Pneumonia in HIV Exposed or Infected Children
Description Diagnostic criteria General and supportive measures Medicine treatment Referral DESCRIPTION In additional to common bacterial and viral pathogens causing pneumonia, opportunistic micro-organisms in a ‘polymicrobial mix’ are common in these children. Many of these children may fail to respond to the standard antibiotic treatment for pneumonia. Micro-organisms commonly involved are: P.
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Referral
DESCRIPTION
In additional to common bacterial and viral pathogens causing pneumonia, opportunistic micro-organisms in a ‘polymicrobial mix’ are common in these children. Many of these children may fail to respond to the standard antibiotic treatment for pneumonia. Micro-organisms commonly involved are:
- P. jiroveci (PJP),
- Candida,
- Mycobacteria, e.g. M. tuberculosis
- Cytomegalovirus.
In addition, S. pneumonia, S. aureus and gram negative bacteria e.g. Klebsiella pneumoniae and Non-Typhoid Salmonella cause a significant proportion of HIV-related pneumonia in early childhood.
P. jiroveci (PJP)
- PJP is a common fungal infection of the lung in infants from 2–6 months.
- Presents as an acute onset of respiratory distress with minimal/absent chest signs in a child who is HIV-exposed or HIV-infected.
- Hypoxaemia and cyanosis are common features in severe disease.
- Chest X-ray shows a range of abnormalities including bilateral perihilar interstitial changes.
Other fungal pneumonias
- Candida albicans and other species, Cryptococcus neoformans and Aspergillus fumigatus may cause pneumonia in immunocompromised children.
- Skin and CNS manifestation may be helpful in suggesting the specific diagnosis.
Cytomegalovirus associated pneumonia in HIV-infected infants
- Presents as an interstitial pneumonitis with acute hypoxic respiratory failure.
- It may present as a multisystem sepsis-like syndrome, with hepatitis, neutropenia, pneumonitis, colitis and thrombocytopenia.
- Often occurs in children who are severely immunosuppressed (CDC Immune category 3) and carries a significant mortality.
- Risk of CMV transmission through breastfeeding is low and, therefore, breastfeeding is not contraindicated.
- CMV co-infection occurs commonly as polymicrobial infection with PJP and bacteria.
Tuberculosis in HIV infected children
- Occurs in children at all ages.
- Presents as acute or chronic illness.
- Multisystem disease.
HIV-infected children with chronic lung disease
- Often presents with lymphoid interstitial pneumonitis and bronchiectasis.
- Secondary infection with bacteria similar to those seen in acute pneumonia are commonly isolated from these children.
DIAGNOSTIC CRITERIA
Investigations
In addition to investigations for pneumonias:
- Screen for HIV infection:
- See Human Immunodeficiency Virus infection, for guidance on testing.
- Investigate for PJP:
- Immunofluorescence on induced sputum sample.
- Fungal infection:
- Request MCS for fungi (blood or sputum).
- Screen children with very severe pneumonia immediately for CMV using CMV viral load, where available.
- A viral load of > 10 000 copies/mL suggests CMV disease: treat.
- A viral load below 10 000 copies/mL is regarded as CMV infection: no therapy recommended.
- Tuberculosis:
- Refer to: Tuberculosis pulmonary, for guidance on testing.
GENERAL AND SUPPORTIVE MEASURES
- Appropriate infection prevention and control measures.
- Adequate nutrition.
- Monitor oxygen saturation.
- Restrict fluid intake.
MEDICINE TREATMENT
If saturation < 92%:
- Oxygen, via nasal prongs or nasal cannula.
Treat for very severe bacterial pneumonia. See: Pneumonia.
In all infants between 2 and 6 months with pneumonia consider PJP and,
ADD
- Co-trimoxazole, IV/oral, 5 mg trimethroprim/25 mg sulphamethoxazole /kg/dose, 6 hourly for 21 days.
- Continue co-trimoxazole prophylaxis at the end of this treatment period until CD4 count recovers to normal.
Children who remain hypoxic on oxygen with proven or highly suspected PJP:
- Prednisone, oral, 1–2 mg/kg, daily for 7 days.
- Taper dose over the next 7 days.
For suspected or confirmed fungal pneumonia (other than PJP):
- Amphotericin B deoxycolate, IV, 0.6–1.0 mg/kg as a single daily dose infused over 4 hours for at least 14 days.
Note: Pre-hydrate before administering amphotericin to prevent renal impairment:
- Sodium chloride 0.9%, IV, 20 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.
OR
- Fluconazole, IV/oral, 10 mg/kg as a single daily dose for at least 14 days.
For confirmed CMV disease:
- Ganciclovir, IV, 5 mg/kg 12 hourly until oral is tolerated
THEN
- Valganciclovir, oral, 16 mg/kg 12 hourly to complete the first 21 days of therapy
THEN
- Valganciclovir, oral, 16 mg/kg daily to complete 42 days of therapy.
For Mycobacterium Tuberculosis:
See: Tuberculosis.
Ensure follow-up for antiretroviral therapy.
REFERRAL
- Not responding to therapy.
- In cases of CMV disease under 6 months of age for follow-up for hearing deficit.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 15: Respiratory System, 15.1 Cough With Predominant Fever And Tachypnoea , 15.1.1 Pneumonia, 15.1.1.3 Pneumonia In HIV-Exposed Or HIV-Infected Children