Pneumonia

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ICD10 CODE: J13-18

Acute infection and inflammation of the lungs alveoli. There are two major types:

  • Bronchopneumonia: involves both the lung parenchyma and the bronchi. Common in children and the elderly
  • Lobar pneumonia: involves one or more lobes of the lung. Common in young people

Cause

Causative agents can be viral, bacterial or parasitic. Pathogens vary according to age, patient’s condition and whether infection was acquired in the community or hospital (Gram negative are more common in hospital).

  • Neonates: group B streptococcus, Klebsiella, coli, Chlamydia and S. aureus
  • Children <5 years: Pneumococcus, Haemophilus influenzae, less frequently: aureus, M. catarrhalis, M. Pneumoniae, viruses (RSV, influenza, measles)
  • Adults and children >5 years: most commonly pneumoniae, followed by atypical bacteria, e.g. Mycloplasma pneumoniae, viruses
  • Immunosuppressed: Pneumocystis (in HIV infected)

Predisposing Factors

  • Malnutrition
  • Old age
  • Immunosuppression (HIV, cancer, alcohol dependence)
  • Measles, pertussis
  • Pre existing lung or heart diseases, diabetes

Investigations

If facilities are available

  • Do a chest X-ray and look for complications, e.g.
    • Pneumothorax, pyothorax
    • Pneumonitis suggestive of pneumocystis jiroveci pneumonia (PCP)
    • Pneumatocoeles (cavities filled with air) suggestive of staphylococcal pneumonia
  • Sputum: For Gram stain, Ziehl-Neelsen (ZN) stain, culture for AFB
  • Blood: Complete blood count

Pneumonia in an Infant (up to 2 months)

In infants, not all respiratory distress is due to infection. But as pneumonia may be rapidly fatal in this age group, suspected cases should be treated promptly and referred for parenteral treatment with antimicrobials. Consider all children < 2 months with pneumonia as SEVERE disease.

Clinical Features

  • Rapid breathing (≥60 breaths/minute)
  • Severe chest indrawing, grunting respiration
  • Inability to breastfeed
  • Convulsions
  • Drowsiness
  • Stridor in a calm child, wheezing
  • Fever may or may not be present
  • Cyanosis and apnoeic attacks (SpO2 less than 90%)

Management

Infants with suspected pneumonia should be referred to hospital after pre-referral dose of antibiotics.

Treatment LOC
  • Admit
  • Keep baby warm
  • Prevent hypoglycaemia by breastfeeding/giving expressed breast milk/NGT
  • If child is lethargic, do not give oral feeds. Use IV fluids with care 
  • Give oxygen to keep SpO2  >94%
  • Ampicillin 50 mg/kg IV every 6 hours
  • Plus gentamicin 7.5 mg/kg IV once daily
    • Neonates < 7 days old: 5 mg/kg IV once daily
    • In premature babies, the doses may need to be reduced (specialist only)

In severely ill infants

  • Ceftriaxone 100 mg/kg IV once daily

Alternative (only use if above not available)

  • Chloramphenicol 25 mg/kg IV every 6 hours (contraindicated in premature babies and neonates < 7 days old)
  • Continue treatment for at least 5 days, and for 3 days after the child is well
  • If meningitis is suspected, continue for 21 days
  • If septicaemia is suspected, continue for 10 days
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Pneumonia in a Child of 2 months-5 years

Clinical Features

  • Fever, may be high, low grade or absent (in severe illness)

Pneumonia

  • Cough
  • Fast breathing (2-12 months: ≥50 bpm, 1-5 years: ≥ 40 bpm)
  • Mild chest wall in-drawing

Severe pneumonia

  • As above plus at least one of the following:
    • Central cyanosis (blue lips, oral mucosa, finger nails or oxygen saturation < 90% using a pulse oximeter)
    • Inability to feed, vomiting everything
    • Convulsions, lethargy, decreased level of consciousness
    • Severe respiratory distress (severe chest indrawing, grunting, nasal flaring)
    • Extrapulmonary features, e.g. confusion or disorientation, may predominate and may be the only signs of pneumonia in malnourished or immunosuppressed children

Management  of pneumonia

Treatment LOC

Non severe pneumonia

  • Give oral amoxicillin dispersible tabs (DT) 40 mg/kg every 12 hours for 5 days O
    • 2-12 months 250 mg (1 tab) every 12 hours for 5 days
    • 1-3 years 500 mg (2 tabs) every 12 hours for 5 days
    • 3-5 years 750 mg (3 tabs) every 12 hours for 5 days

If wheezing present

  • Salbutamol inhaler 1-2 puffs every 4-6 hours until wheezing stops
  • Reassess child for progress after 3 days

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Severe pneumonia

  • Refer to hospital after 1st dose of antibiotic
  • Admit
  • Give Oxygen if SpO2 < 90% with nasal prongs and monitor through pulse oximetry
  • Give ampicillin 50 mg/kg IV every 6 hours or benzyl penicillin 50,000 IU/kg IM or IV
  • Plus gentamicin 7.5 mg/kg IM or IV once daily
    • Continue treatment for at least 5 days, up to 10 days

