Respiratory Distress in an HIV Infected Child (Community Management)

Causes of Respiratory Disease in HIV infected children

• PCP
• Bacterial pneumonia – Streptococcus pneumoniae,Hemophilus influenzae,Staphylococcus aureus,Pseudomonas aeruginosa,Mycoplasma pneumoniae,Chlamydia pneumoniae.
• Mycobacteria (Tuberculosis and Avium Complex)
• Viral pneumonia – Cytomegalovirus,Measles,
  Adenovirus,Parainfluenzae,Influenza, Respiratory syncitial virus,Varicella,Herpes simplex
• Fungal infections – Aspergillosis,Histoplasmosis,Candida,Nocardia.
• Lymphocytic Interstitial Pneumonia
• Congestive Cardiac failure
• Malignancy: Lymphomas.

Community management

Severe pneumonia

• Chest indrawing
• Stridor in a calm child
• Unable to take any feed
• Lethargic or unconscious
• Infants less than 2 months with respiratory rate of > 60 breaths/min

Treatment

• Give first dose of Ceftriaxone IM
• Give first dose of TMP/SMX treatment
• Give oxygen
• If stridor, give nebulised adrenaline
• Keep child warm and refer urgently.

Moderate pneumonia

• Fast breathing – [in a child from 2 months to 12 months > 50 breaths/min. 12 months – 5 years > 40 breaths/min]
• Give oral amoxycillin for 5 days
• Relieve the cough
• If cough more than 14 days, rule out TB, asthma or PCP
• Give TMP/SMX treatment for 5 days
• Mother to bring back child in 2 days
• If condition worsens, she should come back immediately and early referral to the hospital.

TMP/SMX Treatment for PCP

 (Guide for health care workers)

The recommended dose for prophylaxis is trimethoprim 5mg/kg/day and sulphamethoxazole (20 mg/kg/day). The common preparations of TMP/SMX have the following formulation: Trimethoprim 40 mg/5ml and Sulphamethoxazole (200 mg/5 ml).

Amoxycillin treatment for pneumonia

 (Given 3 times/day)

Ceftriaxone dosage and treatment for pneumonia (Given once daily)

Ceftriaxone dosage and treatment for pneumonia (Given once daily)

Investigations

• CBC with differential count
• Blood culture
• Mantoux test
• Gastric lavage or sputum for AFB, PCP, fungus and gram stain
• Chest X-ray.

Management

• Oxygen
• IV Fluids
• Paracetamol: 10 to 15 mg/kg/dose 6 hourly
• Ampicillin – 100 mg/kg/day IV 6 hourly
  Gentamicin – 5 mg – 7.5 mg/kg daily IV in 2-3 divided doses
• If staphylococcus. aureus infection is suspected:
              Add Cloxacillin – 150-200 mg/kg/day in 4 doses IV
                                      OR
              Cefuroxime 200 mg/kg/day 8 hourly IV
• Total duration of treatment 7-10 days
• TSuspect PCP if the child is
        - Less than 12 months old
        - Has tachypnea [ > 50 breaths/min in children aged 2 month – 12 months
        - 40 breaths/min in children aged 12 months – 5 years]
        - Is dyspneic
        - Has cyanosis
        - Has few crepts relative to the degree of cyanosis.
• Begin treating for PCP immediately on suspicion (continue usual treatment of pneumonia
• If there is no improvement within 48 hours of admission, refer to higher center for further management.

Management of suspected PCP

• Oxygen
• TMP/SMX (20 mg/kg/day of TMP component) 6 hourly IV for 5 days changing to orally for 3 weeks if response is adequate
• Consider adding clindamycin 30-40 mg/kg for severe disease
• Prednisolone (if PCP confirmed or in presence of hypoxia)
• Paracetamol 10-15 mg/kg 6 hourly for pain or fever > 37.5 oC.