Pediatric Community

Acquired Pneumonia

General Information
MD
1yo 5 mo/ male
Roman Catholic
Born on May 13, 2015 in Pasig City
MRR St. Pineda Pasig City
Admitted for the 1st time at VRPMC

 CC: fever x 5days

5d
3d
2d
FH

Low grade intermittent fever (Tmax 38)

1x vomiting of previously ingested food
Paracetamol (Tempra) 120mg/mg 10ml Q4

High grade intermittent fever (Tmax 40)

Non-productive cough and colds w/ clear to green nasal discharge
Paracetamol (Tempra) 120mg/mg 10ml Q4

High grade intermittent fever (Tmax 40)

Non-productive cough and colds w/ clear to green nasal discharge
Paracetamol (Tempra) 120mg/mg 10ml Q4

High grade intermittent fever (Tmax 40)

Non-productive cough and colds w/ clear to green nasal discharge
Paracetamol (Tempra) 120mg/mg 10ml Q4
Decreased activity

Past Medical History

No history of mumps and other childhood illness.
No history of Primary Pulmonary Tuberculosis or
Dengue.

No history of accidents, blood transfusion or

trauma.

No known allergies to food and drugs.

Family History
Mother, 28, college graduate, banker,
apparently well

Father, 28, college graduate, banker, apparently

well

No other heredofamilial diseases such as

cardiac, kidney, lung disease, seizures, bleeding
disorders and psychiatric illness.

Personal and Social

Born on May 13, 2015 in Pasig City, full term via NSD
to a 27y/o G2P2 (2002) w/o perinatal/neonatal
complications

The patient lives in a 2-floor well lit, well ventilated

apartment.

6 household members
Patient, father, mother, sister, maternal grandmother,
helper

Drinking water is from a water-refilling station

Garbage is collected twice a week

Nutritional History
The patient is breastfed up to present, with
complementary feedings started at the 6months
of age.

Currently, he has good appetite, breastfeeds

around 5-10 minutes, every 2 to three hours and
consumes about cup of rice with viand

Immunization
Vaccine

Dose

Place

BCG

HEP B

DPT

MANDALUYONG
HEALTH
CENTER

OPV

MEASLES

MMR

HIB

PNEUMOCCOCA L
TDAP
MENIGOCOCCA
L

ROTAVIRUS

Developmental Milestone

Physical Examination
General Survey. Patient is awake, alert, active, in
cardiorespiratory distress, hydrated with the
following vitals signs:

Cardiac Rate: 120bpm

Respiration Rate: 39cpm

Temperature: 39.5C

O2 sat: 93% (room air)

Height: 81.28cm Weight: 10.6kg

IBW:10kg
TCR:1100cal/day TFI:1484cc/day

 HEENT: pink palpebral conjunctiva, white sclerae, with red orange

reflex, 2-3mm pupils equally round and reactive to light, patent
ear canals and nostrils, pink turbinates, moist lips, moist buccal
mucosa, pink pharyngeal wall without post nasal drip.

NECK: supple neck, no tonsilopharyngeal congestion, no

cervicolymphadenopathy, no neck veins, no scalp lesion

CHEST/LUNGS: Symmetrical chest expansion, shallow

subcostal retractions, with bilateral rales, no wheezes good

air entry.

HEART. Adynamic precordium, normal rate and regular rhythm,

no murmurs.

ABDOMEN. Slightly globular, with normoactive bowel sounds, no

tenderness, no organomegaly, no masses, no previous surgical
scars

GENITALIA: Normal looking genitalia.

EXTREMITIES: No gross deformities, full and equal pulses,

capillary refill time <2 secs, good turgor, no edema, no cyanosis

SKIN. No active dermatoses.

Neurologic Examination
Cerebrum: Awake, alert, active, playful, able to manipulate toys

Cerebellum: No nystagmus, no tremors

Cranial Nerves:

I. Not assessed
II. (+) Red Orange Reflex, 2-3mm pupils equally round and reactive to light
III, IV, VI. Intact extraocular muscles
V. Good masseter tone
VII. No Facial asymmetry
VIII. Intact gross hearing
IX, X. (+) Gag reflex, uvula at midline
XI. able to turn head from side to side
XII. Tongue at midline.

