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CASE PRESENTATION
“BRONCHOPNEUMONIA”
Mentor :
dr. Ulynar Marpaung, Sp. A
Written by :
Julianti Mulya Utami 1102010138
Faculty of Medicine Yarsi
Pediatric Department
Rumah Sakit Bhayangkara tk.I R.S. Sukanto-Jakarta
Periode: 16 March – 23 May 2015
ContentsIDENTITY...............................................................................................................................................2
PHYSICAL EXAMINATION (April 5th 2015).......................................................................................7
General Status......................................................................................................................................7
Antropometry Status............................................................................................................................8
Head to Toe Examination....................................................................................................................9
Neurological Examination.................................................................................................................10
Meningeal Sign..............................................................................................................................10
Motoric Examination.....................................................................................................................10
Autonom Examination...................................................................................................................11
Laboratory Investigation................................................................................................................11
FOLLOW UP.....................................................................................................................................12
LITERATURE REVIEW......................................................................................................................16
DEFINITION.....................................................................................................................................16
ETIOLOGY..........................................................................................................................16
PATHOPHYSIOLOGY........................................................................................................17
CLINICAL MANIFESTATIONS.....................................................................................................20
DIAGNOSIS......................................................................................................................................21
TREATMENT...................................................................................................................................22
PREVENTION..................................................................................................................................29
REFERENCES......................................................................................................................................30
IDENTITY
Patient
Name : FAH
Birth Date : October 10th 2014
Age : 6 months
Gender : Male
Address : Ketapang , Munjul
Nationality : Indonesia
Religion : Islam
Date of admission: April 4th 2015
Date of examination: April 10th 2015
Father Mother
Name Mr. T Mrs. M
Age 28 years old 25 years old
Job Entrepreneur Housewife
Nationality Javanese Javanese
Religion Islam Islam
Education High School (graduated)s High School (graduated)s
Earning/month Approximately Rp.2.000.000,- -
Address Ketapang, Munjul.
ANAMNESIS
The anamnesis was taken on April 5th 2015, by alloanamnesis (from patient’s mother).
Chief complain : Fever since 5 days before admission to the hospital.
Additional complains : Cough, shortness of breath,vomit.
3
History Of Present Ilness
A 6 months old child came to Raden Said Sukanto Police Center Hospital emergency
room suffering from fever since 5 days before admission the hospital, fever felt up and down,
reaches normal temperature. Patient’s mother also complaining cough continuously since 6
months before admitted. Cough had been healed, then relaps 5 days before admitted. Other
complaint is vomiting after eat something, phlegm, and hard to breath.
1 day before hospital admission, the child got fever at morning with the 390 C
temperature. Then her mother gave febrifuge. After receiving treatment, the child still fever.
On the admission hospital day, the child still fever and there are shortness of breath. His
father has history of asthma.
History Of Past Illness
Pharyngitis/
Tonsilitis
-
Bronchitis -
Pneumonia -
Morbilli -
Pertussis -
Varicella -
Diphteria -
Malaria -
Polio -
Enteritis -
Bacillary Dysentry -
Amoeba Dysentry -
Diarrhea -
4
Thypoid -
Worms -
Surgery -
Brain Concussion -
Fracture -
Drug Reaction -
Birth History
Mother’s Pregnancy History
The mother routinely checked her pregnancy to the doctor in the hospital. She denied any
problem noted during her pregnancy. She took vitamins routinely given.
Child’s Birth History
Labor : Hospital
Birth attendants : Doctor
Mode of delivery : pervaginam
Gestation : 38 weeks
Infant state : healthy
Birth weight : 3400 grams
Body length : 50 cm
According to the mother, the baby started to cry and the baby's skin is red, no
congenital defects were reported
Development History
First dentition: 6 months
Psychomotor development
Head Up : 1 month old
Smile : 1 month old
Laughing : 1- 2 month old
Slant : 2,5 months old
Speech Initation : 5 months old
5
Prone Position : 5 months old
Food Self : 5 – 6 months old
Sitting : 6 months old
Mental Status: Normal
Conclusion: Growth and development status is still in the normal limits and was
appropriate according to the patient’s age
History of Eating
Breast Milk : Exclusively 6 month.
