Management of pneumonia.
This article discusses practical management of pneumonia (lower respiratory tract infection).
Definition: pneumonia or pneumonitis is inflammation of the lung parenchyma. It may be caused by infectious microorganisms e.g. bacteria, viruses and fungi or non infectious agents like aspiration (of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances), hypersensitivity reactions, and drug- or radiation-induced pneumonitis.
Etiology of infectious pneumonia:
- Neonates: usually bacterial e.g. group B streptococci, listeria and E. coli.
- 1 month-4 year: mainly viral e.g. RSV, adenovirus, parainfluenza & Influenza viruses. If bacterial : Streptococcus pneumonia, H. influenza.
- > 5 years: mainly bacterial e.g. M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type b,* nontypeable). If viral: influenza viruses, adenovirus, other respiratory
- Signs of URTI as rhinitis and cough might precede the condition.
- Constitutional symptoms like fever, malaise, anorexia and vomiting.
- Abdominal pain is common in lower lobe pneumonia whereas in upper lobe pneumonia nuchal rigidity might be present.
- Signs of respiratory distress: tachypnea, SOB, grunting, nasal flaring, retractions and cyanosis.
- On examination: diminished breath sounds with crepitations and wheeze. Dullness on percussion in case of consolidation. Liver may be palpable due to downward displacement.
- Chest x-ray
- CBC, CRP (usually +ve in bacterial, -ve in viral)
- In mildly ill patients hospital admission is not required and home management include: high dose amoxicillin 80-90mg/kg/day in 3 divided doses (7-10 days), amoxiclav 75mg/kg/day in 2 divided doses (7-10 days). If Mycoplasma or Chlamydophilia is suspected azithromycin 10mg/kg/day single daily dose (5 days) will be prescribed.
- Indications of admission:
1-Age <6 mo
2-Sickle cell anemia with acute chest syndrome
3-Multiple lobe involvement
6-Moderate to severe respiratory distress
7-Requirement for supplemental oxygen
10-Vomiting or inability to tolerate oral fluids or medications
11-No response to appropriate oral antibiotic therapy
12-Social factors (e.g., inability of caregivers to administer medications
at home or follow-up appropriately).
- Management for hospitalized patients:
-IVF maintenance (according to age)
-Analgesics and antipyretics e.g. Paracetol bottle 10-15mg/kg/dose 4 times daily.
-Antiemetics in case of vomiting e.g. Ondansetron (zofran) amp 0.15mg/kg/dose 2 times daily or Metoclopromide (plasil) amp 0.1mg/kg/dose 2-3 times daily.
-Antibiotics are the mainstay of treatment -even in viral pneumonia it’s better to give antibiotics because up to 30% of patients with known viral infection may have coexisting bacterial pathogens- e.g. Ceftriaxone vial 50-75mg/kg/day in single or two divided doses, or Claforan vial 200mg/kg/day in 2-4 divided doses. If clinical features suggest staphylococcal pneumonia (pneumatoceles, empyema), initial antimicrobial therapy should also include vancomycin vial 20mg/kg/dose by 3 infusion inside NS over 1 hour, or clindamycin. Duration of antibiotics treatment will be for 10 days.