Acute Community Acquired Pneumonia in Emergency Room

Abstract

Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO's classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.

Recurrent/Persistent Pneumonia Among Children in Upper Egypt

“…There are limited data on the underlying causes predisposing to persistence or recurrence of pneumonia in children. Moreover, only few reports had studied this problem in developing countries 4–8…”

The current status of community-acquired pneumonia management and prevention in children under 5 years of age in India: a review

“…A study [Awasthi et al 2004] clearly showed that 3 days of oral amoxicillin was equally effective as 5 days treatment in cases of nonsevere pneumonia. If there is no improvement in 48 h, amoxicillin should be replaced with co-amoxiclav [Dekate et al 2011].…”

“…In absence of satisfactory improvement in next 48 h, antibiotics should be changed to ceftriaxone [WHO, 2014]. Addition of cloxacillin is recommended, if features of S. aureus infection like boils in skin or abscesses anywhere in the body, rapidly progressive or deteriorating pneumonia, post measles pneumonia, and complications like empyema, pneumatoceles, and pneumothorax are present [Dekate et al 2011].…”

Acute respiratory infection and pneumonia in India: A systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India

“…Cloxacillin should be added if Staphylococcal disease is suspected clinically. Atypical organisms such as Mycoplasma are fairly common in this age group and treatment is with macrolide [54]. The current guideline for patients >18 years of age with community acquired pneumonia [55] also recommends beta-lactams as the first line, since it covers the most common pathogens responsible; however the resistance rate is reportedly higher than in children.…”