If not better after 48 hours, use second line

  • Ceftriaxone 80 mg/kg IM or IV once daily
  • If staphylococcus is suspected (empyema, pneumatocele at X ray), give gentamicin 7.5 mg/kg once daily plus cloxacillin 50 mg/kg IM or IV every 6 hours

Once the patient improves

  • Switch to oral amoxicillin 40 mg/kg every 12 hours for 5 days to complete a total of at least 5 days of antibiotics

Alternative (if above not available/not working)

  • Chloramphenicol 25 mg/kg IV every 6 hours

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Other treatments

  • Give Paracetamol 10 mg/kg every 4-6 hours for fever
  • If wheezing, give salbutamol 1-2 puffs every 4-6 hours
  • Gentle suction of thick secretions from upper airway
  • Daily maintenance fluids – careful to avoid overload especially in small and malnourished children
  • If convulsions, give diazepam 0.5 mg/kg rectally or 0.2 mg/kg IV

 

 

If convulsions are continuous

  • Give a long-acting anticonvulsant, e.g. phenobarbital 10-15 mg/kg IM as a loading dose. Depending on response, repeat this dose after 12 hours or switch to oral maintenance dose of 3-5 mg/kg every 8-12 hours
  • Monitor and record:
    • Respiratory rate (every 2 hours)
    • Body temperature (every 6 hours)
    • Oxygen saturation (every 12 hours)
    • Improvement in appetite and playing
    • Use of accessory muscles of respiration
    • Ability to breastfeed, drink and eat

 

 

Pneumonia in Children > 5 years and adults

Clinical Features

Moderate

  • Fever, chest pain, cough (with or without sputum), rapid breathing (> 30 bpm), no chest indrawing

Severe

  • As above plus:
    • Chest indrawing
    • Pulse >120/minute
    • Temperature > 39.5°C
    • Low BP < 90/60 mmHg
    • Oxygen saturation less than 90%

Note: Extrapulmonary features, e.g. confusion or disorientation, may predominate and may be the only signs of pneumonia in elderly or immunosuppressed patients

Management

Treatment LOC

Moderate pneumonia (ambulatory patients)

  • Amoxicillin 500 mg-1 g every 8 hours for 5 days
    • Children: 40 mg/kg every 12 hours for 5 days.
    • Preferably use dispersible tablets in younger children

If penicillin allergy or poor response after 48 hours (possible atypical pneumonia), give:

  • Doxycycline 100 mg every 12 hours for 7-10 days
    • Child > 8 years only: 2 mg/kg per dose
  • Or Erythromycin 500 mg every 6 hours for 5 days
    • 14 days in cases of atypical pneumonia
      • Child: 10-15 mg/kg per dose

Severe pneumonia (hospitalised patients)

  • Give oxygen and monitor SpO2 saturation with pulse oximeter
  • Benzylpenicillin 2 MU IV or IM daily every 4-6 hours
    • Child: 50,000-100,000 IU/kg per dose

If not better in 48 hours:

  • Ceftriaxone 1g IV or IM every 24 hours
    • Child: 50 mg/kg per dose (max: 1g)

If S. Aureus is suspected

  • Cloxacillin 500mg IV every 6 hours

If other options are not available

  • Chloramphenicol 1g IV every 6 hours for 7 days
    • Child: 25 mg/kg per dose (max: 750 mg)

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Pneumonia by Specific Organisms

Treatment

Stapylococcus pneumonia

This form is especially common following a recent influenza infection. It can cause empyema and pneumatocele.

  • Adults and children >5 years:
    • Cloxacillin 1-2 g IV or IM every 6 hours for 10-14 days
      • Child >5 years: 50 mg/kg per dose (max: 2 g)
  • Child 2 months-5 years
    • Cloxacillin 25-50 mg/kg IV or IM every 6 hours
    • Plus gentamicin 7.5 mg/kg IV in 1-3 divided doses daily
    • Continue both medicines for at least 21 days

Mycoplasma pneumoniae

  • Doxycycline 100 mg every 12 hours for 7-10 days
    • Child >8 years: 2 mg/kg per dose
  • Contraindicated in pregnancy
  • Or erythromycin 500 mg every 6 hours for 5 days
    • Child: 10-15 mg/kg per dose

Klebsiella pneumonia

  • Gentamicin 5-7 mg/kg IV daily in divided doses
  • Or ciprofloxacin 500 mg every 12 hours
    • Child: chloramphenicol 25 mg/kg every 6 hours
  • Give a 5-day course
  • Amend therapy as guided by C&S results

Pneumococcal pneumonia

  • Benzylpenicillin 50,000 IU/kg IV or IM every 6 hours for 2-3 days then switch to oral Amoxicillin 500 mg-1 g every 8 hours for 5 days
    • Children: 40 mg/kg every 12 hours for 5 days.
  • Preferably use dispersible tablets in younger children

Pneumocystis jirovecii Pneumonia

Refer to Pneumocystis Pneumonia section (under HIV infection and AIDS)