Formula milk : -
Baby biscuits : Biscuits milna
Fruit and vegetables : Banana, Carrots
Immunization History
Immunizatio
n
Frequency Time
BCG 1 time 1 month old
Hepatitis B 3 times 0, 1, 6 months old
DPT 3 times 2, 4, 6 months old
Polio 4 times 0, 2, 4, 6 months old
Hib 4 times 2, 4, 6, months old
Family History
Patient’s both parents were married when they were 26 years old and 24 years old,
and this is their first marriage.
There are not any significant illnesses or chronic illnesses in the family declared.
History of her brothers
6
Childbirth Gender Age Age Died Sumption Died
Spontan pervaginam,
gestation aterm
Boy6 months old
- -
Born died : ( - )
Child dies : ( - )
Miscarriage : ( - )
History of Disease in Other Family Members / Around the House
There is no one living around their home known for having the same condition as the patient.
Sosial and Economic History
The patient lived at the house with size 20 m x 10 m together with father and mother.
There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1
room is the bedroom of three of them and 1 room is for guest. There are 4 windows
inside the house. The windows are occasionally opened during the day.
Hygiene:
o The patient changes his clothes everyday with clean clothes.
o Bed sheets changed every two weeks.
PHYSICAL EXAMINATION (April 5th 2015)
General Status
- General condition : mild ill
- Awareness : Compos Mentis
- Pulse : 123 x/min, regular, full, strong.
- Breathing rate : 36x/min
- Temperature : 38,8oC (per axilla)
Antropometry Status
- Weight : 7,3 kilogram
- Height : 70 cm
7
Nutritional Status based NCHS (National Center for Health Statistics) year 2000:
WFA (Weight for Age): 7,3/7,5 x 100 % = 97 % ( good nutrition)
HFA (Height for Age): 70/68 x 100 % = 102 % (good nutrition)
WFH (Weight for Height): 7,5/9 x 100 % = 85 % (normal)
8
Conclusion: The patient has good nutritional status.
9
Head to Toe Examination
Head
Normocephaly, hair (black, normal distributon, not easily removed ) sign of trauma (-),
sunken fontanelle (+).
Eyes
Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-,
sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++
Ears
Normal shape, no wound, no bleeding ,secretion or serumen
Nose
Normal shape, midline septum, secretion -/-
Mouth
Lips: moist
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: hyperemia (+)
Neck
Lymph node enlargement (-), scrofuloderma (-)
Thorax :
i. Inspection : symmetric when breathing , no retraction, ictus cordis is not visible
ii. Palpation : mass (-), tactile fremitus +/+
iii. Percussion : sonor on left lungs
iv. Auscultation :
1. Cor : regular S1-S2, murmur (-), gallop (-)
2. Pulmo : vesicular +/+, Wheezing -/- , Rhonchy +/+
Abdomen :
i. Inspection : Convex, epigastric retraction (-), there is no a widening of the veins, no
spider nevi.
ii. Palpation : supple, liver and spleen not palpable, fluid wave (-),abdominal mass (-)
iii. Percussion : The entire field of tympanic abdomen, shifting dullness (-)
10
iv. Auscultation : normal bowel sound, bruit (-)
Vertebra : There does not appear scoliosis, kyphosis, and lordosis, do not look
any mass along the line of the vertebral Ekstremities : warm, capillary refill time < 2 second, edema(-)
Skin : Good turgor.
