season. Because many people get pneumonia after having the flu, this vaccine also helps prevent pneumonia. Hib Vaccine Haemophilus influenzae type b (Hib) is a type of bacteria that can cause pneumonia and meningitis (an infection of the covering of the brain and spinal cord). The Hib vaccine is given to children to help prevent these infections. The vaccine is recommended for all children in the United States who are younger than 5 years. Its often given to infants starting at 2 months of age. Other Ways To Help Prevent Pneumonia Other steps also can help prevent pneumonia. Wash your hands with soap and water or alcohol-based rubs to kill germs. Dont smoke. Smoking damages your lungs ability to filter out and defend against germs. Keep your immune system strong. Get plenty of rest and physical activity and follow a healthy diet.

If you have pneumonia, limit contact with family and friends. Cover your nose and mouth while coughing or sneezing, and dispose of tissues right away. These measures help keep the infection from spreading. http://www.resoundinghealth.com/casebook/show/379 (OverviewName: Pneumonia Description: NHLBI Creator: Prajkta This casebook is published and has been read 1837 times. This casebook has been marked as a RESOURCE. It is an information stub intended for cloning or bookmarking as the basis of a new, more complete casebook. The author of) Prevention The best way to prevent serious respiratory infections such as pneumonia is to avoid sick people (if possible), and to practice good hygiene. GOOD HYGIENE AND PREVENTING TRANSMISSION Colds and flu are spread primarily from infected people who cough or sneeze. A very common method for transmitting a cold is by shaking hands. Research has found that washing hands frequently can prevent the spread of viral respiratory illnesses. Always wash your hands before eating and after going outside. Using ordinary soap is sufficient. Alcohol-based gels are also effective for everyday use, and may even kill cold viruses. If extreme hygiene is required, alcohol-based rinses are needed. Antibacterial soaps add little protection, particularly against viruses. In fact, one study suggests that common liquid dishwashing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory syncytial virus (RSV). Wiping surfaces with a solution that contains one part bleach to 10 parts water is very effective in killing viruses. CHANGING HOSPITAL PRACTICES Bacteria abound in hospitals and long-term care facilities, and are particularly virulent in areas with the sickest patients, such as intensive care units. Health care facilities are revising many of their practices and educating physicians, nurses, and therapists how to reduce the likelihood of transmitting bacteria. VACCINES Viral Influenza Vaccines (Flu Shot) Description of Vaccines. Vaccines against the flu (or a "flu shot") use inactivated (not live) viruses. They are designed to provoke the immune system to attack antigens contained on the surface of the virus. Antigens are foreign molecules that the immune system specifically recognizes and targets for attack. Timing and Effectiveness of the Vaccine. Ideally, people should get a flu shot every October or November. However, it may take longer for a full supply of the vaccine to reach certain locations. In such cases, the high-risk groups should be served first. Children Who Should Be Vaccinated. The American Academy of Pediatrics (AAP) and the CDC recommend flu shots for all healthy children 6 - 59 months of age, as well as adults who are in regular contact with these children. The flu shot is not approved for children younger than 6 months of age. Children who are receiving long-term aspirin therapy should also be immunized against the flu, because they are at higher risk for Reye syndrome, a life-threatening disease, if they get the flu. Children with Asthma. Recent and major studies have found that the flu shot is safe for children with asthma. It is very important for these patients to reduce their risk for respiratory diseases. Unfortunately, 90% of asthma patients remain unvaccinated.

