Pneumonia

Pneumonia is caused by infection of the lung parenchyma. Pneumonia may be characterized by a higher fever (>38 C), grunting and bronchial breathing in a child who is ill-looking and “toxic”, but by definition any child with tachypnoea and a cough has pneumonia. It can be classified as non-severe, severe or very severe based on clinical features.

Non-severe pneumonia presents with a cough and fast breathing.

Severe pneumonia presents with cough and fast breathing, plus one of the following: lower chest wall in-drawing, auscultatory signs (i.e. decreased breath sounds, bronchial breathing, crackles, increased vocal resonance or pleural rub) or dullness to percussion.

Very severe pneumonia presents as above with at least one of the following: central cyanosis, inability to feed, convulsions, lethargy or decreased level of consciousness, grunting, nasal flaring or any baby less than 60 days old.

Common bacterial causes of pneumonia include:

Neonates: Group B Strep, Klebsiella spp, E. coli, S. aureus and Chlamydia,

Children: S. pneumonia, H. influenza, S. aureus, M. pneumonia and M. catarrhalis

Common viral cause: Influenza, Para-influenza, Respiratory syncytial virus, CMVs and Adenovirus.

Investigations

• CXR if severe pneumonia or PTB
• FBC, diff count and CRP if severe pneumonia
• Blood culture if toxic, extensive consolidation or < 3/12 age (Use strict aseptic technique)
• Nasopharyngeal aspirates (viruses and PCP) are not done routinely
• If severe pneumonia ask physio to collect sputum for viral PCR screen and shell vial culture for CMV.
• TB investigations: Montoux, CXR, Gastric washings or sputum if suspected

Management

• Supportive measures include
  • Oxygen with nasal prongs or CPAP if severe pneumonia with atelectasis.
  • Maintain nutrition: Continue breast and oral feeds. Consider small frequent feeds by oro/nasogastric tube if severe tachypnoea or if enteral feeds are not tolerated.
• Salbutamol nebs only if LAO with significant degree of wheezing is present.
• Antibiotic choice is based on an assessment of severity and likely aetiology.

Antibiotic choices for pneumonia

Non severe pneumonia: Amoxicillin oral, 30 mg/kg/dose, 8 hourly for 5 days.

Severe pneumonia: Ampicillin IV, 25 mg/kg/dose 6 hourly. Once clinical condition allows change to Amoxicillin oral, 30 mg/kg/dose, 8 hourly to complete 5 days of therapy.

Very severe pneumonia (Includes all neonates or very young infants): Ampicillin IV, 25 mg/kg/dose 6 hrly, add Gentamicin IV, 5 mg/kg daily dose for 5–10 days. Once clinical condition allows change to Amoxicillin/clavulanate oral, 30 mg/kg/dose 8 hourly.

Special situations:

Staphylococcal infection (destructive pneumonia with pneumatocoele, pleural effusion or empyema): Add Cloxacillin, IV, 50 mg/kg/dose every 6 hours. Once clinical condition allows change to Flucloxacillin, oral, 12.5–25 mg/kg/dose 6 hourly for at least 21 days.

Atypical organisms (Mycoplasma or Chlamydia) or pertussis suspected: Add Macrolide, eg: Clarithromycin 7.5mg/kg/dose, 12 hourly for 7 days or Erythromycin, 10mg/kg/dose 6 hrly for for 7 days.

Nasocomial infection: Start with Piperacillin/tazobactam, IV, 100 mg/kg/dose 8 hourly, PLUS Amikacin, IV, 15 mg/kg/dose, daily. Adjust therapy according to blood culture sensitivities. For methicillin resistant S. aureus pneumonia: Vancomycin, IV, 15 mg/kg/dose 6 hourly infused over 1 hour.

Suspected P. jiroveci (PJP) infection: (tachypnea, hypoxia, interstitial changes on CXR): Add Bactrim 5mg/kg/dose q6h, start IV until improvement then PO for 21 days. Test for HIV: PCP prophylaxis should continue after discharge. Add Prednisone 1-2 mg/kg/day for 7 days.

Suspected CMV pneumonia: Ganciclovir, IV, 5 mg/kg 12 hourly for 21 days (initial dose) and follow with 5mg/kg daily for 21 days (maintenance dose).

Anaerobic infection due to aspiration syndromes: Add Metronidazole, 7.5mg/kg/dose, 8hrly for 5 days.