Pneumonia

It is infection of the lower respiratory tract (by virus, bacteria or atypical organisms) with inflammation and consolidation of lung/s.

Important differentials include bronchiolitis, pertussis, foreign body, empyema etc

 

Causative organisms

– Viruses: Para-influenza/ influenza viruses, RSV

– Typical bacteria: Pneumococcus, Staphylococcus, H Influenza

– Atypical organisms:Mycoplasma, Chlamydia, Legionella

 

– In Immune-compromised:Gram-ve bacteria, mycobacteria, Aspergillosis, Pneumocystis carinii

– In Cystic Fibrosis:Staph aureus in infancy; Pseudomonas or Burkholderia cepacia in older

– In Neuromuscular disease with aspiration:Anaerobic bacteria

 

Risk factors for LRTI include:

– Gastroesophageal reflux

– Anatomic anomaly of respiratory tract

– Neuromuscular diseases with aspiration

– Immunocompromised states

– Prolonged ventilation / tracheostomy

 

Clinical presentation

Cough + Tachypnoea + Fever = Pneumonia

Often poor feeding, vomiting and irritability

 

Tachypnea is the most consistent clinical manifestation in infants; Also record SaO2

Neonates may often have no physical findings of pneumonia

Infants and children can also have fever with rigors, malaise, pleuritic chest pain and increased work of breathing; and sometimes also wheeze

 

– Viral pneumonia:fever is less prominent; CXR is normal/ streaky infiltrates of bronchopneumonia

 

– Bacterial pneumonia:higher fever, rigors, cough, dyspnea, and auscultatory findings of lung consolidation. CXR may showlobar consolidation, collapse or pleural effusion

 

– Afebrile pneumonia:in young infants is characterized by tachypnea, cough, bilateral crackles on auscultation. CXR may just showhyperinflation

 

Investigations (for severe Pneumonia)

– Not needed for well children who have adequate oral intake & no oxygen requirement

– FBC, U&E, CRP, Blood culture- esp if giving IV antibiotics

– CXR may be normal in early stage; or show consolidation, bronchopneumonia, pleural effusion etc

– Also selectively consider- Nasopharyngeal aspirate, Sputum culture, nasal swab for Pertussis; Mycoplasma serology, Urine antigens for Pneumococcus or Legionella; or diagnostic pleural tap

 

Consider admission if:

– Young infants under 3 months (or <6m)

– SaO2 <92% in air

– Severe recessions/ very tachypnoeic

– Intermittent apnoea or grunting

– Pleural effusion on CXR

– Unwell, toxic or dehydrated

– Not tolerating oral antibiotics and fluids

– Underlying immunocompromised state

– Significant neuromuscular disease

 

Management

Well children can be discharged with oral antibiotics (eg Amoxicillin or Clarithromycin)

Admit to hospital if worrying features*

Monitor temp, HR, RR, SaO2

Use supplemental O2 to keep SaO2 >92%

Ensure adequate oral intake/ hydration; or use IV maintenance fluids

Give oral Amoxycillin or IV Benzylpenicillin as first-line for community-acquired pneumonia

 

– If suspecting atypical organisms, use Clarithromycin or another Macrolide

– If severe illness, consider Co-Amoxyclav & may add Clarithromycin

– If suspecting aspiration, use Co-Amoxyclav

– If ‘bullae’ on CXR, ad Flucloxacillin for Staph aureus cover

– If suspecting influenza, consider adding Oseltamivir

– For hospital-acquired pneumonia, use Tazocin or another as per local policy

 

*Repeat CXR in 2 months if ‘round’ pneumonia, collapsed lung or significant pleural effusion