Neurological Examination
Meningeal Sign
Motoric Examination
Power
Hand
Feet
5 5 5 5/ 5 5 5 5
5 5 5 5/ 5 5 5 5
Tonus
Hand
Feet
Normotonus / Normotonus
Normotonus / Normotonus
Trophy
Hand
Feet
Normotrophy / Normotrophy
Normotrophy / Normotrophy
Physiologic Reflex
Upper extrimities
Biceps
Triceps
Lower extrimities
Patella
+ / +
+ / +
+ / +
11
Achilles + / +
Pathologic Reflex
Upper extrimities
Hoffman
Trommer
Lower extrimities
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
- / -
- / -
- / -
- / -
- / -
- / -
- / -
Clonus
Patella
Achilles
- / -
- / -
Autonom Examination
Defecation
Urination
Sweating
Normal
Normal ( 4-5 times daily )
Normal
Laboratory Investigation
Hematology April 4th 2015
Hematology Results Normal Value
Haemoglobin 10 g/dL 13-16 g/dL
Leukocytes 11.500/µL 5,000 – 10,000/µL
Hematocrits 30 % 40 – 48 %
Trombocytes 365.000/ µL 150,000 – 400,000/µL
Erythrocytes 4,07 million/µL 4 – 5 million/µLWORKING DIAGNOSIS
12
Bronchopneumonia
DD/ Bronchiolitis
MANAGEMENT
O2 1L/m
IVFD RL 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamethasone 3 x 1 mg IV
PCT syrup 3x0,6 cc
Inhalation : twice a day
Ventolin ½ (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc
PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam
FOLLOW UP April 5th 2015 - April 10th 2015.
April 5th 2015. Second day of hospitalization, 7th day of illness
S Fever (+)
Phlegm (+)
Breathless (+)
Productive cough (+)
O General condition: Compos mentis.
13
Heart rate = 112 x/min
Respiratory rate = 34x/min
Temperature = 37,3˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-
A Bronchopneumoni
DD/ Bronchiolitis
P - O2 1L/m
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin ½ (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc
April 6th 2015. Third day of hospitalization, 8th day of illness
S Fever (+)
14
Phlegm (+)
Breathlless (+)
Productive cough (+)
O General condition: Compos Mentis
Heart rate = 120 x/min
Respiratory rate = 30x/min
Temperature = 38.5˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : retraction (+) vesiculer +/+, rhonchi +/+, wheezing -/-
A Bronchopneumoni
P - O2 1L/m
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin ½ (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc
April 7th 2015, Fourth days of hospitalization, 9th day of illness
S Fever (+)
Phlegm (+)
Productive cough (+)
O General condition: Compos mentis.
Heart rate = 110 x/min
15
Respiratory rate = 30x/min
Temperature = 37˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-
A Bronchopneumoni
P IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin ½ (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc
April 9th 2015. Fifth of hospitalization, 11th day of illness
S Fever (-).
Productive cough (+)
O General condition: Compos mentis (+)
Heart rate = 100 x/min
Respiratory rate = 26x/min
Temperature = 36,2˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-
A Bronchopneumonia
P Patient go home
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
16
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin ½ (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc
LITERATURE REVIEW
DEFINITIONPneumonia (pneumonitis) is an inflammatory process in lung parenchyma usually associated
with a marked increase in interstitial and alveolar fluid. Advances in antibiotic therapy have
led to the perception that pneumonia is no longer a major health problem in the United States.
Among all nosocomial infections (hospital acquired), pneumonia is the second most
common, but has the highest mortality. Pneumonia can be divided into three groups, which
guide management: community acquired, hospital or nursing home acquired (nosocomial),
and pneumonia in an immunocompromised person.
There are two clinical definitions of pneumonia:
1. Bronchopneumonia which is a febrile illness with cough, respiratory distress with evidence
of localised or generalised patchy infiltrates on chest x-ray
2. Lobar pneumonia which is similar to bronchopneumonia except that the physical findings
and radiographs indicate lobar consolidation.
ETIOLOGYPneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi.
The most common are:
17
Streptococcus pneumoniae – the most common cause of bacterial pneumonia in
children;
Haemophilus influenzae type b (Hib) – the second most common cause of bacterial
pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia;
in infants infected with HIV, Pneumocystis jiroveci is one of the commonest causes of
pneumonia, responsible for at least one quarter of all pneumonia deaths in HIV-
infected infants.
Age Bacterial Pathogens
Newborns : Group B streptococcus, Escherichia coli, Klebsiella species, Enterobacteriaceae
1- 3 months : Chlamydia trachomatis
Preschool : Streptococcus pneumoniae, Haemophilus influenzae type b, Staphylococcal aureus,
Less common: group A streptococcus, Moraxella catarrhalis, Pseudomonas aeruginosa
School : Mycoplasma pneumoniae, Chlamydia pneumoniae
Risk factors
While most healthy children can fight the infection with their natural defences, children
whose immune systems are compromised are at higher risk of developing pneumonia. A
child's immune system may be weakened by malnutrition or undernourishment, especially in
infants who are not exclusively breastfed.
Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a
child's risk of contracting pneumonia.
The following environmental factors also increase a child's susceptibility to pneumonia:
indoor air pollution caused by cooking and heating with biomass fuels (such as wood or
dung) living in crowded homes parental smoking.
PATHOPHYSIOLOGYTransmission
Pneumonia can be spread in a number of ways. The viruses and bacteria that are commonly
found in a child's nose or throat, can infect the lungs if they are inhaled. They may also
spread via air-borne droplets from a cough or sneeze. In addition, pneumonia may spread
18
through blood, especially during and shortly after birth. More research needs to be done on
the different pathogens causing pneumonia and the ways they are transmitted, as this is of
critical importance for treatment and prevention.
Presenting features
The presenting features of viral and bacterial pneumonia are similar. However, the symptoms
of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia. In
children under 5 years of age, who have cough and/or difficult breathing, with or without
fever, pneumonia is diagnosed by the presence of either fast breathing or lower chest wall in
drawing where their chest moves in or retracts during inhalation (in a healthy person, the
chest expands during inhalation). Wheezing is more common in viral infections.
Very severely ill infants may be unable to feed or drink and may also experience
unconsciousness, hypothermia and convulsions.
19
20
CLINICAL MANIFESTATIONS
The clinical diagnosis of pneumonia has traditionally been made using auscultatory findings such as bronchial breath sounds and crepitations in children with cough. However, the sensitivity of auscultation has been shown to be poor and varies between 33 %- 60% with an average of 50 % in children. Tachypnoea is the best single predictor in children of all ages. Measurement of tachypnoea is better compared with observations of retractions or auscultatory findings. It is nonetheless important to measure respiratory rate accurately. Respiratory rate should be counted by inspection for 60 seconds. However in the young infants, pneumonia may present with irregular breathing and hypopnea.
The symptoms of pneumonia may be nonspecific, especially in infants and younger children. Acute onset of fever, cough, difficulty breathing, poor feeding or vomiting, and lack of interest in normal activities are common. Chest or abdominal pain may be a prominent feature. Abrupt onset of rigors favours a bacterial cause. A significant, persistent cough may predominate in pneumonia caused by M pneumoniae. During influenza season, consider influenza, with or without a secondary bacterial component, as a cause of pneumonia.Children typically experience fever and tachypnea (determined by counting the respiratory rate for 60 s in a calm state; see Table 1). Indrawing, retractions and/or a tracheal tug will indicate respiratory distress (dyspnea). Decreased oxygen saturation indicates hypoxemia and should be measured in all hospital settings. Cyanosis will only be evident with very severe hypoxemia. Normal oxygen saturation does not exclude pneumonia, especially early in the course of the illness.TABLE 1Age-specific criteria for tachypnea
Age
Approximate normal respiratory rates(breaths/min)
Upper limit that should be used to definetachypnea (breaths/min)
<2 months 34–50 60
2–12 months 25–40 50
1–5 years 20–30 40
>5 years 15–25 30
Physical signs suggesting consolidation include dullness to percussion, increased tactile fremitus, reduced normal vesicular breath sounds and increased bronchial breath sounds – all
21
of which can be difficult to detect in young children. The presence of wheezing should suggest the possibility that radiographic changes may be due to atelectasis and mucous plugging from asthma or bronchiolitis rather than pneumonia. Signs of an effusion are dullness to percussion, decreased tactile fremitus, and decreased or absent breath sounds. There may be associated signs of dehydration and/or sepsis.
DIAGNOSISChildren with bacterial pneumonia cannot be reliably distinguished from those with viral
disease on the basis of any single parameter; clinical, laboratory or chest radiograph findings.
1. Chest radiograph
Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not identify
the aetiological agent. However the chest radiograph is not always necessary if facilities are
not available or the pneumonia is mild.
2. Complete white blood cell and differential count.This test may be helpful as an increased
white blood count with predominance of polymorphonuclear cells may suggest bacterial
cause. However, leucopenia can either suggest a viral cause or severe overwhelming
infection.
