Pneumonia
Description Diagnostic criteria General and supportive measures Medicine treatment Modification of antimicrobial therapy Referral ICD-10 code: J18.9 DESCRIPTION Infection of the lung parenchyma characterized by inflammation and consolidation of lung tissue. Management depends on the clinical assessment and classification of severity. For bacterial pneumonia Empiric antibiotics are indicated
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Modification of antimicrobial therapy
Referral
ICD-10 code: J18.9
DESCRIPTION
Infection of the lung parenchyma characterized by inflammation and consolidation of lung tissue. Management depends on the clinical assessment and classification of severity.
For bacterial pneumonia
Empiric antibiotics are indicated in all cases of pneumonia, as delay in treatment is associated with poor outcome. Antibiotic choice is based on an assessment of severity and likely aetiology.
Common bacterial causes of pneumonia include:
Neonates:
- Group B beta-haemolytic Streptococci.
- Klebsiella spp.
- E. coli.
- Chlamydia.
- S. aureus.
Children:
- S. pneumoniae.
- H. influenzae.
- S. aureus.
- M. catarrhalis.
- M. pneumoniae.
Staphylococcal pneumonia should be suspected if there is empyema, pulmonary cavitation or pneumatocoele formation or the presence of extrapulmonary pyogenic infections.
Complications of pneumonia include:
- respiratory failure,
- pleural effusion,
- empyema,
- pneumothorax,
- pleuritis,
- bronchiectasis.
DIAGNOSTIC CRITERIA
- Tachypnoea is age dependent.
| Age | Respiratory rate |
| < 60 days | > 60/minute |
| 2–12 months | > 50/minute |
| 1–5 years | > 40/minute |
| 5–12 years | > 40/minute |
Categories of pneumonia (WHO classification)
| Category | Characteristics |
| 1. Severe pneumonia or very severe disease | Diagnose in an infant under 2 months of age with: - A general danger sign or - Lower chest wall indrawing or - Tachypnoea (> 60 breaths per minute) |
| Diagnose in an HIV-exposed infant or HIV-infected, immune-compromised or malnourished child with lower chest indrawing | |
| 2. Pneumonia | Diagnose in an immune-competent child over 2 months with lower chest wall indrawing or tachypnoea. |
| Tachypnoea is defined as: - > 50 breaths per minute for infants 2–12 months - > 40 breaths per minute for children 1–5 years |
|
| 3. No pneumonia | No signs of pneumonia or severe pneumonia, i.e. upper respiratory tract infection. |
| 4. Danger signs | Diagnose in a child aged 2 months to 5 years with any general danger sign: - Inability to drink - Convulsions - Abnormal sleepiness - Persistent vomiting |
Investigations
- Chest X-ray only when there is failure to respond to therapy, in children with severe pneumonia in whom complications or tuberculosis are suspected, and for admissions. Perform a lateral and AP or PA view if possible. TB work-up if tuberculosis suspected (e.g. TB contact), See: Tuberculosis, Pulmonary.
- In children with severe and very severe disease, perform a blood culture, preferably before initiating antibiotics.
GENERAL AND SUPPORTIVE MEASURES
- Bed rest.
- Clear nasal and oral passages of thick secretions.
- Monitor:
- respiratory rate,
- heart rate,
- SaO2,
- temperature,
- hydration,
- blood pressure,
- Hypoxia (SATS monitor) and/or hypercapnia (blood gas) are indications for ventilatory support.
- Maintain nutrition: Continue breast and oral feeds.
- Consider small frequent feeds by oro/nasogastric tube or IV fluids if respiratory rate > 60/minutes or enteral feeds are not tolerated.
MEDICINE TREATMENT
- Oxygen at 1–2 L/min, humidified, by nasal prongs is preferred.
- Continue oxygen until respiratory distress and hypoxia resolves (a saturation of ≥ 92% off oxygen).
To relieve discomfort:
- Paracetamol, oral/NGT, 15 mg/kg, 6 hourly as required.
If significant degree of wheezing is present:
- Salbutamol, inhalation, 100–200 µg, as required using a metered-dose inhaler with a spacer device or a nebulizer until symptoms are relieved.
Empiric antibiotic therapy
Choice of antibiotic depends on the severity of the condition, the age of the child and the presence of co-morbidity.
Reconsider choice of antibiotic when the results of cultures become available or the child does not improve.
Pneumonia (non-severe):
- Amoxicillin, oral, 45 mg/kg/dose, 12 hourly for 5 days.
Severe or very severe disease:
- Amoxicillin/clavulanate, IV, 25 mg/kg/dose of amoxicillin component 8 hourly (do not exceed 10 mg/kg/day of clavulanate component).
Switch to oral as soon as there is a response:
- Amoxicillin/clavulanate, oral, 45 mg/kg/dose of amoxicillin component 12 hourly to complete 10 days total.
MODIFICATION OF ANTIMICROBIAL THERAPY
If there is a poor response to first line empiric therapy and in the absence of positive cultures consider the possibility of infection with Methicillin Resistant S. aureus (MRSA), or an extended spectrum beta lactamase (ESBL) producing organism, or atypical pathogen.
If mycoplasma is considered, do blood polymerase chain reaction for the specific pathogen.
If nosocomial pneumonia suspected, refer to Nosocomial Pneumonia. Re-evaluate for possible co-morbidity (foreign body, immunodeficiency, heart disease).
Change to:
- Piperacillin/tazobactam, IV, 100 mg/kg/dose 8 hourly.
PLUS
- Amikacin, IV, 15 mg/kg/dose, daily.
If an MRSA pneumonia is confirmed:
- Vancomycin, IV, 15 mg/kg/dose 6 hourly infused over 1 hour for 14 days.
For Mycoplasma pneumonia and other atypical pneumonias:
- Macrolide, e.g.:
- If severely ill initiate:
- Azithromycin, IV, 10 mg/kg/dose daily for 2 days
THEN - Azithromycin, oral, 5 mg/kg/dose daily for 3 days.
OR - Azithromycin, oral, 5 mg/kg/dose daily for 5 days.
- Azithromycin, IV, 10 mg/kg/dose daily for 2 days
For management of complications
- To relieve a tension pneumothorax, do needle aspiration followed by intercostal drain placement.
- Small or asymptomatic pneumothoraces in infants and children (excluding neonates) usually do not require treatment other than close observation, but identify and treat the underlying cause of the pneumothorax.
- For symptomatic pleural effusion, do needle aspiration; if empyema, insert a chest tube for drainage. See: Effusion and Empyema.
REFERRAL
- Patients not improving within 48-72 hours of initiating second-line therapy should be discussed with a paediatrician.
- For possible ICU care if not maintaining saturations in the normal range on oxygen or if clinical features of fatigue.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 15: Respiratory System, Acute Lower Respiratory Tract Infections In Young Children, 15.1 Cough With Predominant Fever and Tachypnoea, 15.1.1 Pneumonia
Click here for 15.1.1.1 Pneumonia, Viral Infection
Click here for 15.1.1.2 Pneumonia Due To Anaerobic Infection
Click here for 15.1.1.3Pneumonia in HIV Exposed or Infected Children
Click here for 15.1.1.4 Pneumonia, Nosocomial
Click here for 15.1.1.5 Recurrent Pneumonia