Motor. 5/5 All extremities

Sensory: Extremities withdraws to painful stimuli

Meningeal Signs: No nuchal rigidity, no Brudzinski, no Kernigs

Admitting Diagnosis
Pediatric Community Acquired Pneumonia-C

Upon Admission

Non-productive cough and colds with clear/green nasal discharge

Decreased activity

HR 120bpm

RR 39cpm

Temp 39.5

O2 sat 93% room air

shallow subcostal retractions, with bilateral rales

A- PCAP-C

NPO

Hooked to D5LR

Paracetamol 100mg/ml drops 1.2ml q4h for fever 37.8C (TD 11.32)

Salbutamol 1 neb +1ml PNSS q6

Cefuroxime 350mg TIVq8 (TD 99.05)

O2 2lpm via nasal cannula

2nd HD

Productive cough and colds with clear nasal discharge

Decreased activity

HR 130bpm

RR 34cpm

afebrile

O2 sat 95% room air

shallow subcostal retractions, with bilateral rales

A- PCAP-C

DFA w/ SAP

Hooked to D5IMB

Paracetamol 100mg/ml drops 1.2ml q4h for fever 37.8C (TD 11.32)

Salbutamol 1 neb +1ml PNSS q6

Cefuroxime 350mg TIVq8 (TD 99.05) D1

O2 2lpm via nasal cannula

3rd HD

Productive cough and colds with clear nasal discharge

fair activity

HR 130bpm

RR 35cpm

afebrile

O2 sat 96% room air

shallow subcostal retractions, with bilateral rales

A- PCAP-C

DFA w/ SAP

Hooked to D5IMB

Paracetamol 100mg/ml drops 1.2ml q4h for fever 37.8C (TD 11.32)

Salbutamol 1 neb +1ml PNSS q6

Cefuroxime 350mg TIVq8 (TD 99.05) D3

Budesonide 250ug 1 neb q8

O2 2lpm via nasal cannula

4th HD

Occasional cough and colds with clear nasal discharge

Good activity

HR 128bpm

RR 32cpm

afebrile

O2 sat 96% room air

shallow subcostal retractions, with bilateral rales

A- PCAP-C

DFA w/ SAP

Hooked to D5IMB

Paracetamol 100mg/ml drops 1.2ml q4h for fever 37.8C (TD 11.32)

Salbutamol 1 neb +1ml PNSS q6

Cefuroxime 350mg TIVq8 (TD 99.05) D3

Budesonide 250ug 1 neb q8

O2 2lpm via nasal cannula

Pneumonia

Inflammation of the lung parenchyma

Infectious
vs
Non infectious

Features
fever
wheeze
Alveolar
infiltrates in
CXR

Bacterial
>38.5
absent
present

Viral
<38.5
present
absent

Inc WBC

present

absent

 2-3y/o peak of viral attack

>5 y/o- S. pneumoniae, M. pneumoniae
Other bacterial causes: group A strep, S.
pyogenes , Staph aureus, H influenzae type B

 TACHYPNEA- most consistent clinical

manifestation

Increased working breathing w/

Intercostal retractions
Nasal flaring
Use of accessory muscles

Viral and bacterial pneumonias are most often

preceded by several days of symptoms of a URTI,
typically rhinitis and cough

Non-infectious causes
Aspiration of food or gastric acid
Foreign body
Hydrocarbon
Lipoid substances
Hypersensitivity reactions and drug
Radiation induced pneumonitis

Who shall be considered as having

community-acquired pneumonia?

Pneumonia
even w/o chest radiograph
COUGH & RESPIRATORY DIFF

OUT PATIENT SETTING

ER SETTING

Pneumonia
should be determined using a chest
radiograph presenting w/COUGH and
RESPIRATORY DIFICULTY

Dehydration 3m-5y

Malnutrition <7y

Pneumonia
should be determined using a chest
radiograph
3-24mos w/o respi symptoms

Diagnostic aids initially requested for

patients w/ PCAP A or PCAP B in an
ambulatory setting
CXR may be requested
To rule out pneumonia related complication
Should not be routinely requested

Should not be routinely requested to determine

appropriateness of antibiotic usage:
CXR, CBC, ESR, CRP, procalcitonin, Blood culture

Diagnostic aids initially requested

PCAP C or PCAP D
hospital setting
PCAP C

Should be done
Etiology
GS/ or CS of pleural fluid
Gas exchange
O2 sat
ABG

 PCAP C
May be done
Confirm clinical suspicion
of multilobar
consolidation, lung
abscess, pleural effusion,
pneumothorax,
pneumomediastinum
CXR PAL

Appropriateness of
antibiotic usage
CRP
Procalcitonin
CXR PAL
WBC count
GS of sputum or
nasopharyngeal aspirate

Determine etiology
Sputum CS
Blood CS

Predict clinical
outcome
CXR PAL
Pulse oximetry

Determine presence
of TB if clinically
suspected
Mantoux test PPD-5 TU
Sputum smear for acid
fast bacilli

Determine metabolic
derangement
Serum electrolytes
Serum glucose

PCAP D
Referral to specialist
should be done

When is antibiotic
recommended?

