Pneumonia

(For more details, refer to Integrated Management of Childhood Illness (IMCI) guidelines).

Table 9.2: Important clinical presentation of pneumonia in under-fives 

Investigations 

• Measure oxygen saturation
• FBC  (look  for  increased  WBC,  neutrophilia)  CRP/ESR  (increased),  ABG  (look  for  pH, bicarbonate),  Blood  culture,  Sputum  culture  and  sensitivity,  Serology  for  HIV  test  (if unknown)
• CHEST  X-ray-PA/LATERAL  (look  for  consideration,  tap  effusion>5cm),  Bronchoscopy (consider  if  immunosuppression,  critically  ill,  failure  to  respond,  suspected  TB  or  PCP  or inadequate
• CT Scan: if patient is not improving, suspicion of fungal, ILD

Non-pharmacological Treatment: 

• Oxygen therapy if available
• Supportive care
  • Remove clothes
  • If wheezing giving rapid-acting bronchodilator: nebulized Salbutamol
  • Ensure that the child receives daily maintenance fluid appropriate for the child’s age but avoid over-hydration. Refer to IMCI/ STG & Essential Medicines List for Children

Pharmacological Treatment  Non-severe pneumonia 

A: amoxicillin (PO) 25mg/kg 8hourly for 5days 

AND 

A: paracetamol (PO) 15mg/kg 8hourly for 5days (if fever present) 

OR  

A: paracetamol (supp) 10–15mg/kg (if there is fever) 

OR 

A: ibuprofen (PO) 15mg/kg 12hourly for 5days 

Give the first dose at the clinic and teach the mother how to give the other doses at home.  Encourage breasting and feeding. 

Severe Pneumonia 

A: benzyl penicillin (IV/IM) 50000 units/kg every 6hours for at least 3days 

THEN 

A: amoxicillin (PO) 40 mg/kg 8hourly for 7days. 

Alternatively  

A: ampicillin (IV/IM) 50 mg/kg every 6hourly for 5days 

AND 

A: gentamicin (IV/IM) 7.5 mg/kg 24hourly for 5days 

THEN   

A: amoxicillin (PO) 40 mg/kg 8hourly for 7days. 

Note:

• For children above 5 years, atypical pneumonia should be considered e.g. mycoplasma
• Consider  alternative  diagnosis  after  three  visits/if not  responding,  refer  patient  to  a pediatrician

Community Acquired Pneumonia (CAP)

CAP refers to a pneumonia that is acquired outside hospital, commonly caused by Streptococcus  pneumoniae,  Haemophilus  influenzae,  Moraxella  catarrhalis,  atypical  bacteria  (i.e.  Chlamydia  pneumoniae,  Mycoplasma  pneumoniae,  Legionella  species)  and  viral  respiratory  pathogens  (i.e  rhinovirus and influenza).

Clinical presentation 

• Fever
• Cough dry or productive with/without purulent sputum,
• Dyspnea
• Pleuritic chest pain
• Decreased tactile fremitus and dullness on chest percussion 
• Tachypnea
• Crepitation/Rales heard over the involved lobe or segment
• Increased tactile fremitus, bronchial breath sounds may be present if consolidation has occurred

Investigations 

• Measure oxygen saturation, use pulse oximetry or Monitor
• FBC (look for increased WBC, neutrophilia)
• CRP/ESR (increased in bacterial infection)
• ABG (look for pH, bicarbonate),
• Serology for HIV test (if unknown)
• Sputum culture and sensitivity - indicated for inpatients and those with severe disease (ICU admission)
• Blood culture (are not recommended for ambulatory patients)
• CHEST X-ray-PA/LATERAL (look for one or more focal pulmonary  infiltrates, consolidation, tap effusion>5cm)
• Bronchoscopy  (consider  if  immunosuppression,  critically  ill,  fail  to  respond,  suspected TB or PCP or inadequate
• CT-CHEST Scan or HRCT: if patient is not improving, suspicion of fungal infection, ILD etc.

Note: Do not use CT chest to diagnose pneumonia 

Non-pharmacological Treatment

• Stop smoking if previously smoking
• Vaccination when indicated, in specialized centre for patient >65yrs and below 5years

Pharmacological Treatment 

First line treatment 

Table 9.3: First Line Treatment of Typical Community Acquired Pneumonia 

Second line treatment 

If no response to first line treatment further investigation is required. If patient is in respiratory distress, or no  response after 3 days of first line treatment, or patient’s condition deteriorates, then investigate, start  empiric treatment while waiting for culture and sensitivity 

S: piperacillin + tazobactam (FDC) (IV) 4.5g 6hourly for 7days 

Table 9.4: Treatment of Typical and Atypical Community Acquired Pneumonias Organism  Specific 

Note:  

• In severe Pneumocystis jirovecii pneumonia (PCP), add 30 – 40mg prednisolone for 14days. Consider tapering down after recovery
• Patients  with  pneumonia  should  be  afebrile for 48-72hours and have improved  clinically before antibiotic therapy is stopped. The duration of therapy may need to be increased if the initial empirical therapy has no activity against the specific pathogen or if the pneumonia is complicated by extrapulmonary infection.

Alternative in Staphylococcal and Klebsiella Pneumonia: 

D: ceftazidime (IV/IM) 2g 8hourly for 7–14days 

This is defined as pneumonia that occurs two days (48hrs) or more after hospitalization but that was not incubating at the time of hospital admission. 

Clinical Presentation 

• Fever
• Increase in respiratory rate
• Shortness of breath

Pharmacological Treatment 

Empirical treatment until bacteriology available 

C: ciprofloxacin (IV) 400mg 12hourly for 7days 

OR  

D: ceftriaxone + sulbactam (FDC) (IV) 1.5g 12hourly for 7days 

Note: In specialized unit, management of CAP/HAP can be changed with supportive culture and sensitivity done. This may necessitate use of other broader spectrum antibiotics for 48-72hours until the results are  obtained 

Clinical presentation

• Cough dry/productive
• Exertional dyspnoea
• Fever
• Tachypnoea
• Chest pain
• There may be signs of AIDS such as thrush, oral hairy leucoplakia or Kaposi's sarcoma
• Scattered crackles and wheeze may be present, or rarely signs of focal consolidation
• Pulse oximetry may show low SaO2 at rest
• Extra-pulmonary disease may manifest as hepatosplenomegaly, lymphadenopathy or ocular disease

Investigations

• Elevated lactate dehydrogenase
• ABG may show hypoxia
• The alveolar-arterial oxygen tension gradient may be increased
• Serum (1-->3) Beta-D-glucan levels (high in PCP) is currently being investigated as a diagnostic test
• Chest X-ray
• CT-CHEST (ground glass infiltrates but has low sensitivity and specificity.)
• Gallium scanning is highly sensitive but with low and variable specificity.
• PFT - Reduction in vital capacity (VC) and the total lung capacity (TLC).

Management 

Refer to Table 9.4 in Pneumonia in Adults - Community Acquired Pneumonia above