3. Blood culture
Blood culture remains the non-invasive gold standard for determining the precise etiology of
pneumonia. However the sensitivity of this test is very low. Positive blood cultures are found
only in 10% to 30% of patients with pneumonia. Even in 44% of patients with radiographic
findings consistent with pneumonia, only 2.7% were positive for pathogenic bacteria. Blood
culture should be performed in severe pneumonia or when there is poor response to the first
line antibiotics.
4. Culture from respiratory secretions
It should be noted that bacteria isolates from throat swabs and upper respiratory tract
secretions are not representative of pathogens present in the lower respiratory tract. Samples
from the nasopharynx and throat have no predictive values. This investigation should not be
routinely done.
5. Other tests
22
Bronchoalveolar lavage is usually necessary for the diagnosis of Pneumocystis carini
infections primarily in immunosuppressed children. It is only to be done when facilities and
expertise are available. If there is significant pleural effusion diagnostic, pleural tap will be
helpful. Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis are
difficult organisms to culture, and thus serological studies should be performed in children
with suspected atypical pneumonia. An acute phase serum titre of more than 1:160 or paired
samples taken 2-4 weeks apart showing four fold rise is a good indicator of Mycoplasma
pneumoniae infection. 17 This test should be considered for children aged five years or older
with pneumonia.
TREATMENTPneumonia should be treated with antibiotics. The antibiotic of choice is amoxicillin
dispersable tablets. Most cases of pneumonia require oral antibiotics, which are often
prescribed at a health centre. These cases can also be diagnosed and treated with inexpensive
oral antibiotics at the community level by trained community health workers. Hospitalization
is recommended only for severe cases of pneumonia, and for all cases of pneumonia in
infants younger than 2 months of age.
Guidelines for referral to hospital or hospital admission
Most children can be managed as outpatients. Specific criteria for admission are not available
for children. Hospitalization is generally indicated if the child is unable to eat or drink, has an
inability to comply with oral therapy, has a concerning social situation, dehydration,
hypotension, sepsis, oxygen saturations of lower than 92%, vomiting, tachypnea, chest
retractions, or any evidence of an empyema or lung abscess . There should be a low threshold
for admitting children younger than six months of age because it can be difficult for
caregivers to recognize deterioration.
I Assessment of severity of pneumonia
The predictive value of respiratory rate for the diagnosis of pneumonia is age specific
(Table 7)
Table 7: Definition of Tachypnoea
Less than 2 months > 60 /min
23
2- 12 months > 50 /min
12 months – 5 years > 40/ min
Assessment of severity is essential for optimal management of pneumonia. Pneumonia may
be categorized according to mild, severe, very severe based on the respiratory signs and
symptoms (Table 8 and Table 9)
Table 8: Assessment of severity of pneumonia in infants below two months old.
Severe pneumonia Severe chest indrawing or fast breathing
Very severe pneumonia Not feeding
Convulsions
Abnormally sleepy or difficult to wake
Fever/ low body temperature
Hypopnea with slow irregular breathing
Table 9: Assessment of severity of pneumonia in children age 2 months to 5 years old
Mild Pneumonia Fast breathing
Severe pneumonia Chest indrawing
Very severe pneumonia Not able to drink
Convulsions
Drowsiness
Malnutrition
Adapted from WHO
II Assessment of oxygenation
The best objective measurement of hypoxia is by pulse oximetry which avoids the need for
arterial blood gases. It is a good indicator of the severity of pneumonia
III Criteria for hospitalization
24
Community acquired pneumonia can be treated at home. It is crucial to identify indicators of
severity in children who may need admission as failure to do so may result in death. The
following indicators can be used as a guide for admission.
1. Children aged <3 months whatever the severity of pneumonia.
2. Fever (>38.50 C), refusal to feed and vomiting
3. Rapid breathing with or without cyanosis
4. Systemic manifestation
5. Failure of previous antibiotic therapy
6. Recurrent pneumonia
7. Severe underlying disorders ( i.e. immunodeficiency, chronic lung disease )
IV Antibiotic therapy
When treating pneumonia clinical, laboratory and radiographic findings should be
considered. The age of the child, local epidemiology of respiratory pathogens and sensitivity
of these pathogens to particular microbial agents and the emergence of antimicrobial
resistance also determine the choice of antibiotic therapy (Table 10 and Table 11) The
severity of the pneumonia and drug costs have also a great impact on the selection of therapy
(Table 5.7).