 PCAP A and B, may be given if the patient is:

> 2 yrs of age or
w/ high grade fever without wheeze

PCAP D
Specialist should be consulted

 PCAP C
Should be given
If alveolar consolidation in CXR is present

May be given if patient is any of the ff:

Inc serum CRP
Inc serum PCT
Inc white cell count
High grade fever w/o wheeze
Beyond 2 yrs of age

What empiric treatment should be administered

if a bacterial etiology is strongly considered ?

pCAP A or B without previous

antibiotic
AMOXICILLIN- DOC
40-50 mg/kg/day
maximum dose of 1500 mg/day in 3 divided doses for at most 7 days
may be given for a minimum of 3 days
may be given in 2 divided doses for a minimum of 5 days

AZITHROMYCIN
10 mg/kg/day OD for 3 days or
10mg/kg/day at day 1 then 5 mg/kg/day for days 2 to 5,
maximum dose of 500mg/day

CLARITHROMYCIN
15 mg/kg/day, maximum dose of 1000 mg/dayin 2 divided doses for
7 days

pCAP
C
w/o
prev
antibiotic

requiring hospitalization
w/ HIB immunization

DOC- Pen G 100,000 u/kg/day in 4 divided doses as

monotherapy

Not completed or uknown HIB immunization

DOC- Ampicillin 100mg/kg/day in 4 divided doses as
monotheraphy

>15 y/o
IV (BLIC, cephalosphorin, carbapenem) + IV extended macrolide
(azith or clarith) OR

IV (BLIC, ceph, carba) + IV respiratory fluoroquinolone

( levofloxacin/ moxifloxacin)

Can tolerate oral feeding, & does not require o2 support,

can be treated on OPD basis
Amoxicillin 40-50mg/kg/day max of 1500mg/day in 3
divided doses for 7 days

 PCAP C who is severely malnourished or

suspected MRSA, or PCAP D
Refer to specialist

Patient established to have M. tuberculosis

infection/disease
Antituberculosis drugs should be started

What treatment should be initially given

if a viral etiology is strongly considered?

 Oseltamivir DOC for lab confirmed or clinically

suspected cases of INFLUENZA
15 kg
= 30 mg 2x/day
>15-23 kg =45 mg 2x/day
>23-40 kg =60 mg 2x/day
>40 kg
=75 mg 2x/day

Use of immunomodulators for the treatment of

viral pneumonia is not recommended

Ancillary treatment as provided in Clinical

Question 11 may be given

When can a patient be considered as

responding to the current antibiotic

 Decrease in respiratory signs and/or

defervescense within 72 hours after initiation of
antibiotic are predictors of favorable response

If clinically responding, further diagnostic aids

CXR, CRP, & CBC should not be routinely requested

What should be done if a patient is not

responding to current antibiotic therapy?

 If an outpatient (pCAP A or pCAP B) or inpatient

(pCAP C) is not responding to the current
antibiotic within 72 hours, consider any of the
following:
Other diagnosis.
Coexisting illness.
Conditions simulating pneumonia.

Other etiologic agents for which C-reactive protein,

chest x-ray or complete blood count may be used to
determine the nature of the pathogen
May add an oral macrolide if atypical organism is
highly considered.

May change to another antibiotic if microbial

resistance is highly considered.

pCAP C may refer to a specialist

If an inpatient classified as pCAP D is not

responding to the current antibiotic within
72 hours, immediate consultation with a
specialist should be done

Can we switch therapy if bacterial

pneumonia be started?

 pCAP C
switch from IV oral 3 days after initiation of current
antibiotic is recommended in a patient who should fulfill
ALL of the following:
Responsive to current antibiotic therapy as defined in
Clinical Question 8.

Tolerance to feeding and w/o vomiting or diarrhea.

W/o any current pulmonary (effusion/empyema; abscess;
air leak, lobar consolidation,necrotizing pneumonia) or
extrapulmonary complications; and

Without oxygen support.

Switch therapy from three [3] days of parenteral

ampicillin to
amoxicillin [40-50 mg/kg/day for 4 days]

For pCAP D, referal to a specialist should be

considered

What ancillary treatment can be

given?

pCAP A/B
SHOULD NOT BE ROUTINELY GIVEN
Cough preparation
Elemental zinc
Vit A
Vit D
Probiotic
Chest physiotherapy

MAY BE GIVEN
Bronchodilator if with wheezing

pCAP C
SHOULD NOT BE GIVEN
Cough preparation
Elemental zinc
Vit A
Vit D
Chest physiotherapy

SHOULD BE GIVEN
O2 and hydration whenever applicable

MAY BE
Bronchodilator for wheezing
Steroid may be added to bronchodilator
Probiotic

How can pneumonia be prevented?

SHOULD BE GIVEN to prevent

pneumonia
Vaccine against
Streptococcus pneumonia (conjugate type)
Influenza
Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus
Influenzae type b

Micronutrient
Elemental zinc for ages 2-59mos to be given for 4-6
mos

 MAY BE GIVEN to prevent pneumonia

Vit D3 supplementation

SHOULD NOT BE GIVEN to prevent pneumonia

Vit A