Older Children and Adults Who Should Be Vaccinated. The following, in order of priority, are the population groups who should be vaccinated each year. The first two groups have the highest need for influenza vaccinations and are given top priority: All adults age 65 and older. Older adults who receive a flu shot have lower hospitalization rates than those who don't. Evidence now suggests that vaccination may help protect against adverse heart events (including after heart surgeries), stroke, and death from all causes in the elderly. Still, studies suggest that only two-thirds of people in this group are vaccinated, mostly because of unwarranted fears of ineffectiveness or adverse effects. People of any age at high risk for serious complications from influenza. Such people include those with heart disease, lung problems, immune deficiencies, diabetes, kidney disease, or chronic blood disease. While there have been concerns about the safety of the vaccinations in certain high-risk patients, such as those with HIV or asthma, studies now suggest that the vaccine is generally safe in these patient groups. Furthermore, their risk for serious complications from influenza outweighs any potential adverse effects from the vaccines. Adults ages 50 - 64 with chronic medical conditions. The US Advisory Committee on Immunization Practices (ACIP) suggests that all adults over age 50 be vaccinated, although this is not a recommendation of the CDC. Other adults who should consider influenza vaccinations include: People at risk for flu complications who are traveling to the tropics at any time or to the Southern Hemisphere between April and September. Pregnant women at risk for flu complications who will be in their second or third trimester during flu season. (Vaccinations should usually be given after the first trimester.) Health care providers with direct patient contact, child care providers, and residents of long-term care facilities. VITAMINS Although some research supports the use of vitamin C for the prevention and treatment of pneumonia, most research says it's too early to recommend vitamin C supplements for the general population. These supplements may be helpful for pneumonia patients who are deficient in the vitamin, however. PNEUMOCOCCAL VACCINES The pneumococcal vaccine protects against S. pneumoniae bacteria, the most common cause of respiratory infections. There are two effective vaccines available: 23-valent polysaccharide vaccine (Pneumovax, Pnu-Immune) for adults 7-valent conjugate vaccine (Prevnar or PCV7) for infants and young children. Experts are now recommending that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria. Pneumococcal Vaccine in Young Children. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Routine vaccination with the PCV7 vaccine began in 2000. In the first 3 years of its use, the vaccine cut pneumonia-related hospital admissions in children under age 2 by nearly 40%. Possibly due to "herd immunity," pneumonia-related hospital admissions in adults ages 18 - 39 also dropped by more than 25% during that time period. Evidence suggests that this vaccination, plus the vaccination against Haemophilus influenzae (an important cause of meningitis), have led to 25,000 fewer cases of serious bacterial infections each year. The pneumococcal vaccine is now recommended by many experts for the following groups: All children up to age 2. The pneumococcal conjugate vaccine (Prevnar or PCV7) has now been added to the Recommended Childhood Immunization Schedule. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Studies are suggesting that it prevents common ear infections, as well as serious infections such as pneumonia. In one study, a similar vaccine under investigation not only protected children in day care from serious respiratory infections, but also helped lead to fewer infections in their younger unvaccinated siblings.

Children up to age 5 who are at risk for pneumonia or complications of influenza, such as those with sickle-cell disease, immune deficiencies, or chronic medical conditions. Other children aged 2 - 5 who are higher risk for serious pneumococcal infections should be considered for pneumococcal polysaccharide vaccination. They include African-Americans, Native Americans, children in group child care, socially or economically disadvantaged children, or those who have had frequent or complicated acute middle ear infections within the past year. (In one study, the vaccine reduced the number of ear infection episodes by 6%.) The recommended schedule of immunization for Prevnar (PCV7) is four doses, given at 2, 4, 6, and 12 - 15 months of age. Infants starting immunization between 7 and 11 months should have three doses. Children starting their vaccinations between 12 and 23 months only need two doses. Those who are over 2 years old need only one dose. Pneumococcal Polysaccharide Vaccine in Older Children and Adults. The pneumococcal polysaccharide vaccine is proving to help reduce the rate of pneumonia in young adults, although not to the degree that it protects young children. Its benefits for the elderly are unclear. Although it may not prevent community-acquired pneumonia, the vaccine might improve the outcome for older adults who develop the disease by reducing the risk of death and admission to an intensive-care unit. Still, pneumonia is declining among adults, which may be due to fewer infections transmitted from vaccinated young children. Many experts now recommend the vaccine for the following older children or adults: All people over age 65. (Anyone vaccinated more than 5 years previously should be revaccinated.) The vaccination is protective against pneumococcal bacteremia (blood infection) in this group, but it does not appear to protect against community-acquired pneumonia itself. Adults with any chronic condition that increases the risk for pneumonia. This includes patients with heart disease, chronic lung disease (COPD or emphysema, but not asthma), or diabetes. Individuals with immune deficiencies, such as HIV, or those undergoing treatments to suppress the immune system. Patients with autoimmune diseases, such as rheumatoid arthritis and lupus. Unfortunately, studies suggest the vaccine may not be as effective in these patients as it is in those with healthy immune systems. Nevertheless, they are at high risk for serious respiratory infections and should be vaccinated. Patients with kidney disease or kidney transplants. Older people who have had transplant operations or those with kidney disease may require a revaccination after 6 years. Patients with problems in the spleen. Alcoholics (especially those with cirrhosis). People living in long-term care facilities. Alaska Natives or Native Americans who may be at increased risk for pneumonia. Because the vaccine is inactive, it is safe for pregnant women and people with immune deficiencies. In fact, when the vaccine is administered to pregnant women, it may actually protect their infants against certain respiratory infections. Protection lasts for more than 6 years in most people, although it may wear off faster in elderly people than in younger adults. Anyone at risk for serious pneumonia should be revaccinated 6 years after the first dose, including those who were vaccinated before age 65. Subsequent booster doses, however, are not recommended. http://www.nytimes.com/health/guides/disease/pneumonia/print.html