1. Management: Patient Diagnostics: CBC and PC to check for infection, Chest X ray IVF: D5IMB to run at 35 ml/hr Medications: 1. NSS nebulization 2 ml q6h 2. Zinc supplementation 10 mg/ml, 1ml OD 3. Penicillin G Sodium 250,000 units q6h IV Hook to pulse oximeter O2 support if O2 sat <95 % For PPD test

2. Treatment Based on the presumptive cause and the clinical appearance of the child

3. Treatment Mildly ill children who do not require hospitalization Amoxicillin Communities with a high percentage of penicillin-resistant pneumococci High doses of amoxicillin (80–90 mg/kg/24 hr) Cefuroxime axetil Amoxicillin/clavulanate School-aged children and in those in whom infection with M. pneumoniae or C. pneumoniae (atypical pneumonias) is suggested Macrolide antibiotic (azithromycin) AdolescentsRespiratory fluoroquinolone (levofloxacin, gatifloxacin, moxifloxacin, gemifloxacin)

4. Treatment Bacterial pneumoniaParenteral cefuroxime (150 mg/kg/24 hr) Cefotaxime Ceftriaxone Staphylococcal pneumonia (pneumatoceles, empyema) Vancomycin Clindamycin Viral pneumoniaWithhold antibiotic therapy (mildly ill, clinical evidence of viral infection, no respiratory distress)

5. Factors Suggesting Need for Hospitalization of Children with Pneumonia Age <6 months Sickle cell anemia with acute chest syndrome Multiple lobe involvement Immunocompromised state Toxic appearance Severe respiratory distress Requirement for supplemental oxygen Dehydration Vomiting No response to appropriate oral antibiotic therapy Noncompliant parents

6. Response to Treatment Uncomplicated community-acquired bacterial pneumonia: respond within 48-96 hours of initiation of antibiotics – Improvement in clinical symptoms: fever, cough, tachypnea, chest pain Radiographic evidence of improvement  substantially lags behind clinical improvement

7. No improvement on appropriate antibiotic therapy (slowly resolving pneumonia): 1.Complications (ie. empyema) 2.Bacterial resistance 3.Nonbacterial etiologies (ie. viruses and aspiration of foreign bodies or food) 4.Bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs 5.Pre-existing diseases such as immunodeficiencies, ciliary dyskinesia, cystic fibrosis, pulmonary sequestration, or cystic adenomatoid malformation 6.Other noninfectious causes (ie. bronchiolitis obliterans, hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, and Wegener granulomatosis) Repeat chest x-ray  1st step in determining the reason for delay in response

8. Always get the HIGHEST RISK

9. PCAP A and B – > 2 years – High grade fever without wheeze If (+) wheeze  viral PCAP C – >2 years old – High grade fever without wheeze – Alveolar consolidation in CXR – WBC >15,000 PCAP D  give antibiotic When is an Antibiotic Recommended?

10. PCAP A or B without previous antibiotic – OPD: Oral amoxicillin – DOC 40-50 mkd in 3 divided doses x 7d Cotrimoxazole, Chloramphenicol PCAP C without prev antibiotic – DOC: Penicillin G IV (100,00 mkd in 4 divided doses) – (-) Primary Hib -> Ampicillin IV 100mkd in 4 divided doses PCAP D  consult specialist Empiric Treatment

11. Decrease in respiratory signs (esp tachypnea) and defervescencew within 72 hours If persistent > 72 hours  reevaluate When can a Pt be considered as Responding to Current Antibiotic?

12. PCAP A or B – Change antibiotic – Start macrolide – Reevaluate PCAP C not responding within 72 hrs – Consult specialist – Possibly: resistance, (+) complication, other dx PCAP D – Immediate reconsultation If patient is not responsive to tx:

13. 2 – 3 days after initiation of antibiotic – Responding – Able to feed – No complications Switch Therapy

14. Inpatient: oxygen and hydration – O2 sat > 95% If (+) wheezing  bronchodilator Not routinely given – Cough prep, CPT, bronchial hygiene, neb using NSS, steam inhalation, topical solution, bronchodilators, herbal med Ancillary Treatment

15. Malnutrition – Increased risk Tuberculosis Special Consideration

16. Prevention: VACCINESOther Supplements Pneumococcal – 6 wks PCV7 – 2 years PPV Hib – 6w, 10 w, 14 w, 12 m Influenza – Yearly starting at 6 mo MMR/Measles – 12 mo/9 mo Varicella – 12 mo Pertussis – 6w, 10w, 14w Zinc supplementation – Infant: 10 mg – > 2 y: 20 mg – Reduces incidence – Inhibits viral replication Vitamin C