The majority of childhood infections are caused by viruses and do not require any antibiotic.
However, it is also very important to remember that we should be vigilant to choose
appropriate antibiotics especially in the initial treatment to reduce further mortality and
morbidity.
Table 10: Susceptibility (%) pattern of Streptococcus pneumoniae found in Malaysia 20
Antibiotic Susceptible Intermediate Resistance
Azithromycin 98.1 1.9
Cefuroxime 99.6 0.4
Chloramphenicol 95.1 1.5 3.4
25
Chlindamycin 9.2 0.4 0.4
Cotrimoxazole 86.4 3.9 9.7
Erythromycin 98.4 0.4 1.1
Penicillin 93.0 7.0
Tetracycline 78.2 0.8 21.0
Table 11: Predominant bacterial pathogens of children and the recommended
antimicrobial agents to be used.
Pathogens Antimicrobial agent
Beta- lactam susceptible
Streptococcus pneumonia Penicillin, Cephalosporins
Haemophilus influenzae type b Ampicillin,Chloramphenicol,
Cephalosporins
Staphylococcus aureus Cloxacillin
Group A Sreptococcus Penicillin,Cephalosporin
Mycoplasma pneumoniae Macrolides such as erythromycin and
Azithromycin
Chlamydia pneumoniae Macrolides such as erythromycin and
Azithromycin
Bordetella pertussis Macrolides such as erythromycin and
Azithromycin
Table 12: Commonly used antibiotics and their dosages
Intravenous Antibiotics Dosages
Amoxycillin-Clavulanate Acid 10-25mg/kg/dose 8 hrly
26
Ampicillin -sulbactam 10-25 mg/kg/dose 8 hrly
Ampicillin 100mg/kg/day 6 hrly
C. Penicillin 25,000-50,000U/kg/dose 6 hourly
Cefuroxime 10-25 mg/kg/dose 8 hrly
Cefotaxime 25-50mg/kg/dose 8 hrly
Cloxacillin 25-50mg/kg/dose 6hrly
Co-trimoxazole (trimethoprim ) 4 mg/kg/dose 12 hrly
Erythromycin 7.5mg kg/dose 6 hrly
Oral Antibiotis Dosages
Azithromycin 10-15 mg/kg/day daily dose
Augmentin 114 mg 12 hourly (less than 2 years)
228 mg 12 hourly (more than 2 years)
Cefuroxime 125 mg 12 hourly (less than 2 years)
250 mg 12 hourly (more than 2 years)
Cotrimoxazole 4 mg/kg/dose 12 hourly
Cloxacillin 50mg/kg /dose 6 hourly
Erythromycin Estolate 7.5 mg/kg/dose 12 hour ly
Penicillin V 7.5 - 15 mg/kg/dose 6 hourly
INPATIENT MANAGEMENT
I Antibiotic therapy
For inpatient management of children with severe pneumonia, the following antibiotic
therapy is recommended.
27
1st line lactams drugs: Benzlypenicillin, Amoxycillin, Ampicillin,Amoxycillin-
Clavulanate
2nd line Cephalosporins : Cefotaxime, Cefuroxime, Ceftazidime,
3rd line Carbapenem: Imepenam
Others Aminoglycosides: Gentamicin, Amikacin
If there are no signs of recovery; especially if the patient remains toxic and ill with spiking
temperature for 48-72 hours, a 2nd of 3rd line antibiotic therapy need to be considered. If
Mycoplasma or Chlamydia species are the causative agents, a macrolide is the appropriate
choiceA child admitted to hospital with severe community acquired pneumonia must receive
parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a
second or third generation cephalasporins and macrolide should be given. Staphylococcal
infections and infection caused by Gram negative organisms such as Klebsiella sp are more
frequently reported in malnourished children.
Staphyloccoccal infection
Staphylococcus aureus is responsible for a small proportion of acute respiratory infections in
children. Nevertheless a high index of suspicion is required because of the potential for rapid
deterioration. It is chiefly a disease of infants with a significant mortality rate. Radiological
features suggestive of Staphylococcal pneumonia include the presence of multilobar
consolidation, cavitation, pneumatocoeles, spontaneous pneumothorax, empyema and pleural
effusion. Treatment with high dose intravenous cloxacillin (200mg/kg.day) for a longer
duration and drainage of empyema will result in good outcome in the majority of cases.
II Supportive treatment
1. Fluid therapy
Oral intake should cease when a child is in severe respiratory distress. In severe pneumonia,
inappropriate secretion of anti-diuretic hormone is increased, dehydration is therefore
uncommon. It is important that the child should not be overhydrated.
2. Oxygen therapy
28
Oxygen reduces mortality associated with severe pneumonia. It should be given especially to
children who are restless, tachypnoea with severe chest indrawing, cyanosed or not tolerating
feeds. The SpO2 should be maintained above 95%.
3. Anti-tussive remedies
It is not recommended as it causes suppression of cough and may interfere with airway
clearance. Adverse effects and overdosa ge have been reported.
4. Chest physiotherapy
The function of chest physiotherapy is to assist in the removal of tracheobronchial secretions
resulting in an increase gas exchange and reduction in the work of breathing. However, trials
have found no clinically discernible benefit or impact of chest physiotherapy on the course of
illness in bronchiectasis, cystic fibrosis, pneumonia, bronchiolitis, asthma, acute atelectasis,
inhaled foreign body and post extubation babies. There is no evidence to suggest that chest
physiotherapy should be routinely performed in pneumonia
Penicillin allergy
If the previous suspected allergic reaction included an urticarial rash, hypotension or
bronchospasm, the reaction may have been immunoglobulin E (IgE) mediated and all beta
lactams should be avoided. For children with nonsevere pneumonia who are treated as
outpatients, clarithromycin and azithromycin are reasonable choices, while keeping in mind
that pneumococcal resistance to antimicrobials is increasingly common. For more severe
pneumonias with suspected IgE-mediated penicillin allergy, options should be discussed with
a paediatric infectious diseases physician. If the previous suspected allergic reaction did not
appear to be IgE mediated, cephalosporins can be used. Cefuroxime axetil can be used in
place of amoxicillin, while recognizing that pneumococcal coverage is inferior with these
drugs.
OUTPATIENT MANAGEMENT
In children with mild pneumonia, their breathing is fast but there is no chest indrawing. Oral
antibiotics at an appropriate dose for an adequate duration is effective for treatment27, 28, 29,
29
30, 31. The mother is advised to return in two days for reassessment or earlier if the child
appears to deteriorate.
PreventionPreventing pneumonia in children is an essential component of a strategy to reduce child
mortality. Immunization against Hib, pneumococcus, measles and whooping cough
(pertussis) is the most effective way to prevent pneumonia.
Adequate nutrition is key to improving children's natural defences, starting with exclusive
breastfeeding for the first 6 months of life. In addition to being effective in preventing
pneumonia, it also helps to reduce the length of the illness if a child does become ill.
Addressing environmental factors such as indoor air pollution (by providing affordable clean
indoor stoves, for example) and encouraging good hygiene in crowded homes also reduces
the number of children who fall ill with pneumonia.
In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk
of contracting pneumonia.
30
REFERENCES
1.World Health Organization. Pneumonia. Fact sheet No. 331.2011. Available at
www.who.int/mediacentre/factsheets/fs331/en. Accessed 03.08.2012 Pneumonia in Children
2.Garna H dan Heda M.2005. Pneumonia Dalam Pedoman Diagnosis Dan Terapi 3rd Ed : Bagian IKA
FK UNPAD Bandung.th ; 2010.Hal; 403 – 8
3.http://dx.doi.org/10.5772/54052 163 [2] Singh V, Aneja S. Pneumonia – management in the
developing World. Pediatr Respir Rev 2011;12:52-59
4.Rahajoe Nastiti N, Supriyanto Bambang, dkk. Pneumonia. Buku Ajar Respirologi Anak. Edisi
Pertama. Jakarta : Badan Penerbit IDAI. Th; 2010.hal; 351-363
31
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